Surg Neurol
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Comparative Study
A comparison between anterior and posterior spinal implant systems.
In four patients with intractable pain from metastatic cancer, application of current through electrodes placed on the anterior surface of the cord produced analgesia and pain relief below the level of implant without the development of paresthesias. Application of current through electrodes placed on the dorsal columns in these patients also relieved pain, but to a lesser degree and with the development of associated paresthesias. In one patient, application of current from anterior electrodes to posterior electrodes produced a zone of dissociated sensory loss. While it is simpler to implant electrodes over the dorsal columns, the anterior location may be superior when currents are to be applied for the pain relief in the lower lumbar and sacral dermatomes.
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Results are reviewed of dorsal column electrical stimulation for chronic pain in a series of 80 patients. In the light of the experience gained from this series, indications and patient suitability for this form of therapy are discussed. Complications occurring after implantation are tabulated.
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Serious questions are raised as to whether electrical control of pain is related to stimulation of the dorsal columns per se or the conduction of the electrical impulse via the cerebrospinal fluid to the ventrolateral columns. Percutaneous on-surface spinal cord stimulation is advocated as an accurate screening method before implantation. Of 27 patients who underwent dorsal column stimulator implants, the last three patients also underwent ventral column stimulator implants. Results in the patients with both implants tend to predict much better results with the possibility that ventral column stimulation alone is sufficient.
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A percutaneous technique is described for implanting a dorsal or ventral column stimulator for pain control with minimal surgical trauma. If the patient does not respond to percutaneous on-surface spinal stimulation, a percutaneous cordotomy can be carried out, as the needle is already in the correct position. Stimulation of the cord at the C1-2 level can be used for treatment of trigeminal neuralgia.
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Although the basic efficacy of dorsal column stimulation (DCS) has been shown, its optimal use remains to be defined. Since 1970, a program designed to maximize clinical success with DCS has been under way at Temple University Health Sciences Center. This article reviews patients screening, operative technique, new instrumentation and postoperative adjustment in DCS. Clinical results and long-term impressions of 90 implants in 75 patients are reported.