Milan Spaic

Microsurgical DREZotomy for Pain of Spinal Cord and Cauda Equina Injury Origin: Clinical Characteristics of Pain and Implications for Surgery in a Series of 26 Patients

Summary. The result of the DREZotomy procedure used for the treatment of chronic intractable neuropathic pain caused by injuries at the T9-L4 spine level in 26 patients has been reported. For the purpose of identifying the most favorable pain pattern for DREZ surgery we retrospectively analyzed the effectiveness of surgical treatment on different forms of pain in the follow-up period of 13–50 months, 37 months on average. All pain forms were classified according to subjective sensory pain expression including the rhythm and topography of the pain. Three groups of pain were formed according to subjective sensory equivalents: pain of thermal quality (burning, boiling, baking, warm etc.), pain of mechanical-nonthermal quality (shooting, cutting, stabbing, sharp, incisive, cramping, constriction, distraction, throbbing etc.). The third group was the combination of the previous two. Success in pain relief has been defined as a 50% or greater reduction in pain after surgery such that pain no longer interferes with patient activities of daily living and sleeping pattern and no longer requires routine analgesic pain medication. Our results revealed that the pain of mechanical-nonthermal nature and intermittent rhythm, confined to segmental topography was the most responsive to the DREZ surgical treatment so that 90% patients suffering from this pain pattern experienced a good long-term pain relief (70% had complete long term pain relief). Neuropathic pain of thermal quality with the diffuse infralesional distribution and steady rhythm was the most resistant to the DREZ surgical treatment: neither patient had long-term relief of this pain pattern. In the group of patients suffering from pain consisting of combined mechanical and thermal sensory components with confined pain territory, 75% experienced a good long-term pain relief (50% had complete long-term pain relief). Immediate pain relief was obtained in 88% of patients and was long lasting in 69% of the total series. Our results pointed to confined territory, intermittent rhythm and mechanical nature of the pain as the most relevant predictors of the expected pain relief achieved by the DREZ surgery.

DREZ surgery on conus medullaris (after failed implantation of vascular omental graft) for treating chronic pain due to spine (gunshot) injuries.

Summary¶ The results of DREZlesioning procedure used for the treatment of chronic intractable pain due to deafferentation caused by gunshot injuries at the thoracolumbar (T10-L1) spine level are reported in six patients The specificity of these cases arises from the fact that all the patients underwent, after decompressive laminectomy, an implantation of vascularized omental graft on the injured cord segments, 4–17 months after injury. Because of the failure of this method, which did not improve spinal function nor hinder the development of pain, surgery in the DREZ was performed 2–5 years after implantation. The results of the microsurgical DREZotomy procedure in those patients, 7–12 months after the surgery were: 4 patients with complete pain relief and 2 patients with pain relieved of 80%. All the patients with well-confined segmental pain were completely cured.

Penetrating Craniocerebral Injuries from the Former Yugoslavia Battlefields

In the period from September 10 th 1991 to December 31 st 1992, the total of 162 patients with penetrating craniocerebral war injuries from the former Yugoslavia battlefields were treated in the Military Medical Academy (MMA) in Belgrade. The severity of injury was graded according to the Glasgow Coma Score (GCS) as mild (13–15), moderate (9–12), and severe (3–8). The extensity of the cerebral lesion was classified as unilobar, multilobar, bihemispheric, transventricular, and haematoma with shift. Injuries were divided into those caused by bullets or shrapnel. According to the missile path, these were tangential, uncrossed, and crossed injuries. The patients were divided into the two groups according to the treatment that they received: Group A- 90 patients who were referred directly to the MMA without surgical treatment, and group B-72 patients who were treated surgically (minimal debridment or simple wound closure) in the local hospitals before the evacuation to the MMA. The outcome was assessed on the discharge from the MMA according to the Glasgow Outcome Scale (GOS). Severe penetrating injuries had poor outcome as compared to moderate and mild injuries (p=0.001). Multilobar and bihemispheric injuries as compared to unilobar, and crossing as compared to uncrossing or tangential injuries had a poor outcome (p=0.001). Bullet injuries had a poor outcome then shrapnel injuries (p=0.016). For the treatment of the complications or additional debridement 6.5% patients from the group A and 78% from the group B were reoperated. There was no statistically significant difference regarding the final outcome of the patients from the group A comparing to the group B (p = 0.169). Severity of the injury, extensity of the cerebral lesion, the missile path, and the type of missile significantly influenced the final outcome. Minimal debridement of penetrating gunshot injuries was not a sufficient solution because it required a high rate of reoperation in the later stage.

Electrophysiological evaluation of chronic neuropathic pain of spinal cord injury origin

Abstract The chronic neuropathic pain of spinal cord injury origin has been shown to be related to permanent neurochemical changes in the dorsal horn neurons thus producing spontaneous discharges of central nociceptive neurons resulting in chronic pain. There is a doubt, however, regarding the possible supraspinal neurogenic mechanism contributing to the generation of this chronic neuropathic pain phenomenon. To address this issue we determinated the functional condition of the thalamocortical transsmission by obtaining somatosensory evoked potentials from the stimulation of median nerves in the group of 23 paraplegics suffering from chronic posttraumatic neuropathic pain. We prospectively collected and analysed data from 23 patients, 21 males and 2 females, aged from 22 to 59 years (mean age, 35.8 y) suffered from chronic neuropathic pain of the spinal cord and cauda equina injury origin who underwent neurophysiological investigation by obtaining somatosensory evoked potentials from the stimulation of median nerves. Somatosensory evoked potentials were defined according to three-grade scale: normal findings (C), slightly abnormal (B), abnormal findings (A). Our findings revealed pathological somatosensory evoked potentials in 17 patients (73.9%). Only 3 (13%) patients had normal findings, and 3 (13%) slightly abnormal according to our criteria. Pathological findings in a majority of our patients, with changes in the primary cortical complex N20-P25, could be indicative for the dysfunction of thalamocortical afferences in patients with paraplegic pain.

Intracranial – extracranial meningioma: a case report of a rare entity

Abstract Meningiomas are common benign intracranial tumors. However, intracranial meningiomas with extracranial extension are exceedingly rare lesions with only a few reported cases in the literature. We report a case of an 86 years old female patient presented with enlarging mass over left parietal region for last 3 years. Besides cosmetic, she had no complaints. Head CT scan with bone window showed a large tumor consisting of intracranial and extracranial part, suggestive for meningioma. Patient was operated, and both parts of tumor were removed. Taking into account surgery indication and patient’s age, bone flap was returned. The postoperative course was uneventful and patient fully recovered. In the case of epicranial tumor attached to the underlying bone, meningioma should be excluded.

Hordotomija u lečenju bolnih stanja

During the time interval from January 1978 to January 2003, total of 128 chordotomy procedures have been done due to cancer’s pain at the Institute of neurosurgery in Clinical Center of Serbia. That pain has been mostly of uncontrolled intensity and it was resistant on applied conservative treatment. Bilateral chordotomy has been performed in 6 patients only in exceptional cases when fixed paraplegia has proved; unilateral chordotomy has been performed in 122 cases. Bilateral chordotomy is much more dangerous than unilateral one because of greater possibility of appearance of motor deficits, sphincteral disturbances or subsequent formed pain. This procedure has several negative aspects. Firstly, it is an opened surgical intervention in general anesthesia and therefore, there is no communication with patient. We had a habit to perform DREZ surgery rather than chordotomy when ever it has been indicated. In 80.1% of all cases, the successfulness of surgery has been marked as excellent, in 15.2% of all cases, it has been marked as good, and in 4.7% of all cases, bad outcome has been detected. The rate of complication was 4.4%.