Volker Lindner

Optimal Treatment of Phantom Limb Pain in the Elderly

SummaryPhantom limb and stump pain is a common sequela of amputation. In geriatric patients with an amputated limb and multiple other illnesses, drug therapy may be problematic and invasive techniques may be risky.Interactions between pathophysiological mechanisms in the peripheral and central nervous systems may be responsible for the initiation and maintenance of chronic phantom limb and stump pain. These mechanisms include: (i) peripheral damage to nociceptive fibres and dorsal root ganglion cells, which acquire abnormal sensitivity to mechanical, thermal and chemical stimuli; (ii) the prolonged sensitisation of central nociceptive ‘second order’ neurons in the dorsal horn of the spinal cord, which become hyperexcitable and start responding to non-noxious stimuli; and (iii) the degeneration of nociceptive neurons, which may trigger the anatomical sprouting of low threshold mechanosensitive terminals to form connections with central nociceptive neurons. This may subsequently induce functional synaptic reorganisation in the dorsal horn.The provision of a pain-free perioperative interval using regional anaesthetic techniques is likely to reduce the incidence of phantom limb pain. The therapy of manifest pain is difficult, and treatment should start as soon as possible to prevent chronic pain. In the acute state, the infusion of calcitonin and oral opioid analgesics have proven to be helpful, while established phantom limb pain may respond to antidepressants, anticonvulsants and drugs that mimic or enhance γ-aminobutyric acid function. Pharmacological treatment should be combined with transcutaneous electrical nerve stimulation, sympathetic blockade and psychotherapy. In addition, new therapeutic strategies are now being tested; examples include capsaicin, new anticonvulsants and N-methyl-D-aspartate antagonists. Patients with severe pain should be referred to a pain specialist to ensure optimal and timely interventional pain management.

Efficacy and Tolerability of Rizatriptan 10 mg in Migraine: Experience With 70 527 Patient Episodes

As patients who suffer from migraine need long‐term treatment, the safety and consistent efficacy of such therapy is very important. Concurrent illness and additional medication can interfere with the treatment chosen for the attacks of migraine. The objective of this open‐label study was to investigate the efficacy and tolerability of rizatriptan, in the treatment of up to three attacks of migraine, in the clinical setting. From October 1998 to July 1999, 6 174 doctors enrolled 33 147 patients into the study (26 644 women, 650 men). The mean age was 42.7 years. We were able to examine standardized migraine diaries relating to 25 501 patients and 70 537 migrainous episodes. Rizatriptan scored consistently high on efficacy and showed a consistently rapid onset. There was no evidence of tolerance to repeated use. An effect was reported within 1 hour of ingestion in 79% of attacks treated. In 27.8% of attacks, remission of headache was complete at 1 hour. Two hours after ingestion, 74% of attacks had subsided completely.

Central mechanisms of controlled-release metoprolol in migraine: a double-blind, placebo-controlled study

β-Blockers are widely used in the prophylaxis of migraine and have been described as very effective drugs in many studies. Some investigators have demonstrated that the clinical improvement of migraine corresponds to the normalization of the contingent negative variation (CNV), a slow cortical potential measuring cortical information processing. However, most of these studies have contained a variety of methodological pitfalls, which we attempted to address in the current study. Twenty patients suffering from migraine without aura were randomly divided into two groups. The groups were treated either with controlled-release metoprolol or placebo for 3 months, using a double-blind design. Twice before and once after each month of the treatment the CNV was recorded. After 3 months, a significant reduction of migraine frequency, duration and intensity was demonstrated for the metoprolol compared with the placebo group. The CNV was characterized by a marked reduction of the amplitude of the total CNV and postimperative negative variation and normalization of the eartly CNV habituation following treatment. Therefore, metoprolol may exert its prophylactic effect in migraine through the influence on cortical information processing and excitability represented by the CNV.

Small fibre function in primary autonomic failure

A case of primary autonomic failure (AF) with uncomplicated Parkinsons disease is presented with clinical and neurophysiological data. Special emphasis is placed on new methods of examining impairment ofunmyelinated sympathetic and afferent C-fibres. Sympathetic vasoconstrictor responses in the skin induced by deep inspiration were examined quantitatively with laser Doppler flowmetry. The vasoconstriction was markedly depressed in primary AF compared with healthy controls and similar to secondary forms of AF. Peripheral nociceptive C-fibre function was quantitatively assessed by measurement of axon reflex vasodilatation induced by histamine iontophoresis. The axon reflex vasodilatation was completely intact in primary AF in contrast to patients with secondary peripheral small fibre neuropathy. The results indicate that sympathetic C-fibres are considerably affected by the degenerative disease, whereas the afferent C-fibres seem to be totally preserved. Modern neurophysiological methods of testing sympathetic and afferent small fibre function in combination with other neurophysiological tests, e.g. brain-stem auditory evoked potentials, might help to diagnose and differentiate primary AF in early stages and make it easier to distinguish between secondary autonomic neuropathies of unknown origin that often also involve unmyelinated afferent fibres.

Changes in Cerebral Haemodynamics in Cases of Post-Lumbar Puncture Headache: A Prospective Transcranial Doppler Ultrasound Study

We used transcranial Doppler ultrasonography in 45 patients to investigate if changes in haemodynamics in the major arteries of the brain base occurred after lumbar puncture and whether or not patients with or without post-lumbar puncture headache differ with respect to their cerebral haemodynamic parameters before and after lumbar puncture. Before lumbar puncture, patients with post-lumbar puncture headache differed from patients without post-lumbar puncture headache in that they showed significantly higher flow velocities and significant asymmetry of flow velocities with lateralization to the right (p £ 0.05). Patients without post-lumbar puncture headache, on the other hand, showed non-significant flow velocity lateralization to the left. Forty-eight hours after lumbar puncture, both groups demonstrated symmetrical flow velocities. In addition, only patients with post-lumbar puncture headache showed a significant reduction in the flow velocity of the right middle cerebral artery (p £ 0.05). These findings suggest that it is not only absolute flow velocity that plays a part in the event of headache, the interhemispheric relation of cerebral haemodynamics also plays a fundamental role.

Idiopathic Lambert-Eaton myasthenic syndrome associated with minimal-change glomerulonephritis and psoriatic arthritis

Sirs: Certain neurological autoimmune disorders such as the Lambert-Eaton myasthenic syndrome (LEMS) [7, 12] are often associated with paraneoplastic syndromes and other autoimmune disorders [1]. LEMS is a myasthenic autoimmune syndrome associated with a specific anti-Ca channel PQ type autoimmune antibody, which leads to about 40 % destruction of Ca channels on the terminal endings of motor axons [8, 18]. Severe muscle weakness, in contrast to the case in myasthenia gravis, improves with repetitive stimulation or muscle contraction. This “increment” is the essential clinical test for diagnosis, followed by antibody detection [1]. In 70 % of cases LEMS is associated with neoplasia. In 62 % of such cases this is a bronchial oat cell carcinoma, but association with other cancers such as those of breast, prostate, stomach, and rectum as well as lymphomas have been described [1, 19]. In one-third of the cases no neoplasm can be found even after extensive search [1]. This so-called cryptogenic or idiopathic LEMS (k-LEMS) is often associated with HLA-B8 and DR3 [4, 27] and is based on an unknown autoimmune process. Some authors have described a more frequent association of this k-LEMS with other autoimmune disorders, which suggests a possible common pathophysiological basis. We describe a patient with an apparently unique combination of autoimmune disorders including the k-LEMS, psoriatic arthritis (PA) and minimalchange glomerulonephritis (MCGN). The 39-year-old man reported having a slowly progressive weakness of the legs for the previous 5 months. His walking distance was reduced to 50 m. After walking he felt pain in his thighs, radiating from his arthritic knee joints. He further noticed wasting of his upper calves and suffered an aching, cramping pain of his proximal limb muscles that was not related to exertion. The weakness was apparent after walking especially on his “bad days” although he could not identify any clear circadian time course. He also complained of progressive swallowing difficulty that was accompanied by dryness of the mouth. His speech was slurred and he had a weak voice. He did not notice any sensory deficits or “muscle twitching”. Despite a loss of energy he denied having loss of appetite, constipation, difficult micturition, impotence, fever or night sweating. In the past medical history he had suffered from MCGN since childhood (renal biopsies confirmed this in 1973 and 1975) which had become exacerbated in the past year with oedema of face, ankles and lower limbs, a 10-kg weight loss, extensive albuminuria and proteinuria (up to 9 g/day). Renal biopsy indicated MCGN without any major glomerular or tubulo-interstitial changes. The MCGN was treated with cortisol. On presentation to us he still took 5 mg prednisone per day. Four years previously PA had been diagnosed with numerous psoriatic plaques, onychodystrophy, arthritis, negative rheumatoid factor and positive radiological and scintigraphic findings. His PA had remained active and worsened in the month before admission. On neurological examination the patient showed a slight bilateral ptosis; his speech was slurred and of low volume. The strength of hip and knee flexion was impaired (Medical Research Council grade 4). There was generalised weakness without other localised pareses. No fasciculations were seen. Tendon reflexes were very weak, but pathological reflexes were absent. Sensation and coordination were unimpaired. The patient showed a positive Gower’s sign and had difficulty in rising from a chair. Walking was possible only in knee hyperextension. On general examination there were no further abnormal findings except a swollen, hot and red left knee, several psoriatic plaques, pitting of toe nails and a ridged nail of the third left finger. Lumbar puncture on admission yielded normal cerebrospinal fluid. Albumin and IgG in the serum were slightly elevated, antibodies against Yersenia enterocolica were highly elevated (IgM: 3323 U/l; IgA: 1054 U/l). The HLA status was: A1, A2, B8, B57, CW6, DR7, DR17. Anticalcium PQ-type antibodies were positive (222.4 pmol/l, laboratory threshold value: 25–30 pmol/l; test kit: Gesellschaft für Diagnostika und Medizinische Geräte, Hamburg, Germany) whereas anti-ACh receptor antibodies were negative (<0.20nmol/l) as was rheumatoid factor (<10.5 IU/ml). Markers for tumours and autoantibodies were all negative. On repetitive testing creatine kinase was always within normal limits. The distal motor latency was prolonged, with a normal peripheral conduction velocity. On admission electromyography showed LETTER TO THE EDITORS

Die neue Kopfschmerzklassifikation der International Headache Society

A completely new classification system for headache disorders, cranial neuralgias and facial pain has been prepared by a headache classification committee working within the International Headache Society (IHS). The committee is made up of an international body of experts, who spent almost 3 years on the preparation of the classification, publishing it in 1988 (Cephalalgia 8 Suppl 7ratio1ff., 1988). The German translation appeared a year later (Nervenheilkunde 8ratio161-203, 1989). The new classification system is structured in 13 main groups, each with finer divisions into subgroups. Preliminary experience with application of the new classification in 243 patients is reported. The advantages and the problems encountered are discussed. On balance, the new IHS classification is proving to be a very useful basis for the diagnosis of painful conditions affecting the head and face. It is indispensable for a modern headache clinic.A completely new classification system for headache disorders, cranial neuralgias and facial pain has been prepared by a headache classification committee working within the International Headache Society (IHS). The committee is made up of an international body of experts, who spent almost 3 years on the preparation of the classification, publishing it in 1988 (Cephalalgia 8 Suppl 7∶1ff., 1988). The German translation appeared a year later (Nervenheilkunde 8∶161–203, 1989). The new classification system is structured in 13 main groups, each with finer divisions into subgroups. Preliminary experience with application of the new classification in 243 patients is reported. The advantages and the problems encountered are discussed. On balance, the new IHS classification is proving to be a very useful basis for the diagnosis of painful conditions affecting the head and face. It is indispensable for a modern headache clinic.ZusammenfassungEine von Grund auf neue Einteilung von Kopfschmerzerkrankungen, Kopfneuralgien und Gesichtsschmerzen wurde von einemKopfschmerz-Klassifikations-Komitee der International Headache Society (IHS), das sich aus einem internationalen Expertengremium zusammengesetzt, in fast 3jähriger Arbeit erstellt und 1988 veröffentlicht (Cephalalgia 8 [Suppl 7]:1 ff, 1988). Die deutsche Übersetzung erschien 1 Jahr später (Nervenheilkunde 8∶161–203, 1989). Das neue Klassifikationssystem gliedert sich in 13 Hauptgruppen, die durch Subgruppen feiner unterteilt sind. Es wird über erste Erfahrungen mit der Anwendung der neuen Klassifikation bei 243 Patienten berichtet. Die Vorteile und die Probleme werden erläutert. Insgesamt erweist sich die neue IHS-Klassifikation als eine sehr praktikable Grundlage für die Diagnostik von Kopf- und Gesichtsschmerzen. Ihre Anwendung ist für eine zeitgemäße Kopfschmerzsprechstunde unentbehrlich.

Der vergessene Schmerz

ZusammenfassungBei einer 55 Jahre alten Frau war es innerhalb von 17 Jahren und nach einer 12 Jahre zurückliegenden lumbalen Bandscheibenoperation zu einem schweren chronifizierten lumbalen Schmerzsyndrom gekommen, das zu völligem sozialem Rückzug führte. Die Patientin war nicht mehr geh-und stehfähig, pendelte nur noch zwischen Bett und Rollstuhl hin und her. Die medikamentösen und invasiven neurochirurgischen und anästhesiologischen Maßnahmen zur Schmerzbehandlung eskalierten. Ein intrathekaler Katheter zur Morphinapplikation mußte wegen Meningitiskomplikationen entfernt werden. Ein Epiduralkatheter mußte wegen wiederholter Funktionsstörungen mehrfach revidiert werden. Im Zuge einer mit der Patientin abgesprochenen Morphinentzugstherapie trat erst ein epileptischer Anfall, dann im Gefolge eines akuten Kreislaufversagens mit zerebraler Hypoxie ein schweres amnestisches Syndrom auf, das die Erinnerung für die letzten 20 Lebensjahre auslöschte und damit auch für die gesamte Schmerzkrankheit. Die Patientin konnte schmerzfrei und unkompliziert mobilisiert werden. Auch nach allmählichem Abklingen des amnestischen Syndroms gelang es durch konsequente ärztliche Führung, einen Rückfall in die Schmerzkrankheit zu verhindern. Die Patientin wurde wieder voll belastbar und benötigte keine schmerztherapeutischen Maßnahmen mehr. Der Verlauf lehrt, daß chronischer Schmerz mit überwiegend psychodynamischer Genese und damit kortikalzerebraler Generierung intakte Gedächtnisleistungen voraussetzt. Fehlt die Erinnerung, so ist auch kein Schmerz vorhanden, und dies läßt sich therapeutisch nutzen.AbstractA 55-year-old female patient developed a severe chronic lumbar pain syndrome over a period of 17 years. An intervertebral disc operation was performed 5 years after the start of the painful illness. The patient later developed resistance to therapy and was unable to stand or walk. She was confined to bed and wheelchair and socially completely withdrawn. Drug therapy and invasive therapeutic techniques escalated. An intrathecal catheter for morphine administration had to be removed owing to bacterial meningitis, and repeated malfunction led to several revisions of an epidural catheter. Withdrawal of the morphine therapy, carried out with the patient’s agreement, was complicated by an epileptic seizure and an acute circulatory failure with cerebral hypoxia. The succeeding severe amnestic syndrome extinguished all recollection of the last 20 years, including the entire course of the painfull illness. The patient could then be mobilised without pain. Consistent care avoided a relapse into the pain syndrome as the amnestic syndrome gradually receded. The patient was fully able to accept responsibility and not longer required special pain therapy. The course demonstrates that chronic pain disorders of a predominantly psychodynamic, and therefore corticocerebral, genesis are dependent on an intact memory. In such cases memory failure can induce pain relief.

Die neue Kopfschmerzklassifikation der International Headache Society@@@The International Headache Society's new headache classification system: Erfahrungen bei der praktischen Anwendung

A completely new classification system for headache disorders, cranial neuralgias and facial pain has been prepared by a headache classification committee working within the International Headache Society (IHS). The committee is made up of an international body of experts, who spent almost 3 years on the preparation of the classification, publishing it in 1988 (Cephalalgia 8 Suppl 7ratio1ff., 1988). The German translation appeared a year later (Nervenheilkunde 8ratio161-203, 1989). The new classification system is structured in 13 main groups, each with finer divisions into subgroups. Preliminary experience with application of the new classification in 243 patients is reported. The advantages and the problems encountered are discussed. On balance, the new IHS classification is proving to be a very useful basis for the diagnosis of painful conditions affecting the head and face. It is indispensable for a modern headache clinic.A completely new classification system for headache disorders, cranial neuralgias and facial pain has been prepared by a headache classification committee working within the International Headache Society (IHS). The committee is made up of an international body of experts, who spent almost 3 years on the preparation of the classification, publishing it in 1988 (Cephalalgia 8 Suppl 7∶1ff., 1988). The German translation appeared a year later (Nervenheilkunde 8∶161–203, 1989). The new classification system is structured in 13 main groups, each with finer divisions into subgroups. Preliminary experience with application of the new classification in 243 patients is reported. The advantages and the problems encountered are discussed. On balance, the new IHS classification is proving to be a very useful basis for the diagnosis of painful conditions affecting the head and face. It is indispensable for a modern headache clinic.ZusammenfassungEine von Grund auf neue Einteilung von Kopfschmerzerkrankungen, Kopfneuralgien und Gesichtsschmerzen wurde von einemKopfschmerz-Klassifikations-Komitee der International Headache Society (IHS), das sich aus einem internationalen Expertengremium zusammengesetzt, in fast 3jähriger Arbeit erstellt und 1988 veröffentlicht (Cephalalgia 8 [Suppl 7]:1 ff, 1988). Die deutsche Übersetzung erschien 1 Jahr später (Nervenheilkunde 8∶161–203, 1989). Das neue Klassifikationssystem gliedert sich in 13 Hauptgruppen, die durch Subgruppen feiner unterteilt sind. Es wird über erste Erfahrungen mit der Anwendung der neuen Klassifikation bei 243 Patienten berichtet. Die Vorteile und die Probleme werden erläutert. Insgesamt erweist sich die neue IHS-Klassifikation als eine sehr praktikable Grundlage für die Diagnostik von Kopf- und Gesichtsschmerzen. Ihre Anwendung ist für eine zeitgemäße Kopfschmerzsprechstunde unentbehrlich.