Migraine is one of the main causes of disability in modern world. Treatment of chronic refractory migraine (RCM) would be a challenge even for experienced physician. The aim of this study was to analyze the effect of combination therapy for RCM: greater occipital nerve’s (GON) pulsed radiofrequency (PRF) and botulinum toxin injections. We observed 6 female patients, suffering from RCM according to the European Headache Federation criteria. All patients had long history of migraine (5–44 years) with conservative treatment failure (at least three medication groups). Their migraine could be classified as refractory for long period of time (1–10 years). All of our patients passed a combination of PRF and BTA injection as consecutive 1-day treatments. Botulinum toxin type A injections were done in accordance to the PREEMPT protocol, followed by ultrasound-guided PRF of GONs bilateral. The observation period was 6 months after the procedure. We observed a positive response to treatment in all patients with dramatic reduction of pain intensity (from 7 ± 1 to 2 ± 2 on NRS scale) and significant decrease in the number of headache days (from 22 ± 5 to 4 ± 4) during first month after treatment. Two patients (30%) were pain free after the treatment until the end of the observation. No adverse effects were registered. Bilateral GON’s PRF followed by botulinum toxin therapy as 1-day treatment may be a useful option for the treatment of refractory chronic migraine. These interventional procedures are effective, minimally invasive, inexpensive, safe, and well-tolerated and can be performed on an outpatient basis.
BackgroundFour-dimensional (4D) ultrasound scanning (3D real-time mode) can improve the orientation of the anatomy of the area of interest and navigation by controlling the needle position. The objectives of this study were to identify the optimal technique for navigation and to assess clinically the efficacy of 4D ultrasound navigation for epidural anaesthesia at lower thoracic and lumbar levels.DesignSingle-centre case series study was performed.MethodsSixteen patients were included. First, conventional 2D scanning was performed, followed by 4D reconstruction, and the basic tissues with high acoustic impedance (bone structures) and available acoustic windows were determined. Movement of the needle was controlled on the sagittal plane in 2D mode and at the same time in 4D mode (3D real-time mode). To improve the visibility of the needle, the 3D reconstruction was rotated during manipulation.ResultsThe 4D scanning mode provided 100 % visibility of compact bone tissues and 93 % visibility of the posterior complex. Needle visualisation strongly depended on the rotation of the reconstructed image with the sensor remaining motionless. The needle was redirected in one patient (7 %) because it was in contact with the vertebral lamina. Dilation of the epidural space during saline injection was observed in five patients (36 %). A change in the puncture level was not required any patients; no complications associated with epidural puncture were observed.ConclusionsUltrasound navigation in 4D could improve epidural anaesthesia due to the enhanced spatial orientation of the operator. The technique of “position contrast” should be used for reliable needle visualisation.Electronic supplementary materialThe online version of this article (doi:10.1007/s40477-014-0150-1) contains supplementary material, which is available to authorized users.
Background: Radicular pain is one of the most common types of pain, with an approximate prevalence ranging from 13 to 40%. The most common cause of radicular pain is a herniated disk or degenerative stenosis in the paramedian zone of the spinal canal, with damage to the nerve root above the foramina. Objective:The aim of this retrospective study was to evaluate the efficacy of epidural pulsed radiofrequency (PRF) in the treatment of radicular pain after failed epidural steroid injection (ESI) and dorsal root ganglion pulsed radiofrequency (DRG-PRF) attempts.Methods: Epidural pulsed radiofrequency was performed on seven patients suffering from radicular pain in L3-S1 dermatomes with anatomical causes, which correlated with the clinical evaluation and radiological findings. PRF was applied in monopolar mode with the following characteristics: frequency 2 Hz (20 ms pulse, 480 ms pause), amplitude 65V, exposure time 360 sec, temperature in the action zone not exceeding 42 degrees Celsius. Results:The effect duration lasted from 4 months to more than one year in 4 patients. The minimum time to relapse was less than 2 weeks, with a maximum duration of more than a year. The absence of pain allowed responders to discontinue basic analgesic therapy. Increasing the activity, rated by them as "substantial" (3 QoL points or more) a month after the procedure, was noted by 5 patients.A year later, the improvement was maintained in 4 patients. Limitations:The main limitation of this study is the small sample size of heterogeneous patients and the absence of a comparison group. Conclusions:Our findings suggest that the epidural PRF is a useful option for treating radicular pain after unsuccessful attempts of the ESI and PRF of DRG for long-term effects. Efficacy of an ePRF can depend not only on the stimulation parameters but also on the point of action.
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