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27 Noviembre 2009

STEREOTACTIC THALAMOTOMY OF NUCLEY.CM, PF AND DM IN PAIN. ENRIQUE RUBIO GARCIA.

Archivado en: ANATOMIA, dolor — Enrique Rubio @ 21:31

estereotaxia2Basis of this thesis.
Try to demonstrate that bilateral and symmetrical lesion of the nucleus of the thalamus,
Central Medium (CM), Parafascicular (PF) and Medial Dorsal (DM) produces analgesia
in intractable pain by medical and surgical procedures.
Fundamentals of the effectiveness of these lesions.
It is known since the 1960s by the work of Hassler, the lesion of the somatosensory
nuclei of the thalamus. Postero Lateral ventral (VPL) and Ventral Postero Medial
(DPM), produced two types of alterations:
a. - A dramatic loss of all sensitivities contralateral and the appearance of a high
percentage of patients with contralateral dysesthesia unbearable for the patient.
b. - Rarely pain disappeared and when it did was for short periods (109,102). These
features were consistent with the known Dejerine-Roussy syndrome.
Traducir The observation of animals allows to see two types of systems of conduction.
One primitive thickness, of bilateral representation and with previous stay and the trunk
of encéfalo that constitutes the Paleoespinotalamico, that leads almost exclusively to
painful sensations and is typical for birds. Another system of later conduction
filogenéticamente of appearance, that is the Neoespinotalamico, typical for mammals
and still more of primates that picks up the contralateral projections of the sensitive
routes. By the Paleoespinotalamnico system, they walk the sensitive routes that after
making stay in the trunk of brain and mixing themselves with the reticular system,
happen bilaterally towards both we destroyed, on the inside of the medullary lamina
intern and are known as nuclei intralaminar thalamus and form what is called
extralemniscales routes of sensitivities (43.150.174.198,). This demonstrated that all the
sensitive stimuli do not happen through the somatosensorial nuclei of both we
destroyed, but many of them were extralemniscales, constituting fibers reticulumtalamicas
of medial disposition to the tract talamico hawthorn that they finish in the
intralaminar nuclei of the thalamus: Paracentral, Lateral Power station, Center Mediano
and Parafascicular. This system of sensitive transport is primitive, of deep sensations,
painful and bad located. Whereas the sensations that also end at nuclei VPM and VPL
of both we destroyed they are but concrete superficial and barely painful. So that the
injury of nuclei VPL and VPM; it only broke the balance of the relays of the nonpainful
sensations that did not secure therapeutic action (8174,201,224).
Nauta showed that pain extralemniscal pathways were multipless in both animals and
humans and their collateral projections terminated in the intralaminar nuclei of the
thalamus (184.185).
In the 1960s it was shown by several authors, the lesions of the intralaminar nuclei
followed from the disappearance of chronic pain
The injury had to be bilateral and symmetrical and within the internal medullary lamina
and cut down to make it both effective and this was demonstrated in autopsies
(223.227).
The emotional component of pain arrival into the prefrontal lobe through sensory
projections that reached the nucleus DM, allowing the telencephalo the analysis of the
painful sensation . They knew leucotomy practiced by Nobel laureate Egas Moniz in
1927, which is changed the personality of the patient who received it but also increases
the pain threshold and the patient was often heard to say that pain no longer mattered.
The same effect was obtained with lesions of the rostral cingulate, the DM nucleus and
the anterior thalamic nucleus lesions as well as practices in the prefrontal lobe
(40,60,236).
Injuries of intralaminary nucley chronic pain patient were analgesics, CM, PF, DM,
extending to the reticular nuclei extralemniscal they received the pain and the DM, it
conveys the pain informing the prefrontal lobes of the emotional component of pain.
Materials and Methods.
From the years between 1969 and 1980, were operated on 50 patients who suffer pain
resistant to all known medical and surgical procedures.
The intervention was performed with local anesthesia by placing a framework designed
by Leksell stereotactic, which was placed in the skull with three fasteners subject
entering the skull to the inner table after local anesthetic injection
The location of the nuclei was performed with ventriculography through a burr hole at
the bilateral and symmetrical coronal suture and 2.5 cm from the midline. The contrast
was introduced into the ventricular system was a mixture of air and Dimer X. The total
was 8 cc. It was crucial to injec the contras tinto the foramen of Monro, so that when
filling the third ventricle could see the anterior and posterior gray commissures (AC and
PC) with clarity .
.
The core lesions are located just outside the third ventricle to the next location, taken
from the Atlas Schatelbram and Bayley.
X. - 6mm in front of the CP
Y. - 2mm above the plane CA-CP
Z. - lll Paret external lateral ventricle.
The lesions were made with liquid nitrogen circulating inside a metal catheter of 2.4
mm in diameter and designed by Cooper. (Cooper
Criosurgery Systen)
Traducir The total lesion volume is a cylinder of 6 mm. diameter by 12 mm of
generating.
The lesion began cooled off the tip of the cannula to reach 200 degrees below zero.
After the criotalamotomia, the skin incisión
was closed and was transferred the patient to his room, wide awake
Results according to the Etiology of Pain
Numero immediate results
Tumor 39 patients 39 Without .pain 100% 36 without pain 92.3% 2 moderate 5.1% 1 no change
2.5%
late outcomes observation time
Between 1 and 6 months 1 is well 30 years later Abdominal lymphoma
Deafferentation 11 patients 11 without pain 100% 2 painless 18.18% 6 Moderate 63.6% 7 3 equal to
27.27% . 6 months to 8 years
Complications.
1 patient with a very bad state death the 3 th days
3 seizures
1 transient Parinaud syndrome
31 patients presented frontal syndrome, emotional indifference between 2 and 7 weeks
long.
Discussion.
This thesis was made in times where the methods of medical analgesia were very poor
and analgesics use in surgical analgesia were mutilating providing postoperative pain
for deafferentation
The results were better in patients with pain tumor in the origin, where a 92.3 5 died
without pain. Quite possibly the shorter duration of his life after the intervention was
responsible for these findings
In patients with deafferentation pain results were poor as only 18.18% lived without
pain. These patients lived longer and it determines recurrence of pain.
Complications are rare, since theonly patient who died had a very bad state, like most
tumor patients undergoing surgery.
Frontal syndrome presenting many patients, it was beneficial that the pain was a fact
then I stopped worrying and let them live with some comfort.
Conclusions
1 .- The lesion of the nucleus of the thalamus intralaminaares with criotalamotomia
produces a high percentage of analgesia. Immediate to the surgery.
2 .- After two week the good results are reduced to 70%.
3 .- In the tumor bearing patient outcomes are higher. The indifference of the frontal
syndrome allowed them to live more confortable.
4 .- Patients with skim lesions, of which markedly improved
5 .- A high percentage of patients stopped being addicted to drugs markedly, it was
lower in patients suffering deafferentation pain.
6 .- In patients with deafferentation pain and markedly lived longer after surgery the
results were clearly worse. Patients with pre dysesthesias intervenion rarely improves
them (postherpetic neuralgia, brachial plexus Chunking).
7 .- Can be considered rare complications and mortality of this dubious statistic is too
low

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