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PubMed2005

Local anesthetic sympathetic blockade for complex regional pain syndrome.

BACKGROUND: Local anesthetic blockade of the sympathetic chain is widely used to treat reflex sympathetic dystrophy (RSD) and causalgia. These two pain syndromes are now conceptualized as variants of a single entity: complex regional pain syndrome (CRPS). A recent meta-analysis of the topic has been published. However, this study only evaluated studies in English language and therefore it could have overlooked some randomized controlled trials. OBJECTIVES: This systematic review had three objectives: to determine the likelihood of pain alleviation after sympathetic blockade with local anesthetics in the patient with CRPS; to assess how long any benefit persists; and to evaluate the incidence of adverse effects of the procedure. SEARCH STRATEGY: We searched the Cochrane Pain, Palliative and Supportive Care Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, and conference abstracts of the World Congresses of the International Association for the Study of Pain. Bibliographies from retrieved articles were also searched for additional studies. SELECTION CRITERIA: We considered for inclusion randomized controlled trials that evaluated the effect of sympathetic blockade with local anesthetics in children or in adult patients to treat RSD, causalgia, or CRPS. DATA COLLECTION AND ANALYSIS: The outcomes of interest were the number of patients who obtained at least 50% of pain relief shortly after sympathetic blockade (30 minutes to 2 hours) and 48 hours or later. We also assessed the presence of adverse effects in each treatment arm. A random effects model was used to combine the studies. MAIN RESULTS: Two small randomized double blind cross over studies that evaluated 23 subjects were found. The combined effect of the two trials produced a relative risk (RR) to achieve at least 50% of pain relief 30 minutes to 2 hours after the sympathetic blockade of 1.17 (95% CI 0.80-1.72). It was not possible to determine the effect of sympathetic blockade on long-term pain relief because the authors of the two studies evaluated different outcomes. AUTHORS' CONCLUSIONS: This systematic review revealed the scarcity of published evidence to support the use of local anesthetic sympathetic blockade as the 'gold standard' treatment for CRPS. The two randomized studies that met inclusion criteria had very small sample sizes, therefore, no conclusion concerning the effectiveness of this procedure could be drawn. There is a need to conduct randomized controlled trials to address the value of sympathetic blockade with local anesthetic for the treatment of CRPS.

Adult↗
PubMed1993

Autonomic nervous system function.

Tests of autonomic function for the clinical autonomic neurophysiology laboratory should be noninvasive, sensitive, specific, reproducible, physiologically and clinically relevant, and not be excessively time-consuming. Laboratory evaluation is strongly indicated when the following are suspected: (1) generalized autonomic failure, (2) benign autonomic disorders that mimic life-threatening disorders, (3) distal small-fiber neuropathy, (4) the autonomic neuropathies, (5) sympathetically maintained pain, and (6) the postural orthostatic tachycardia syndrome. The preparation of the subject is important. Recommended tests should evaluate an adequate number of relevant autonomic systems. The Mayo laboratory utilizes two test batteries, the autonomic reflex screen and the reflex sympathetic dystrophy (RSD) screen. The former comprises the quantitative sudomotor axon reflex test (QSART), orthostatic blood pressure (BP) and heart rate (HR) responses to tilt, HR response to deep breathing, the Valsalva ratio, and beat-to-beat BP responses to the Valsalva maneuver, tilt, and deep breathing. The RSD screen comprises the recording of skin temperature, resting sweat output, and QSART distributions bilaterally.

Autonomic Nervous System↗
PubMed2000

The Charcot foot.

AIMS: To review the clinical manifestations of the Charcot foot in diabetes mellitus, with particular reference to theories concerning aetiology. METHODS: Systematic review of the published literature, searching for the keywords 'Charcot', 'foot and diabetes' and 'neuropathy' on Medline, as well as by examination of the references in recent published reviews. CONCLUSIONS: The Charcot foot of diabetes mellitus is a common problem, and yet is not widely recognized by non-specialists. The failure of professionals to identify the condition in its early phases is probably largely responsible for the gross deformity which follows continued weight-bearing. The condition is confined to those with severe peripheral neuropathy. It is thought to result from three factors: motor neuropathy leading to the development of abnormal forces within the foot, subsequent disorganization of the foot as a result of associated osteopenia and progressive destruction from continued weight-bearing, enabled by reduced pain sensation. The cause of the osteopenia is not known, but it is associated with increased bone blood flow, which may be mainly the result of loss of sympathetic innervation. The importance of increased limb blood flow in the pathogenesis of the Charcot foot has been recognized for over a century. Paradoxically, the increased flow is associated with evidence of macrovascular disease, in that the prevalence of vascular calcification of pedal vessels approaches 90%. After an interval of many months, the condition tends to evolve: the increased blood flow lessens, the osteopenia is reduced and the disorganized bones become sclerotic. This tendency for the condition to evolve remains unexplained, since it would not be expected if the condition was caused solely by progressive denervation. As a result, it is suggested that another factor may be involved in the pathogenesis of the Charcot foot: an abnormal vasomotor reflex, analogous to reflex sympathetic dystrophy, occurring against a background of severe peripheral neuropathy. The resolution of the condition occurs because it is the reflex component of the hyperaemia which proves self-limiting.

Diabetic Foot↗
PubMed1993

[The stellate ganglion blockade].

Stellate ganglion block is a selective sympathetic blockade affecting one side of the head and neck, and the upper extremity and upper part of the thorax on the same side. It is an important method of treating impaired vascular circulation, sympathetic reflex dystrophy, causalgia and herpes zoster in the area other indications, e.g. acute hearing loss and retinal arterial spasms, are still disputed. The anatomy of the cervical sympathetic chain, the technique used to achieve the block (paratracheal access) and tests of the effectiveness of stellate ganglion blockade are described. The side-effects and complications of the method and other means of sympathetic blockade are discussed. Patients need to be informed of the possible complications and the alternatives available before being asked to give informed consent.

Autonomic Nerve Block↗
PubMed1993

[Sympathetic skin response--physiologic principles, normal values and clinical use].

Sympathetic skin reflex (SSR) was evaluated in the lower extremities of 60 normal volunteers aged 17 to 72 (mean age 38 +/- 16 years, 28 females, 32 males). SSR was obtainable in all volunteers and most often consisted of a biphasic wave with initial negative deflection. Mean latency was 2.16 +/- 0.20 s. Mean variation in a second repetitive measurement was 0.21 +/- 0.14 s. The SSR was not age- or sex dependent. There was a weak positive correlation of the SSR with the height of the volunteers (r = 0.271; p = 0.037). SSR was investigated in 39 patients with polyneuropathy (age 59 +/- 18). SSR was pathological in 51% on one or both legs. There was no correlation of the SSR to the aetiology nor to the type of lesion (axonal versus demyelinating polyneuropathy) nor to clinical symptoms. The applicability of the SSR is reviewed from the literature regarding polyneuropathy, erectile dysfunction, central degenerative diseases, multiple sclerosis, sympathetic reflex dystrophies, spinal and peripheral nerve lesions. SSR is briefly compared to alternative methods. SSR appears to be a reasonable method to describe a small section of the autonomic nervous system (sympathetic sudomotor function) and to calculate group differences. There appears to be no close correlation to any of the autonomic disturbances in individual patients.

Adolescent↗
PubMed1985

Reflex patterns in postganglionic vasoconstrictor neurons following chronic nerve lesions.

Lesions of limb nerves in man may be associated with a variety of painful disorders with trophic changes described by the generic term 'reflex sympathetic dystrophy'. Our hypothesis is that pain and trophic changes are produced by an abnormal discharge pattern in postganglionic neurons supplying the limb (see refs. 3,24). In relation to this hypothesis, reflex patterns in postganglionic vasoconstrictor neurons supplying the skin (CVC) and the skeletal muscle (MVC) of the cat hindlimb were investigated at various times after a peripheral nerve lesion had been produced. These reflex patterns were compared with those in animals without nerve lesions (control preparations). The following lesions were made: cutting and ligating the superficial peroneal nerve (skin nerve) with subsequent neuroma formation, suturing the central stump of the superficial peroneal nerve to the peripheral stumps of muscle branches of the deep peroneal nerve, suturing the central stumps of muscle branches of the deep peroneal nerve to the peripheral stump of the superficial peroneal nerve, cutting and resuturing the superficial peroneal nerve, deafferentation of the whole hindlimb. The responses of vasoconstrictor neurons to stimulation of arterial chemoreceptors, arterial baroreceptors (cardiac rhythmicity of postganglionic activity) and cutaneous nociceptors were tested. In the animals with nerve lesions, the following groups of postganglionic vasoconstrictor neurons were analyzed: neurons projecting to the lesioned nerve, neurons projecting to hairy skin through an intact skin nerve (sural nerve) and neurons projecting to skeletal muscle through intact muscle nerves. In control preparations without nerve lesions, MVC neurons were excited by stimulation of arterial chemoreceptors and cutaneous nociceptors and inhibited by stimulation of arterial baroreceptors. Most CVC neurons were inhibited by stimulation of chemoreceptors and nociceptors and weakly inhibited by stimulation of baroreceptors. In animals with nerve lesions a and b, many CVC neurons in the lesioned nerves, as well as in the non-lesioned cutaneous nerve nearby, behaved in the same manner as MVC neurons. With respect to the control, this difference proved to be statistically significant. In preparations with lesions a, b and c, MVC neurons did not change their reflex patterns. After nerve lesions d and e, no major changes of reflex patterns were observed in CVC and MVC neurons. The inhibitory influence of arterial baroreceptors on CVC activity decreased in deafferented preparations (lesion e).(ABSTRACT TRUNCATED AT 400 WORDS)

Afferent Pathways↗
PubMed1997

Severe self-healing nail dystrophy in a patient on peritoneal dialysis.

The unusual case of a patient on peritoneal dialysis who progressively developed onychodystrophy of the hands 2 months after Acinetobacter peritonitis had been reported. The nail disease consisted of acute pseudoclubbing, elkonyxis, severe Beau's lines and onychomadesis and showed spontaneous recovery within 4 months. Although reminiscent of severe Beau's lines and reflex sympathetic dystrophy, this observation shows a peculiar nail disorder of unknown cause.

Acinetobacter Infections↗
PubMed1987

Sympathetic dysfunction in patients with persistent pain after prolapsed disc surgery. A thermographic study.

Vasomotor function in the lower limbs was tested by means of thermography in 48 patients with and without residual complaints after surgery for a prolapsed intervertebral disc. There is a definite correlation between the severity of the complaints and the thermographic responses which corresponds well with the evidence for a sympathetic reflex dystrophy of the legs (causalgia).

Adult↗
PubMed1984

Basic concepts of pain and pain therapy.

Pain originating in the peripheral nervous system is based on the excitation of nociceptive afferent fibers, which are contained among A-delta- and C-fibers from skin, viscera, joints and muscles. Often, this excitation originates at the peripheral fiber ending, the nociceptor. Nociceptors are excited by strong stimuli, which may eventually become destructive. Nociceptor excitability is enhanced by endogenous chemical substances as occur, e.g., during inflammation. Some analgesic substances, e.g. acetylsalicylic acid, inhibit the synthesis of prostaglandins and related metabolites, which is thought to be a mechanism of peripheral analgesia. Some forms of chronic pain are due to pathophysiological conditions of peripheral axons. Neuralgic pain may be caused by prolonged compression of a nerve. Here, ectopic impulse generation at the site of compression is considered a mechanism of pain. In a nerve regenerating after trauma the sprouts are sensitive to mechanical and chemical influences and thus may produce abnormal discharges in the neuroma. Sympathetic influences might enhance excitability of sprouts in the neuroma. Excitation of nociceptors by the sympathetic nervous system probably also occurs in other situations of chronic pain, such as Sudeck's syndrome. Here, the chronic pain may be sustained by a positive feedback loop via somato-sympathetic reflexes (sympathetic reflex dystrophy). Similar mechanisms of positive feedback also occur in the skeletomotor system, where chronic pain conditions can be sustained by inappropriate muscle tone. In the central nervous system much of the information from the nociceptive afferent fibers is contained in the discharges of multireceptive neurons.(ABSTRACT TRUNCATED AT 250 WORDS)

Analgesia↗
PubMed1993

[Chemical neurolysis using alcohol (alcoholization) in the treatment of spasticity in the hemiplegic].

Spasticity is a source of disability for the hemiplegic patient. It leads to various disorders influencing the quality of gait: at the lower limb varus equinus foot deformity, toe-claw and/or hip adduction with adductors spasticity. At the upper limb, flexion deformity of the wrist and the hand makes grasp and grip ineffective and spasticity of the Pectoralis Major muscle is considered as a main cause of sympathetic dystrophy. Neurolysis with alcohol injection in the nerve trunk or at the motor point destroys the gamma fibers and reduces spasticity, without impairing motor command. The effects on spasticity, motricity, and deformity of 33 chemical neurolysis with alcohol are analysed with a six months follow-up (27 hemiplegic patients, 28 to 62 years old, mean = 54.5). The authors have used 60% alcohol concentration. Sciatic nerve injection significantly reduces triceps spasticity (7/11), improves the range motion of the ankle, and allows the patient to take off the ankle device. Those fair results are still present at the fourth month after injection. Similar results are reported after injection of the obturator nerve for hip adduction deformity (2/3), median nerve injection for wrist and hand deformity (6/6). Pectoralis Major injection in the motor point is effective for 10 of the 13 cases, preventing sympathetic reflex dystrophy or contributing to its dramatic improvement.

Adult↗
PubMed1998

Spinal cord stimulation revisited.

The proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. We analyze 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System; Medtronic Neurological, Inc Minneapolis, MN, USA) by a single satisfactory diagnosis 1992 through 1995. A rigid selection protocol was used: 1. A satisfactory diagnosis of the pathologic process resulting in pain was made. 2. A corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, e.g., vascular peripheral nerve, spine. 3. Lack of satisfactory response to noninterventional pain management modalities by an interdisciplinary pain clinic. 4. Independent psychological evaluation, including a structured interview was performed by a psychologist specialized in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. Fifteen patients were female and twelve were male. All were Caucasian. Their ages ranged from 27 to 84 years (mean:48). The average follow-up was 21 months (range: 48-6). All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trial (three cervical and twenty-one thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continue to use the stimulator. The same number would choose to receive in an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography was documented in the patients with RSD. We conclude that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.

Adult↗
PubMed1995

Peripherally induced tremor and parkinsonism.

OBJECTIVE: Trauma to the peripheral nervous system is a well-recognized cause of dystonia and tremor, but peripherally induced parkinsonism has not previously been documented. We seek to characterize peripherally induced tremor and parkinsonism and propose possible mechanisms for this phenomenon. DESIGN: Review of records of patients evaluated in the Movement Disorders Clinic between 1977 and 1993. In addition to demographic and clinical information, the records were screened for any potential predisposing factors. PATIENTS: Twenty-eight patients in whom the onset of tremor, parkinsonism, or both was anatomically and temporally related to local injury. INTERVENTION: The type and site of injury were verified by history and examination of records whenever possible. Severity of tremor and parkinsonism was assessed by clinical rating scales. Three patients with tremor and parkinsonism had their striatal [18F]-fluorodopa uptake and raclopride binding measured with positron emission tomography. MAIN OUTCOME MEASURE: Response to conventional antitremor and antiparkinsonian medication was assessed by a clinical rating scale. RESULTS: Severe local injury preceded the onset of movement disorder by 47.5 +/- 74.7 days (mean +/- SD). The mean age at onset of movement disorder was 46.5 +/- 14.1 years. Tremor was present in all 28 patients, 11 of whom exhibited additional parkinsonian features. In 20 patients, the movement disorder spread beyond the original site. Possible predisposing factors were identified in 13 patients; nine had essential tremor or a family history of essential tremor. In addition to tremor, dystonia and myoclonus were evident in 13 and three patients, respectively. Reflex sympathetic dystrophy was present in six patients. Tremor did not improve with medications, and only seven patients with parkinsonism responded to therapy with levodopa. CONCLUSION: Central reorganization in response to peripheral injury may give rise to a motor disturbance, including tremor and parkinsonism.

Adult↗
PubMed1990

Corneal surface irregularities and episodic pain in a patient with mucolipidosis IV.

Mucolipidosis IV is a lysosomal storage disease characterized by prominent involvement of the corneal epithelium. A 5-year-old boy with mucolipidosis IV experienced recurrent episodes of severe ocular pain, tearing, and ipsilateral facial flushing. This was suggestive of reflex sympathetic dystrophy, a syndrome of pain and sympathetic hyperactivity. The examination revealed marked corneal surface irregularities, corresponding to massive accumulations of intracytoplasmic storage material in the epithelium. Episodic pain in patients with mucolipidosis IV is an important symptom, presumably reflecting the distinctive corneal ultrastructural abnormality in this disease.

Cataract Extraction↗
PubMed2003

Sympathectomy for neuropathic pain.

BACKGROUND: Neuropathic pain is defined as pain initiated or caused by a primary lesion or dysfunction in the nervous system. Some examples of this condition are phantom limb pain, post-stroke pain and complex regional pain syndrome type I (reflex sympathetic dystrophy) and type II (causalgia). Treatment options include drugs, physical treatments, surgery and psychological interventions. The concept that many neuropathic pain syndromes, particularly RSD and causalgia are "sympathetically maintained pains" has historically led to attempts to temporarily or permanently interrupt the sympathetic nervous system. Chemical sympathectomies use alcohol or phenol injections to destroy the sympathetic chain, but this effect is temporary until regeneration of the sympathetic chain occurs. Surgical ablation can be performed by open removal or electrocoagulation of the sympathetic chain, or minimally invasive procedures using stereotactic thermal or laser interruption. OBJECTIVES: The review aimed to assess the effects of both chemical and surgical sympathectomy for neuropathic pain. Secondary objectives were to compare the effects of sympathectomy with no treatment, placebo or conventional treatment, and to evaluate whether the technique of sympathectomy influences the outcomes of the procedure. SEARCH STRATEGY: We searched MEDLINE and EMBASE up to February 2003 and the latest issue of the Cochrane Library (Issue 1, 2003). We screened references in the retrieved articles, literature reviews and book chapters. We also contacted experts in the field of neuropathic pain. SELECTION CRITERIA: Clinical trials and observational studies assessing the effects of sympathectomy (surgical or chemical) for neuropathic pain of both central or peripheral origin were included. DATA COLLECTION AND ANALYSIS: Two reviewers applied the selection criteria to titles and abstracts. Full articles of potentially eligible trials were obtained and the same reviewers applied the inclusion criteria to the studies. The methodological quality of the studies was evaluated. The studies were also evaluated for clinical relevance according to a classification developed by our group. Statistical pooling was not possible due to heterogeneity of data; instead a narrative description of each included study was performed. MAIN RESULTS: We included four studies. One randomized trial comparing radiofrequency sympatholysis with phenol sympathectomy was rated as low methodological quality and it showed that radiofrequency sympatholysis does not offer advantage over phenol techniques. However, a modified technique produced sympatholysis comparable to that produced by 6% phenol, with less incidence of post-sympathectomy neuralgia. REVIEWER'S CONCLUSIONS: The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience. Furthermore, complications of the procedure may be significant, in terms of both worsening the pain or producing a new pain syndrome; and abnormal forms of sweating (compensatory hyperhidrosis and pathological gustatory sweating). Therefore, more clinical trials of sympathectomy are required to establish the overall effectiveness and potential risks of this procedure.

Humans↗
PubMed1994

Characterization of immunoreactive forms of human osteocalcin generated in vivo and in vitro.

Three monoclonal antibodies recognizing the 5-13, 25-37, and 43-49 sequence of the human osteocalcin were used in competitive and two-site radioimmunoassays (RIA) to characterize specifically various immunoreactive forms of circulating human osteocalcin. The intact molecule accounts for 36% of total in normals (2.6 nM), 46% in patients with osteoporosis (3.1 nM), and 26% in chronic renal failure (6.9 nM). Four fragment were detected in addition to the intact molecule in the serum of healthy adults and patients with metabolic bone disease. N-terminal, mid, and mid C-terminal fragments were present in minute amounts (each accounting for 5-14% of the total circulating osteocalcin immunoreactivity). In contrast, the N-terminal midfragment, probably resulting from the cleavage around amino acids 43-44, represents about 30% (2 nM) of the total osteocalcin immunoreactive level in normals and patients with osteoporosis and up to 50% (13 nM) in patients with chronic renal failure. This large N-terminal midfragment, representing 75-80% of the intact osteocalcin level, is not lower when the plasma assay is performed immediately after sampling (within 20 minutes at 4 degrees C with proteinase inhibitors), indicating that it circulates in vivo. In addition, this fragment was detected in the supernatant of osteoblastic cells, representing about 28% of the intact peptide. Levels of N-terminal midfragment were not changed after treatment of patients with metabolic bone disease (Paget's disease, reflex sympathetic dystrophy, fibrous dysplasia, and osteoporosis) by bisphosphonate, suggesting that it is not released during bone resorption. The osteocalcin level measured with the two-site immunoradiometric assay specific for the intact molecule or with a conventional bovine RIA was rapidly decreased after incubation of serum at room temperature (-20 and -15%, respectively, after 3 h), whereas the total level of intact osteocalcin plus N-terminal midfragment was not changed. Intact osteocalcin loss can be partially avoided by proteinase inhibitors and by incubating serum at 4 degrees C. In conclusion, we characterized multiple immunoreactive forms of osteocalcin that circulate in addition to the intact molecule, none of them being specifically altered in osteoporosis. The N-terminal midfragment circulates in a large amount, probably resulting from cleavage of the intact molecule in the circulation and/or at peripheral sites. These fragments can also be generated in vitro by proteolytic degradation of the intact molecule. To obtain reliable intact osteocalcin values but also reliable levels measured with conventional competitive RIA, careful control of the sampling conditions is warranted.

Adult↗
PubMed1994

Microvascular response in the rabbit ear to total body cooling: a model for study of human digits.

Conditions such as Raynaud's disease, cold intolerance following digit replantation, and reflex sympathetic dystrophy are all exacerbated by diminished blood flow in the digits. The rabbit ear, being similar to the human digit, is an excellent model for studying microvascular responses during thermoregulation and was used in this study of microcirculatory changes during total-body cold stress. In eight rabbits a window was placed in one ear each, and the underlying vascular beds were photographed with the unanesthetized animal at room temperature (23 degrees C) and in a cold room (6 degrees C). Luminal arterial diameters constricted more than venular diameters during cold stress (39.6% vs. 16.5%, respectively, of the control diameters; P = 0.014). All responses were linear; the slopes of the regression lines were significantly different between arterioles and venules (P < 0.0001). This study suggests that decreased circulation in response to cold is due to decreases in the diameter and number of vessels available for perfusion, as predicted by the Poiseuille equation.

Animals↗
PubMed2003

Clinical application of drug pump for spasticity, pain, and restorative neurosurgery: other clinical applications of intrathecal baclofen.

Intrathecal baclofen has been successfully used for control of severe spasticity. Baclofen, an agonist of GABA-B receptor, has other potential effects on pain and recovery from coma. Sporadic episodes of dramatic recovery from persistent vegetative state are reported after intrathecal administration of baclofen. There are also reports on the use of baclofen for neuropathic pain including post-stroke central pain syndrome. Baclofen is also used for control of dystonia due to cerebral palsy or reflex sympathetic dystrophy. On the other hand, epidural spinal cord stimulation has been used for pain, spasticity, dystonia, or attempt to improve deteriorated consciousness, though the effects seem variable and modest. Similarity between baclofen and spinal cord stimulation is interesting in that both involves in spinal GABAergic system. The GABAergic system in the spinal cord plays a pivotal role in various clinical effects of these procedures.

Baclofen↗
PubMed1995

[Treatment of posterior cruciate ligament rupture and recent knee dislocations by olecranisation of the patella without surgical repair].

Olecranisation of the patella was described and first used by Grammont (1984) to maintain reduction of the knee joint after posterior cruciate repair and reconstruction. Since 1985 we used this technique in 18 acute posterior ruptures and knee dislocations which did not undergo surgery. Knee laxity is assessed under general anaesthesia with radiographic control. A 4 or 5 mm. Steinmann pin is introduced medially at the top of the patella and drilled vertically through the bone to continue behind the patella tendon. After reduction of the posterior drawer, the pin is passed into the anterior part of the tibia. Full mobility between 0 degrees and 90 degrees is maintained. Physiotherapy started immediately and early weight bearing is allowed with a posterior splint. Olecranisation prevents posterior subluxation of the tibia and gives an anterior tibial subluxation force which is minor in flexion but major in extension. We followed up our patients for 1 to 8 years. The latest testing with radiographs demonstrate posterior drawer but all patients report good results. Early physiotherapy avoids stiffness, amyotrophy, and reflex sympathetic dystrophy. Olecranisation appears to give similar results more quickly and with fewer complications than P. C. L. surgery.

Acute Disease↗