SummaryOver the past four decades, techniques and devices for spinal cord stimulation have undergone considerable refinement. Currently, percutaneous implantable electrodes are placed in the epidural space and a low-frequency electrical current is used to modify the transmission of chronic pain signals in the dorsal columns of the spinal cord.Before permanent implantation, the spinal cord stimulation will be examined during a test phase to determine its analgesic effect and tolerability.We have reviewed our experience in 88 patients with chronic nonmalignant pain. The follow-up of our study ranged from 15 to 75 months, with an average of 60 months.The indication for SCS in these 88 patients was mainly neuropathic pain syndromes.The patients were followed up by the Visual Analog Scale (VAS), level of activity and subjective assessment of the quality of life. On the basis of the patients' self-assessments using the VAS, the degree of pain relief was excellent=good in 72 of 88 patients (82%). At the end of the follow-up period, 50% of the patients were in a better psychological status and 86% of the patients reported an improvement in activities of their daily living and a reduction in the use of analgesic medication. Ninety percent of the patients stated that they would go through the procedure again for the same result.The findings of the present study indicate that spinal cord stimulation is an efficacious therapy for the treatment of chronic non-malignant pain.

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Intraspinal drug infusion using implantable pumps and catheter systems is a safe and effective therapy for selected pain patients with severe chronic pain. It improves pain relief, reduces drug-related side effects, decreases the need for oral analgesia and enhances quality of life in a segment of chronic pain patients whose pain has not been controlled with more conservative therapies. Intrathecal drug therapy has therefore established its role in the treatment of malignant pain, benign pain and severe spasticity.Careful patient selection and management as well as a multidisciplinary approach are determinants of successful treatment. Current practices for patient selection and management, screening, drug selection, dosing and implantation for intrathecal drug delivery systems are discussed.

This is a report of a case of a subdural haematoma with resulting paraplegia after attempted spinal anaesthesia. Epidural and subdural haematomas are rare complications after central neural blockade. The complication described here was the result of an unsuccessful attempt to puncture the spinal channel. The patient was a 72-year-old woman with a fracture of the left femoral neck, which it was intended to stabilize operatively. Findings that made lumbar spinal puncture difficult were severe overweight, and lordosis and scoliosis of the lumbar spine resulting from degenerative changes. Spinal anaesthesia was suggested because the patient had eaten shortly before and because she suffered from asthma. From the aspect of haemostasis no contraindications were present, and the anaesthesist was experienced in spinal anaesthesia even under difficult anatomical conditions. Several unsuccessful attempts were made to puncture the lumbar spinal channel while the patient was lying on her right side. It was also impossible to reach the spinal channel from a median or left paramedian approach. We used atraumatic pencil-point needles (Sprotte gauge 24, 90 mm). No blood was aspirated during any of the attempts. The surgical intervention was finally performed under a general anaesthetic in view of the urgency. No significant complications occurred during the operation, and no neurological abnormalities were observed immediately after or in the next 8 h after the operation. At 12 h after the operation a paraparesis was found caudal to L3. After this had been verified by radiological and neurological tests, neurosurgical decompression was carried out as quickly as possible. During the operation a distinct subdural haematoma without any detectable source of bleeding was discovered. Even after surgical revision and evacuation of the remaining haematoma it was not possible to reverse the paraplegia, in spite of rehabilitation measures. Despite a certain fragility of the vessel and pretreatment with pentoxifylline and thromboembolic prophylaxis with low-molecular heparin starting postoperatively, it must be assumed that a vessel accompanying one of the spinal nerves was punctured, possibly, the radiculomedullary vessel of Adamkiewicz. A similar case was published in 1988 by Parker. In the present case it must be assumed that the vessel was punctured during a paramedian approach in the area of the foramen intervertebrale, as the spinal channel was definitely not entered. Although this is an extremely rare complication, we conclude that close neurological controls are essential at least during the first 24 h after surgery, even after an unsuccessful attempt at central neural blockade.

Experiences with long-term intraspinal infusion of opioid drugs using the new implantable medication pump VIP 30 in patients with chronic non-malignant pain are reported. During a 19-month period 10 patients with chronic pain--mainly mixed nociceptive-neuropathic pain--underwent implantation of the medication pump for long-term treatment. The mean follow-up period was 9.5 months. Pain relief was classified as very good in 22.2%, good in 44.4%, moderate in 22.2% and poor in 11.1%. In 88.9% of the cases the patients stated they would undergo the same procedure again. Technical problems (catheter dislocation) developed in 1/10 patients could be surgically corrected. One pump including catheter was explanted because of an infected seroma within the pocket area. Long-term intrathecal application of opioids with the VIP 30 pumps is an effective and safe treatment in patients with chronic non-malignant pain.