Conventional radiofrequency treatment in five patients with trigeminal neuralgia

Introduction: In trigeminal neuralgia, when drug treatment proves ineffective, other management options must be considered. In this context, conventional radiofrequency of Gasser's ganglion is a safe and effective alternative. Material and Methods: We describe 5 patients with long-evolving trigeminal neuralgia subjected to conventional radiofrequency according to the Sweet technique, with a follow-up of two years. Results: Pain relief was complete after two months in all cases. One patient suffered an unexpected episode of nausea, vomiting and foul odor sensation that subsided after three days of rest and drug treatment. Three patients described non-painful hypoesthesia in the region of the treated nerve branch that subsided within three months. The patients remained free of symptoms over long-term follow-up. In one case the same radiofrequency technique had to be repeated after 21 months because of the reappearance of symptoms in the same zone, followed by immediate pain relief. Conclusions: In our series of patients trigeminal neuralgia was not controlled by drug treatment, and conventional radiofrequency targeted to Gasser's ganglion proved very effective, with no major complications

Hemodynamic and ventilatory changes during implant surgery with intravenous conscious sedation

Purpose: This study was conducted to determine the hemodynamic and ventilatory changes during implant surgery with intravenous conscious sedation, and whether preoperative anxiety, gender or age influence these parameters. Patients and Methods: A prospective study carried out between May 2004 and February 2007, on 102 patients treated with dental implants under local anesthesia and conscious intravenous sedation. Patients completed a questionnaire prior to surgery to evaluate preoperative dental anxiety using Corah's scale. The hemodynamic and ventilatory changes were evaluated by monitoring systolic pressure (SP), diastolic pressure (DP), heart rate (HR) and oxygen saturation (SaO2). These values were collected at 5 points during surgery; before commencing the operation (baseline value), during local anesthetic injection, at the moment of incision and raising of a mucoperiosteal flap, during implant placement, and finally at suturing. Intravenous conscious sedation was administered between baseline value and injection of the local anesthetic. Results: The highest SP and DP were recorded at baseline and at suturing. The highest HR was recorded at the moment of incision and raising of the mucoperiosteal flap; the lowest SaO2 was recorded at local anesthetic injection. There was no relationship between hemodynamic and ventilatory values and preoperative anxiety or gender. A greater age was associated with higher SP and lower SaO2, these differences being statistically significant. Conclusions: Most of the cardiovascular and ventilatory changes induced by the implant surgery with intravenous conscious sedation were within normal ranges. The results indicate that midazolam with fentanyl do not produce important hemodynamic and ventilatory changes, being a good association for intravenous conscious sedation in dental implant surgery. © Medicina Oral S. L

Relationship between preoperative anxiety and postoperative satisfaction in dental implant surgery with intravenous conscious sedation

Purpose: To study if patient preoperative anxiety is related to age and gender and to compare preoperative anxiety with postoperative patient and surgeon satisfaction in dental implant surgery under intravenous conscious sedation. Materials and Methods: Dental implants were placed in 102 patients under local anesthesia and intravenous conscious sedation. The procedures were performed with or without dental extractions, and with or without bone regeneration. Anxiety was evaluated using Corah?s Dental Anxiety Scale and levels of surgeon and patient satisfaction were evaluated on an adapted scale. Results: Low preoperative anxiety was observed in 27.8% of patients, moderate in 50%, and high in 22.2%. Mean value of anxiety was 9.8+/-3.7. The level of surgeon satisfaction was adequate in 87.8% of the surgeries; patients were awake and nervous in 4.4% of surgeries, and excessively sleepy, with little cooperation in 7.8% of surgeries. Regarding patient satisfaction, the procedure was comfortable for 23.3% of patients, neither comfortable nor uncomfortable for 28.9%, a slightly uncomfortable experience for 36.7%, and very uncomfortable for 10% of patients. Younger patients and women were observed to have more anxiety, the difference being statistically significant. Patients with higher preoperative anxiety expressed a lower level of satisfaction, with statistically significant differences. There was no significant relationship between preoperative patient anxiety and postoperative surgeon satisfaction. Conclusion: Anxiety was higher in younger patients and women. In this study, a higher preoperative patient anxiety was associated with lower patient satisfaction, but had no influence on postoperative surgeon satisfaction

Radiofrequency treatment of cervicogenic headache

Objectives: In the clinical management of facial pain, a possible cervical origin must be considered. A clinical exploration is therefore essential. The disorder originates in the intimate connections between the cranial portion of the spinal cord and the trigeminal system. Although solid evidence supporting the use of radiofrequency (RF) treatment is lacking, it remains one of the management options to be taken into account. The present study evalu - ates the efficacy of RF in application to cervicogenic headache. Study design: We present three cases of severe facial pain arising from different cervical structures. Results: In two cases the pain originated in cervical roots C2 and C3, while in the third patient the trigger point was located at the level of the atlantoaxial joint. Pulsed RF was applied for 4 minutes at the dorsal ganglion of C2 and C3 in the first two cases, and for 8 minutes at intraarticular level in the third patient. The pain gradually sub - sided during the first month in all cases. The first two patients reported 70% improvement after one month, 60% improvement after 6 months, and 30-50% after one year, versus baseline. The third patient reported complete pain resolution lasting approximately 5 months, after which the pain reappeared with the same intensity as before. Conclusions: Radiofrequency is a satisfactory treatment option, affording adequate analgesia, though the effects are sometimes temporary

Application of machine learning algorithms in thermal images for an automatic classification of lumbar sympathetic blocks

Purpose There are no previous studies developing machine learning algorithms in the classification of lumbar sympathetic blocks (LSBs) performance using infrared thermography data. The objective was to assess the performance of different machine learning algorithms to classify LSBs carried out in patients diagnosed with lower limbs Complex Regional Pain Syndrome as successful or failed based on the evaluation of thermal predictors. Methods 66 LSBs previously performed and classified by the medical team were evaluated in 24 patients. 11 regions of interest on each plantar foot were selected within the thermal images acquired in the clinical setting. From every region of interest, different thermal predictors were extracted and analysed in three different moments (minutes 4, 5, and 6) along with the baseline time (just after the injection of a local anaesthetic around the sympathetic ganglia). Among them, the thermal variation of the ipsilateral foot and the thermal asymmetry variation between feet at each minute assessed and the starting time for each region of interest, were fed into 4 different machine learning classifiers: an Artificial Neuronal Network, K-Nearest Neighbours, Random Forest, and a Support Vector Machine. Results All classifiers presented an accuracy and specificity higher than 70%, sensitivity higher than 67%, and AUC higher than 0.73, and the Artificial Neuronal Network classifier performed the best with a maximum accuracy of 88%, sensitivity of 100%, specificity of 84% and AUC of 0.92, using 3 predictors. Conclusion These results suggest thermal data retrieved from plantar feet combined with a machine learning-based methodology can be an effective tool to automatically classify LSBs performance

El ganglio simpático lumbar como objetivo terapéutico específico en el Síndrome de Dolor Regional Complejo en Miembro Inferior. La termografía como herramienta de soporte para optimizar la precisión del bloqueo. Relevancia clínica de su uso

Introducción: El Síndrome de Dolor Regional Complejo (SDRC) abarca una sintomatología muy variada que precisa de un tratamiento que se ajuste a cada paciente en función de su estadio evolutivo. Los bloqueos simpáticos constituyen una herramienta recomendable, sin embargo, la falta de eficacia demostrada en la literatura le resta validez. Nuestro trabajo describe los resultados clínicos de una serie de bloqueos simpáticos lumbares realizados bajo control radioscópico y termográfico (TIR) en un grupo de pacientes afectos de SDRC en miembro inferior. Este trabajo fue completado con un estudio morfológico en 4 cadáveres. Material y métodos: 27 pacientes con SDRC tipo I en miembro inferior fueron sometidos a una serie de 3 bloqueos simpáticos lumbares a nivel de L4 con anestésicos locales y corticoides, utilizando la TIR como herramienta de soporte intraprocedimental. Se recogieron una serie de variables clínicas en el momento basal, antes de cada bloqueo, al mes, 3 y 6 meses tras los bloqueos mediante un protocolo estandarizado. Asimismo, se tuvieron en cuenta otras variables evolutivas. En el estudio anatómico se realizaron 2 bloqueos simpáticos en 4 cadáveres frescos, bajo control radioscópico a nivel del cuerpo vertebral de L2 y de L4 contralateral. Se les inyectó un medio de contraste y posteriormente fueron diseccionados. Describimos la anatomía de la cadena simpática y la distribución del contraste. Resultados: Un 23,75% de los bloqueos requirieron alguna recolocación para conseguir el patrón termográfico deseado. Hubo un descenso en el dolor medido mediante la escala analógica visual en todos los momentos comparándolo con los valores basales, pero sólo un 37% fueron categorizados como respondedores, definido por un descenso del EVA ≥ 30% con desaparición del dolor en reposo. Observamos una mejora en la mayoría de las variables clínicas registradas tales como parestesia, edema, asimetría térmica y de color percibida, y sudoración, así como una mejora de la limitación funcional. La única variable relacionada con la probabilidad de ser respondedor fue el tiempo de inmovilización reducido. En el estudio anatómico encontramos un ganglio simpático a cada nivel vertebral, bilateralmente, con una morfología fusiforme y tamaños heterogéneos. Constatamos la variabilidad de la posición, aunque lo más frecuente en nuestra disección fue, para el ganglio simpático de L2 y L3 la mitad superior de la vértebra, y la mitad inferior para L4. La distribución del contraste fue predominantemente en sentido craneocaudal a nivel de L2, y con mayor componente transversal en L4. Las imágenes radioscópicas obtenidas durante el procedimiento no representaban con exactitud el alcance de la solución de contraste. Conclusión: En nuestra serie de bloqueos simpáticos lumbares, la tasa de respondedores fue de un 37%. Por otra parte, en base a nuestros hallazgos anatómicos, nuestra recomendación es realizar los bloqueos simpáticos a nivel de la 3ª ó 4ª vértebra lumbar, mediante un abordaje extraforaminal y evitando la parte medial del margen anterolateral del cuerpo vertebral. Si consideramos como respuesta favorable no sólo la disminución global del dolor, sino la desaparición de los síntomas satélites del SDRC y la mejoría de otras escalas que miden la evolución del síndrome, y ante la ausencia de complicaciones reseñables, el bloqueo simpático lumbar realizado bajo control radioscópico e implementado con la TIR que certifique los cambios de temperatura ocurridos a tiempo real, resulta recomendable.Introduction: Complex Regional Pain Syndrome (CRPS) encompasses a widely varied symptomatology which requires a multidisciplinary treatment that is adjusted to each patient based on their evolutionary stage. Sympathetic blocks are a recommended tool, however, the lack of efficacy demonstrated in the literature tends to give it a secondary role. Our work describes the clinical results of a series of lumbar sympathetic blocks performed under radioscopic and thermographic control (TIR) in a group of patients with CRPS in the lower limb. This work was completed with a morphological study in 4 cadavers. Material and methods: 27 patients with CRPS type I in the lower limb, with severe pain and functional limitation, underwent a series of 3 lumbar sympathetic blocks at the L4 level with local anesthetics and corticosteroids, using infrared thermography as an intraprocedural support tool. A series of clinical variables were collected at baseline, prior to each block, and one, three and six months after the blocks, in a standardized checklist that assessed each of the clinical categories of CRPS stipulated in the Budapest criteria. In addition, other evolutionary variables were considered. Moreover, in the anatomical study, 2 simulated sympathetic blocks were performed in 4 fresh human cadavers, cryopreserved, under radioscopic control at the level of the L2 vertebral body and the contralateral L4 body. Dye was injected, and the areas were dissected following a specific protocol. We then describe the anatomy and the dye's spread compared to the contrast medium's spread on fluoroscopy. Results: 23,75% of the blocks required some repositioning to achieve the desired thermographic pattern. A decrease in pain measured on a visual analogic scale was observed at all time points compared to pre-blockade data, but only 37% of the cases were categorized as responders, representing a ≥ 30% decrease in VAS, with the disappearance of pain at rest. An improvement of most of the clinical variables recorded was observed, such as tingling, edema, perception of thermal asymmetry, difference in colouring and sweating, and an improvement of functional limitation. Logistic regression analysis showed the main variable to explain the probability of being a responder was immobilization time (odds ratio of 0.89). In the anatomical study, we found a sympathetic ganglion at each vertebral level, bilaterally, with a fusiform morphology and heterogeneous sizes. We verified the variability of the position, although the most frequent in our dissection was, for the sympathetic ganglion of L2 and L3, the upper half of the vertebra, and the lower half for L4. Contrast distribution was predominantly in the craniocaudal direction at the level of L2, and with a greater transverse component at L4. The radioscopic images obtained during the procedure did not accurately represent the extent of the contrast solution. Conclusion: In our series of lumbar sympathetic blocks, the responder rate was 37%. On the other hand, based on our anatomical findings, our recommendation is to perform sympathetic blocks at the level of the 3rd or 4th lumbar vertebrae, using an extraforaminal approach and avoiding the medial part of the anterolateral margin of the vertebral body. If we consider as a favorable response not only the global decrease in pain, but also the disappearance of CPRS’s satellite symptoms, and the improvement of other scales that measure the evolution of the syndrome, noting the absence of significant complications, the lumbar sympathetic block performed under radioscopic control and implemented under IRR, which certifies changes in temperature that have occurred in real time, is recommended