Rupert Reichart's research while affiliated with Universitätsklinikum Jena and other places

Background Prialt® was approved by the European Medicine Agency in February 2005. Besides morphine, it is the only analgesic approved for long-term intrathecal infusion in the treatment of chronic pain. As it does not bind to opioid receptors, its use in the treatment of chronic pain seemed to be safer and to lead to less adverse events compared with morphine. However, it is an orphan drug and studies of its long-term use are rare.QuestionsWhat role does Prialt® play in the treatment of chronic pain compared with other analgesics given intrathecally? What impact do the initial dose and the rate of infusion have on the analgesic effect and on the incidence of side effects?Material and methodsMedical reports were used to identify all patients receiving ziconotide monotherapy from February 2005 to the end of the analysis period in October 2018 in our department. Furthermore, a questionnaire was created and given to the patients to find out more about their experience with ziconotide.ResultsThe study included 12 patients, all of whom suffered from at least one adverse event. The most common adverse events were forgetfulness and paraesthesia, each affecting 25% of the patients. One third of the patients discontinued ziconotide therapy due to severe adverse events. The mean initial dose was 1.98 µg/day.DiscussionZiconotide was used at the Jena University Hospital according to the latest guidelines. Nevertheless, morphine and other opioid analgesics are still more frequently used in the intrathecal management of chronic pain. There are various reasons for this, but the narrow therapeutic index, the high incidence of adverse events, and the difficulties in finding the right dose are among the most important.

Chronic pain syndromes caused by degenerative and post‐infectious changes in the cervical spine continue to pose significant management challenges to neurosurgeons and pain practitioners. The identification of an individualized treatment plan, astute surgical technique, comprehensive and multimodal analgesia and adequate rehabilitation processes do not necessarily result in diminished pain. We present the case of a chronic pain patient treated surgically for degenerative cervical myelopathy secondary to cervical spinal stenosis. Following this surgery, the patient experienced an intractable postoperative pain syndrome that had anatomical borders, an intensity and a character that was different to the background chronic pain from which they suffered. We successfully implanted a cervical spinal cord stimulation (SCS) lead in the period following their stenosis surgery, which had good therapeutic effect on the postoperative‐onset pain. To the best of our knowledge, this is the first description of SCS having a strong positive effect on an acute exacerbation of neuropathic pain. At follow‐up 12 months later, assessment of the patient's pain diary revealed a modal pain intensity of NRS 3/10 over the preceding three months. The Brief Pain Inventory (Short Form) scores at this point in time were 10/40 in the pain severity domain and 18/70 in the interference with function domain, demonstrating the long‐term effectiveness of this SCS strategy. While SCS has hitherto been untested as a therapy for acute‐onset pain, this report demonstrates its utility as a salvage treatment in select cases of uncontrollable postoperative pain. This article is protected by copyright. All rights reserved.

Erratum zu: Schmerz 2017 10.1007/s00482-017-0259-1 Liebe Leserinnen und Leser, bitte beachten Sie, dass die zunächst online veröffentliche Version dieses Artikels korrigiert wurde. Die ehemalige Tab. 1 ist entfallen und die Angaben zu den ethischen Richtlinien wurden angepasst. Der …

Objective This prospective study evaluated the time to response and outcomes of navigated repetitive transcranial magnetic stimulation (TMS) at a frequency of 10 Hz in patients with chronic neuropathic pain. Methods This prospective study included patients with unilateral chronic neuropathic pain. All patients received motor cortex stimulation at 10 Hz over nine consecutive days using repetitive TMS. Outcome was evaluated over a six-week follow-up period using the visual analogue scale, the German Pain Questionnaire and time to pain reduction. Results Fifty patients (23 female, 27 male) were recruited. Two patients were excluded from analysis owing to premature discontinuation of treatment and follow-up. 31/48 patients in the cohort suffered from atypical facial pain. The pain duration ranged approximately from six months to 27 years. After six weeks, 28/46 patients reported a significant level of pain relief (P < 0.001). Conclusion Navigated repetitive TMS for chronic pain is a non-invasive modality with demonstrable clinical benefit. In particular, patients with atypical facial pain with a clear clinicoanatomical correlate responded well to high-frequency stimulation. Patients with a mean pain history of less than five years benefited significantly from this treatment, so early treatment with repetitive TMS should be encouraged.

Background: Subcutaneous peripheral nerve field stimulation (sPNFS) is an established procedure for the treatment of chronic localized neuropathic pain of peripheral origin. The treatment of nummular headache primarily focuses on conservative methods with limited prospects of success. The role of sPNFS in the treatment of nummular headache has not been investigated as yet. Question: Is the sPNFS an option in the management of nummular headache? Materials and methods: In addition to a summary of established methods in the treatment of nummular headache, sPNFS as a possible form of therapy is discussed. Results: A positive effect of sPNFS in terms of the treatment of nummular headache is shown. Discussion: sPNFS stimulates free subcutaneous nerves and transmits a pleasant form of paraesthesia in the area of pain. If regular conservative therapy has already been exhausted, then sPNFS might be an effective new option in the treatment of nummular headache. sPNFS is a minimally invasive and low-risk procedure. However, the high treatment cost and restrictions regarding fitness to undergo MRI are points of criticism. Further studies are needed to define its potential and role in the treatment of nummular headache.

Background: Poverty is an important problem in Germany. The health effects of poverty can lead to a higher risk of disease and the arising of chronic affections. On the other hand chronic illness may support the development and continuance of poverty. The context of chronic pain and poverty has not been analyzed so far. Objectives: We investigated the correlation between chronic pain and poverty. Materials and methods: In a prospective manner we interviewed 20 patients with pain syndromes during our consultation hour regarding their household income. Further, data from the German Federal Statistical Office were analyzed with respect to the correlation between the incidence of a chronic pain diagnosis and household income. Results: At 1546 €, the average household income of the patients studied was below the poverty level. The analyzed data showed that women suffered from chronic pain more often than men did and also had a lower income. Another economic inequality was found between Eastern and Western Germany. There was a statistically significant correlation between income and the incidence of the diagnostic codes for chronic pain (R52.1, 2, 9) for men. Conclusion: Our investigation showed the correlation between chronic pain and poverty. A commitment and cooperation of German medical associations and federal politics is necessary to overcome this sociopolitical issue.

Introduction The correct positioning of spinal cord stimulator leads is assessed radiographically during their percutaneous implantation for trial stimulation. Usually the C-arm is repositioned several times to allow imaging in different planes, which may extend the total duration of surgery. The study aimed to evaluate whether the concurrent intraoperative use of two C-arms could safely reduce the duration of surgery. Materials This retrospective study included cases of percutaneous implantation of an SCS lead for trial neurostimulation between 2006 and 2011. The duration of the surgical intervention was recorded, along with the duration of the preparation stage in the operating room (OR). In addition, total radiation exposure time per case was recorded. Results 94 patients underwent percutaneous implantation of an SCS lead (72 thoracolumbar, 22 cervical). In 73 cases two C-arms were used, with 21 cases performed with a single C-arm. In the both the cervical and thoracolumbar groups, a biplanar configuration was associated with a significant reduction in the mean length of the surgical phase, by 29 minutes (p=0.017) and 14 minutes respectively (p=0.016), albeit while increasing the duration of the preoperative preparation stage. There was no significant difference in the total duration in the OR or in the total radiation exposure time between groups. Conclusions Here we present a technical note on the use of a biplanar fluoroscopy configuration for percutaneous implantation of SCS leads. This arrangement correlated with a reduction in surgery duration without increasing total radiation exposure, representing a practical and safe adjustment to current practice.

Background Spinal cord stimulation (SCS) is an established procedure for treatment of chronic neuropathic pain of peripheral origin. The efficacy of SCS in case of central poststroke pain (CPSP), especially thalamic pain, has not been adequately proven. Objectives The efficacy of SCS as an extracranial neurostimulation method for the management of central pain syndrome was investigated. Materials and methods In this study, relevant pharmacological and nonpharmacological measures for central pain management were reviewed. A case of successful SCS for thalamic pain after ischemic insult is presented. Explanatory approaches of pathophysiological processes and a review of the current literature underline our results. Results In the case presented, SCS was found effective in the treatment of thalamic pain. Conclusion The efficacy of SCS might be caused by segmental and supraspinal processes and collaboration of activating and inhibiting pathways. The integrity of the spinothalamic tract is mandatory. SCS is a treatment option for central pain syndrome, especially thalamic pain. Comparable studies confirm the potency of this technique. In contrast to other neuromodulation procedures spinal cord stimulation is less invasive, has a lower perioperative risk and is often less expensive. Further studies are needed to define its potential and role in the treatment of thalamic pain.

Introduction Chronic neuropathic disorders remain difficult to treat. Analgesic medication often achieve only an insufficient effect, therefore other non-pharmacological treatment has to be considered. One option for management of intractable pain is stimulation of the motor cortex by implantation of an epidural electrode. This effect of invasive stimulation could be replaced by transcranial magnetic stimulation. Objectives The objective of the study was to observe the pain reducing effect of non-invasive transcranial magnetic stimulation (rTMS) in patients suffering from different types of chronic neuropathic pain. Materials and methods The study was prospective. We included patients suffering from chronic pain syndroms, such chronic facial pain, poststroke pain, phantom pain and FBSS. The corresponding primary motor cortex has been stimulated with high-frequent, repetitive transcranial magnetic stimulation (rTMS). Stimulation was daily repeated. The individual pain level was assessed by the visual analogue scale (VAS) and documented daily for three weeks. The first follow up was done after 6 weeks. Results We included 45 patients (24 female/21 male) between 31 and 78 years of age. The follow up was done at least after six weeks, further intervals were determined individually with a maximum follow up time of 4 years. A pain reduction in terms of a decrease in the VAS scale was obtained in 58% of patients over all groups, ranging from 2 to 8 points on VAS with a mean value of 3,6. Regarding the etiology of pain we observe a responding rate of 72% in the facial pain group, 40% in the poststroke pain group, 25% in the FBSS group and no responding in the phantom pain group. The pain reduction occurred with a delay between 4 days and 3 weeks, and showed a long term effect up to 10 months. Conclusion Non-invasive transcranial magnetic stimulation seems to be applicable for neuropathic pain syndromes. In chronic facial pain we could observe a higher responding rate than in any other chronic pain syndrome. Pain reduction has a long term effect, which outlast the stimulation period.