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Days with No Symptomatic Evect Or Objective Change in His Letters, Correspondence, Erratum, Book reviews 251 1 Weetman J, Anderson M, Gregory RP, et al. ics were permitted during the trial but Bilateral posteroventral pallidotomy for severe patients discontinued all other chronic anal- antipsychotic induced tardive dyskinesia and dystonia,. J Neurol Neurosurg Psychiatry gesic medications 3 weeks before study entry. 1997;6:554–6 At the beginning and end of each treatment 2 Obeso JA, Guridi J, DeLong M. Surgery for period, patients rated their level of pain over Parkinson’s disease. (editorial) J Neurol Neuro- surg Psychiatry 1997;62:2–8 the preceding 24 hours on a 10 cm visual 3 Laitinen LV, Bergenhein T, Hariz MI. Leksell’s anologue pain scale (VAS), ranging from 0 posteroventral pallidotomy in the treatment of (“no pain”) to 10 (“worst pain ever”). Parkinson’s disease Neurosurgery 1992;76:53–61 Present pain intensity (PPI, “rate how much 4 Chien, C-P, Jung K, Ross-Townsend A. Meth- odologic approach to measurement of tardive pain you have at this moment,” using a simi- dyskinesia: piezoelectric recording and concur- lar 0–10 scale) and the McGill pain question- rent validity test on five clinical scales. In: Ta r - naire (MPQ) were recorded at the initial and dive Dyskinesia: research and treatment. Spec- 4 trum Publications New York 1980;233–66. final visits of each treatment period. At the 5 Andrew J, Watkins ES. A stereotaxic atlas of the end of each treatment period patients pro- human thalamus and adjacent structures. vided a global assessment of pain relief: none, Baltimore: Williams and Wilkins, 1969 6 Cardoso F, Jankovic J, Grossman RG, Hamilton mild, moderate, or excellent, as compared WJ. Outcome after stereotactic thalamotomy with the level of pain preceding each for dystonia and hemiballismus. Neurosurgery treatment period. The global assessment of Postoperative MRI confirming the position of 1995;36:501–6. pain relief was dichotomised (none/mild stereotaxic lesions in the right thalamus (black v arrows). moderate/excellent) for purposes of analysis. Gabapentin in the treatment of painful The protocol was approved by the Institu- tional Review Board at St Elizabeth’s Medical diabetic neuropathy: a placebo days with no symptomatic eVect or objective Center and all patients gave written informed controlled, double blind, crossover trial change in his AIMS score. consent. In April 1997 ventral thalamotomy was There were 31 men and nine women, with Painful neuropathy is a common and disa- an average age of 62 years (SD 10.9 years, performed on the right side in two stages bling problem in patients with longstanding under local anaesthesia. A Bennett spheroid diabetes mellitus. Tricyclic antidepressant range 43–82 years). All but one had adult guide had previously been inserted under drugs and other chronic analgesics have been onset diabetes mellitus, with a mean duration general anaesthesia using CT guidance and a beneficial in some patients,1 but no agent of 14 years (SD 9.9 years, range 6 months-40 Leksell frame. Details of the lesions are successfully relieves pain in most patients and years). Ten had neuropathic pain limited to shown in the table. The first lesion was rela- adverse eVects often preclude their use in the feet, 19 had pain in the feet and legs, and tively anterior and it reduced the torticollis, high doses. Anecdotal reports suggest that 11 had pain in the feet, legs, and hands. The neck pain, hypertonia, and the dyskinesia of gabapentin ameliorates pain associated with mean duration of neuropathic pain was 4 the contralateral limbs and allowed him to neuropathy and other neurological condi- years (SD 3.5 years, range 4 months-15 smile and laugh. One week later a second tions with few side eVects.23We conducted a years). Twenty five had previously used lesion was placed posteriomedial to the first. randomised, double blind, placebo controlled narcotics or other chronic analgesics to man- This abolished the residual “cogwheeling” of trial to study the eVect of low dose gabapen- age their pain. the left upper limb and improved his dexter- tin in patients with painful diabetic neu- Nineteen patients were randomised to the ity. There were no surgical complications. ropathy. active drug and 21 to placebo during the first Postoperative MRI (figure) 8 months after We recruited 40 patients with painful treatment period. The mean reduction in the the procedure confirms the position of the diabetic neuropathy who had (1) diabetes for MPQ score was 8.9 points with gabapentin two lesions in the right thalamus. at least 6 months on a stable dosage of insu- compared with 2.2 points with placebo Twelve months later the patient remains lin or oral hypoglycaemic agent, (2) distal (p=0.03, two sample t test). There were no well with minimal dystonic neck movements symmetric sensorimotor neuropathy as diVerences in the mean change of the VAS or and no evidence of abnormal posturing of the shown by impaired pin prick, temperature, or PPI scores between gabapentin and placebo left arm and oV all medication. His AIMS vibration sensation in both feet and absent or (table). Fourteen patients reported moderate score is now 8/40. reduced ankle reflexes, and (3) daily neuro- or excellent pain relief with gabapentin only, Although the eYcacy of thalamotomy has pathic pain in the acral extremities, of at least six with placebo only, and three with both; 17 long been recognised in secondary dystonia6 moderate severity, for over 3 months that reported none or mild relief after both treat- we are not aware of any reports of its use in interfered with daily activity or sleep. Ex- ments (p=0.11, McNemar’s test). There were drug induced dystonia. The mechanism of cluded were those with diabetes and chronic no serious adverse events. Adverse eVects drug induced dystonia is not yet known and renal insuYciency, painful diabetic plexopa- were significantly more common with gabap- extrapolating the surgical results for treat- thy, or lumbosacral polyradiculopathy, pe- entin (12 patients) compared with placebo ment of dystonia of other aetiologies may not ripheral vascular disease, another painful (four patients, p<0.001, McNemar’s test). be appropriate. The reported mortality from condition, or other cause for neuropathy. The most common side eVects of gabapentin thalamotomy ranges from 0.4% to 6%.2 Patients were randomly assigned to gabapen- were drowsiness (six patients), fatigue (four), Recent experience with pallidotomy indicates tin (300 mg capsules) or placebo for 6 weeks and imbalance (three). All adverse eVects an incidence of severe clinical complications (phase I) followed bya3weekwashout resolved promptly after discontinuation of of between 2%-8%.2 Because of the proximity period and then crossover (phase II). The the drug. of the optic tract to the globus pallidus dose of gabapentin or placebo was increased Anecdotal reports suggest that gabapentin persistent visual defects are a well known risk by one capsule every 3 days to a stable dosage has beneficial eVects in patients with various of pallidotomy, up to 14% in one series.3 It is of one capsule three times daily (900 mg/day) painful neurological conditions, including too early to be certain of long term eYcacy that was maintained throughout the remain- HIV neuropathy,2 postherpetic neuralgia,2 but 12 months after operation the patient der of the treatment period. The low dosage and reflex sympathetic dystrophy.3 The remains well and oV all medication. We con- of gabapentin was chosen to minimise mechanism of action of gabapentin in amelio- clude that thalamotomy should also be adverse eVects that might compromise blind- rating pain is unknown, but animal studies considered in patients with medically refrac- ing. Treatment with stable dosages of non- suggest that its pain modulating properties tory drug induced tardive dystonia and steroidal anti-inflammatory agents or narcot- may be linked to the release of the neuro- dyskinesia. CEMHILLIER Comparison of mean change in pain scales between gabapentin and placebo CMWILES B A SIMPSON Pain scale Gabapentin Placebo DiVerence p Value Departments of Neurology and Neurosurgery, MPQ 8.9 (2.3) 2.2 (2.2) 6.7 (3.2) 0.03 University Hospital of Wales, Heath Park, VAS 1.8 (0.5) 1.4 (0.3) 0.4 (0.6) 0.42 CardiV CF4 4XW,UK PPI 1.2 (0.4) 0.3 (0.5) 0.9 (0.7) 0.2 No of patients reporting moderate or excellent pain relief* 17 9 0.11 Correspondence to: Dr C E M Hillier, Department of Neurology, University Hospital of Wales, Heath *Global assessment of pain relief. Park, CardiV CF4 4XW, UK. Telephone 0044 1222 MPQ=McGill pain questionnaire; PPI=present pain intensity; VAS=visual analogue scale; numbers in 746441; fax 0044 1222 744166. parentheses are SD. 252 Letters, Correspondence, Erratum, Book reviews transmitter GABA in spinal cord pathways drome were investigated. Conventional elec- 9 years old and disclosed abnormality. The that modify pain perception.5 tromyographic investigation with concentri- needle insertion, mechanical stimulation, and There was statistical improvement in only cal needle electrodes in the biceps brachii and mild muscular contraction induced sponta- one of four end points, the MPQ score, with tibialis anterior showed continuous muscle neous activity. Myotonic discharges (fig 1 A gabapentin compared with placebo. The activity (myotonic burst, high frequency and B) were found in all examined muscles MPQ is a valid, consistent, and reliable discharges of single motor units with “bi- (abductor digiti minimi, quadriceps femoris, measure of subjective pain experience, and zarre” rhythmic activity). The single motor tibialis anterior, biceps brachii).There were usually correlates with other measures of pain unit action potential (MUAP) was studied in also spontaneous high frequency biphase 4 intensity, including the VAS and PPI scales. detail by monopolar surface selective elec- potentials.
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