Spinal cord stimulation for the management of pain: Recommendations for best clinical practice

Spinal cord stimulation (SCS) is an accepted method of pain control. SCS has been used for many years and is supported by a substantial evidence base. A multidisciplinary consensus group has been convened to create a guideline for the implementation and execution of an SCS programme for South Africa (SA). This article discusses the evidence and appropriate context of SCS delivery, and makes recommendations for patient selection and appropriate use. The consensus group has also described the possible complications following SCS. This guideline includes a literature review and a summary of controlled clinical trials of SCS. The group notes that, in SA, SCS is performed mainly for painful neuropathies, failed back surgery, and chronic regional pain syndrome. It was noted that SCS is used to treat other conditions such as angina pectoris and ischaemic conditions, which have therefore been included in this guideline. These recommendations give guidance to practitioners delivering this treatment, to those who may wish to refer patients for SCS, and to those who care for patients with stimulators in situ. The recommendations also provide a resource for organisations that fund SCS. This guideline has drawn on the guidelines recently published by the British Pain Society, and parts of which have beenreproduced with the society’s permission. These recommendations have been produced by a consensus group of relevant healthcare professionals. Opinion from outside the consensus group has been incorporated through consultation with representatives of all groups for whom these  recommendations have relevance. The recommendations refer to the current body of evidence relating to SCS. The consensus group wishes to acknowledge and thank the task team of the British Pain Society for their help and input into this document

A Countermeasure for Space Motion Sickness

Overall, the results obtained in both the U.S. and the Russian space programs indicate that most space crews will experience some symptoms of motion sickness (MS) causing significant impact on the operational objectives that must be accomplished to assure mission success. At this time the primary countermeasure for MS requires the administration of Promethazine. Promethazine is not a benign drug, and is most frequently administered just prior to the sleep cycle to prevent its side effects from further compromising mission objectives. Clearly other countermeasures for SMS must be developed. Currently the primary focus is on two different technologies: (1) developing new and different pharmacological compounds with less significant side effects, (2) preflight training. The primary problem with all of these methods for controlling MS is time. New drugs that may be beneficial are years from testing and development, and preflight training requires a significant investment of crew time during an already intensive pre-launch schedule. Granted, motion sickness symptoms can be minimized with either of the two methods detailed above, however, it may be possible to develop a countermeasure that does not require either extensive adaptation time or exposure to motion sickness. Approximately 25 years ago Professor Geoffrey Melvill Jones presented his work on adaptation of the vestibuloocular reflex (VOR) using optically reversed vision (left-right prisms) during head rotations in the horizontal plane. It was of no surprise that most subjects experienced motion sickness while wearing the optically reversing prisms. However, a serendipitous finding emerged during this research showing that the same subjects did not experience motion sickness symptoms when wearing the reversing prisms under stroboscopic illumination. The mechanism, by which this side-effect was believed to have occurred, is not clearly understood. However, the fact that no motion sickness was ever noted, suggests the possibility of producing functionally useful adaptation during space flight without the penalty of disabling motion sickness by controlling the rate of the adaptive process by means of an appropriate stroboscopically presented environment. After several recent meetings with Professor Melvill Jones, we were encouraged to repeat the motion sickness portions of his and Mandl's 1981 stroboscopic experiment. In conducting this experiment we used a randomized cross-over design where subjects were randomly assigned to either a stroboscopic flash or no strobe for their first exposure in the experimental design. Twenty subjects (19 subjects completed the study) read a short passage from Treasure Island mounted on the wall approximately 1 m from their eyes while wearing left-right reversing prisms. The strobe on time of 3 microseconds and flash frequency of 4 Hz was set to equal that used in the original study. Motion sickness was scored using a modified Miller and Graybiel scale that we constructed to include symptoms that may be elicited under conditions where reversing prisms are worn. On this scale a score of 5 represented Malaise IIa (mild motion sickness) and a score of 8 or above is approaching frank sickness. Symptoms were tracked and recorded every 5 min during the task. Testing was limited to 30 min unless the subject had reached the MIIa score, at which time the test was terminated. Performance under stroboscopic illumination was significantly better than when the subjects read under normal room illumination while wearing the left-right reversing prisms. Based on these results we developed a goggle system using LCD material that can be strobed. To evaluate the effectiveness of stroboscopic goggles we tested an additional 9 subjects in addition to retesting 10 used in the stroboscopic pilot study described above. These 19 subjects wore a pair of strobing LCD goggles that could be cycled at 4 Hz. These subjects wore the goggles while also wearing left-right reversg prisms. Results while wearing the goggles showed that none of the 19 subjects scored at the MIIa level on the motion sickness rating scale. When the goggles did not flash (no strobe), 11 of the 19 developed symptoms above the MIIa criteria. As a countermeasure the goggles seem to be effective, even with an on time of 10 msec (time the goggles are clear). We have also collected anecdotal data, from our personnel in the Neuroscience Laboratory at the Johnson Space Center, suggesting that the goggles may effective in preventing carsickness

Spinal cord stimulation for the management of pain: Recommendations for best clinical practice

Spinal cord stimulation (SCS) is an accepted method of pain control. SCS has been used for many years and is supported by a substantial evidence base. A multidisciplinary consensus group has been convened to create a guideline for the implementation and execution of an SCS programme for South Africa (SA). This article discusses the evidence and appropriate context of SCS delivery, and makes recommendations for patient selection and appropriate use. The consensus group has also described the possible complications following SCS. This guideline includes a literature review and a summary of controlled clinical trials of SCS. The group notes that, in SA, SCS is performed mainly for painful neuropathies, failed back surgery, and chronic regional pain syndrome. It was noted that SCS is used to treat other conditions such as angina pectoris and ischaemic conditions, which have therefore been included in this guideline. These recommendations give guidance to practitioners delivering this treatment, to those who may wish to refer patients for SCS, and to those who care for patients with stimulators in situ. The recommendations also provide a resource for organisations that fund SCS. This guideline has drawn on the guidelines recently published by the British Pain Society, and parts of which have been reproduced with the society’s permission. These recommendations have been produced by a consensus group of relevant healthcare professionals. Opinion from outside the consensus group has been incorporated through consultation with representatives of all groups for whom these recommendations have relevance. The recommendations refer to the current body of evidence relating to SCS. The consensus group wishes to acknowledge and thank the task team of the British Pain Society for their help and input into this document

Extraforaminal ligament attachments of the thoracic spinal nerves in humans

An anatomical study of the extraforaminal attachments of the thoracic spinal nerves was performed using human spinal columns. The objectives of the study are to identify and describe the existence of ligamentous structures at each thoracic level that attach spinal nerves to structures at the extraforaminal region. During the last 120 years, several mechanisms have been described to protect the spinal nerve against traction. All the described structures were located inside the spinal canal proximal to the intervertebral foramen. Ligaments with a comparable function just outside the intervertebral foramen are mentioned ephemerally. No studies are available about ligamentous attachments of thoracic spinal nerves to the spine. Five embalmed human thoracic spines (Th2–Th11) were dissected. Bilaterally, the extraforaminal region was dissected to describe and measure anatomical structures and their relationships with the thoracic spinal nerves. Histology was done at the sites of attachment of the ligaments to the nerves and along the ligaments. The thoracic spinal nerves are attached to the transverse process of the vertebrae cranial and caudal to the intervertebral foramen. The ligaments consist mainly of collagenous fibers. In conclusion, at the thoracic level, direct ligamentous connections exist between extraforaminal thoracic spinal nerves and nearby structures. They may serve as a protective mechanism against traction and compression of the nerves by positioning the nerve in the intervertebral foramen

Report on the marine Mollusca obtained during the first expedition of Prof. A. C. Haddon to the Torres Straits in 1888-89

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Trauma-intrusive hallucinations and the dissociative state

Background Research has supported a model of dissociation mediating the experience of hearing voices in traumatised individuals. Aims To further understand this model by examining subtypes of the dissociative experience involved in trauma-intrusive hallucinations. Method The study involved four hospitals, 11 psychiatrists and 69 participants assessed using the Psychotic Symptoms Rating scale, the PTSD Symptoms Scale Interview and the Dissociative Subtype of PTSD Score Results In total, 59% (n = 41) of the participants heard voices and they were compared with the 41% (n = 28) who did not. The severity of PTSD symptoms did not predict experience of hearing voices. Regression analysis indicated that two scales of dissociation (derealisation/depersonalisation and loss of awareness) were equally good predictors of the extent of hearing voices. Adding other possible predictors (age of trauma <18, sexual violence) was relevant but did not enhance the prediction. Conclusions This research supports the proposal that trauma-intrusive voices are mediated by symptoms of dissociation. The supported model describes general, rather than trauma specific, symptoms of dissociation mediating the experience of hearing voices. The concept of anchoring is discussed and suggests a potential treatment strategy, which could be useful in the clinical management of hearing voices

Stereotactic proton beam therapy for intracranial arteriovenous malformations

Purpose: To investigate hypofractionated stereotactic proton therapy of predominantly large intracranial arteriovenous malformations (AVMs) by analyzing retrospectively the results from a cohort of patients. Methods and Materials: Since 1993, a total of 85 patients with vascular lesions have been treated. Of those, 64 patients fulfilled the criteria of having an arteriovenous malformation and sufficient follow-up. The AVMs were grouped by volume: <14 cc (26 patients) and <14 cc (38 patients). Treatment was delivered with a fixed horizontal 200 MeV proton beam under stereotactic conditions, using a stereophotogrammetric positioning system. The majority of patients were hypofractionated (2 or 3 fractions), and the proton doses are presented as single-fraction equivalent cobalt Gray equivalent doses (SFEcGyE). The overall mean minimum target volume dose was 17.37 SFEcGyE, ranging from 10.38-22.05 SFEcGyE. Results: Analysis by volume group showed obliteration in 67% for volumes <14 cc and 43% for volumes <14 cc. Grade IV acute complications were observed in 3% of patients. Transient delayed effects were seen in 15 patients (23%), becoming permanent in 3 patients. One patient also developed a cyst 8 years after therapy. Conclusions: Stereotactic proton beam therapy applied in a hypofractionated schedule allows for the safe treatment of large AVMs, with acceptable results. It is an alternative to other treatment strategies for large AVMs. AVMs are likely not static entities, but probably undergo vascular remodeling. Factors influencing angiogenesis could play a new role in a form of adjuvant therapy to improve on the radiosurgical results. © 2005 Elsevier Inc.Articl