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Endometriosis is best regarded as a chronic disease that can vary in symptomatology over time. Endoscopic therapy for relief of pelvic pain as well as infertility is a therapeutic option. The formation of a rational treatment plan before surgery will ensure a minimum number of reproductive surgeries over the patient's lifetime.
STUDY OBJECTIVE: To evaluate the effectiveness of laparoscopic surgical treatment for women with chronic pelvic pain. DESIGN: Prospective evaluation of women treated consecutively between January 1, 1989, and December 31, 1992. SETTING: A private practice. PATIENTS: One hundred women with chronic pelvic pain. INTERVENTIONS: Laparoscopic treatment was performed in all patients. Pain level was rated on a scale of 1 to 10 (1 = no pain, 10 = severe, disabling pain). Patients recorded their pain levels before and 1 month, 3 months, and 6 months after surgery, as well as at intervals of 1, 2, and 3 years after surgery. MEASUREMENTS AND MAIN RESULTS: Preoperatively, the average pain level reported by the patients was 8.2. At 1 month after laparoscopic surgical therapy, it had dropped to 3.6, at 6 months to 1.9, and at 3 years to 2.2. Twenty patients reported pain levels of 5 or greater at the 6-month interval. Six of them proceeded to hysterectomy, and four of these six were found to have adenomyosis. Eleven of the 100 who had pain levels greater than 5 after initial procedure had no further therapy, and 3 underwent repeat laparoscopy. CONCLUSION: Extensive laparoscopic surgery to restore normal pelvic anatomy and remove all diseased tissue, including treatment of all endometriosis, resection of ovarian cysts, resection of adhesions, removal of the appendix, and treatment of hernias when indicated, together with laparoscopic uterosacral nerve vaporization or presacral neurectomy, results in significant improvement in reported pain levels.
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During the period from September 1990 to March 1992, 155 nerve blocks were performed for 125 patients as part of the clinical management of pain due to malignant disease. The efficacy, in terms of pain score reduction, and spontaneously reported side effects secondary to these procedures were prospectively audited. Neural blockade was undertaken in accordance with strict clinical criteria, and medication was optimized with the aim of achieving maximum analgesia with minimum side effects at all times. Pain was assessed before the block, 24 hours after the block and at follow-up (two to six weeks) using visual analogue scores or verbal rating scales. All patients were audited. The total (all patients, all blocks) median (lower-upper quartile) pain score dropped from 8 (6-10) cm before the block to 2 (0-4) cm at 24 hours after the block (p < 0.05) and to 1 (0-4) cm at follow-up (p < 0.005). A concomitant reduction in analgesic requirements was observed. The incidence of serious side effects was low (two patients in this series). The results indicate the usefulness of these techniques for patients in the palliative care setting.
Dorsal and ventral spinal roots at cervical, thoracic, lumbar and sacral levels in dystrophic, dy/dy, mice of both 129/ReJ and C57Bl/6J phenotypes showed a complete lack of Schwann cell sheaths of any sort around the majority of their nerve fibres. This condition, termed amyelination, is more extensive (up to 1-5 cm in length) in the longer lumbar and sacral roots than in the shorter roots or in the proximal regions of the sciatic nerve which are also affected to some extent. Amyelination does not appear to be a consequence of myelin or Schwann cell degeneration, as debris is uncommon. Heterozygous carriers are not affected in any obvious way. Myelinated fibres, with Schwann cells of peripheral origin, occur immediately adjacent to the spinal cord in both dorsal and ventral roots, while in dorsal roots unmyelinated fibres also occur, as in normal animals. Amyelinated fibres begin to appear a few internodal lengths away from the cord and are present until near, or within, the dorsal root ganglion, where they become myelinated again. The portion of an axon which has no myelin begins at a normal appearing paranodal region (termed a half node of Ranvier) at the end of a myelin internode. Resumption of myelination likewise begins at a half node. A few myelinated axons may be seen in any given cross section of a root, but as a rule a given myelinated fibre does not remain myelinated throughout the whole length of the root. It is suggested that the nerve lesions develop where the nerves are lengthening rapidly as the animal grows and changes its shape. How these nerve changes release to those in muscle is conjectural.
BACKGROUND AND OBJECTIVES: Lumbar sympathetic and celiac plexus block are widely used to treat chronic pain of diverse etiologies. To avoid complications and confirm the correct position of the needle, fluoroscopy and computed tomography have been used to follow the procedure visually. Our objective was to examine whether ultrasonography could be used instead of these techniques. METHODS: Forty-eight neurolytic sympathectomies were performed using ultrasonographic guidance. The results were evaluated clinically and by color-doppler technique as applicable. RESULTS: This new technique was shown to provide excellent results in ensuring the safe passage of the needle and documenting the correct spread of neurolytic agent (phenol-glycerol). The correct position of the needle was achieved on the first attempt in all cases. CONCLUSIONS: The benefits of this technique are that it is inexpensive, there is no radiation, and the anatomy involved can be thoroughly examined before and after the procedure. Phenolglycerol may be the best choice as the neurolytic agent because it provides excellent contrast.
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An anatomopathologic study of 18 cases of pure meningeal carcinomatosis is presented. In five of these cases, the brain, spinal cord, choroid plexuses, cerebral vessels, and prevertebral soft tissues, including the lumbosacral nerve plexuses and ganglia, were examined microscopically in an attmept to determine the routes of tumor spread. Our results suggest that the malignant cells reach the cerebrospinal leptomeninges via perineural, endoneural, and perivascular lymphatics and sheaths through the intervertebral and possibly cranial foramina. Involvement of the choroid plexuses appears to be secondary to, rather than the avenue for, leptomeningeal carcinomatosis, with the tumor cells reaching the choroid plexuses via the perivascular sheaths of choroidal vessels. Leptomeningeal carcinomatosis was the only manifestation of metastatic spread beyond regional lymph nodes in about 40% of all reported cases in which this information is available. This implies that radiation or other forms of local therapy to the cerebrospinal leptomeninges may provide an effective means of palliation in many of these cases.
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