Introduction. Spinal cord stimulation (SCS) is an accepted cost-effective therapy for many chronic pain syndromes. Its effects on pregnancy have not been studied because of stringent regulation and manufacturers' recommendations. However, childbearing women who had SCS become or choose to become pregnant despite these policies. It is paramount to monitor, document, and report these effects of SCS during pregnancy to build clinical experience and guide recommendations and management. Methods. We reviewed the literature for SCS in pregnancy and added new case report of a young woman who had SCS implanted for chronic pain, became pregnant and at the end of the second trimester the lead extender had to be divided to relief pain at the lead site. Results. We found only one previous case report in this field and we add another case. Discussion. Our case is different from the previously reported case in that the implantable pulse generator (IPG) of our case was implanted in the anterior abdominal wall, while the previously reported case was implanted in the subclavicular fossa. Therefore our case highlights the need to implant the IPG in a way that avoids stretching the lead extender by the expanding abdomen. Conclusion. SCS seems to be safe in the first two trimesters of pregnancy based on these two case reports and the abdominal wall should be avoided as a site for IPG implantation in these patients. However, more cases are required to establish the safety of SCS in pregnancy.

Objectives.  This study is to evaluate long-term lead failure in spinal cord stimulation. Materials and Methods.  One hundred and seven patients with permanently implanted spinal cord stimulators were studied for 14 years. All suspected paddle-lead failures were studied prospectively using preoperative radiography and intraoperative electric interrogation. Lead failure was defined as complete loss of electric stimulation due to lead malfunction. Primary lead failure was defined as first lead failure after permanent implantation of a new lead and recurrent lead failure was defined as any lead failure after any lead replacement. Results.  Primary lead failure occurred in 14.9% and recurrent lead failure in 56.2%. Two (12.5%) of the primary failures and two (22.2%) of the recurrent failures were due to lead fractures. The mean time to primary lead failure was 37.9 months and to recurrent lead failure was 23.7 months. Conclusion.  The incidence of primary lead failure remains low at 14.9% in the long run, but it is a significant adverse risk factor for recurrent paddle-lead failure. Great care should be undertaken to prevent lead failures by appropriate anchoring.

INTRODUCTION: Transitional cell carcinoma of renal pelvis and ureter account was traditionally treated with nephroureterectomy. With the advent of rigid and flexible ureteroscopes endoscopic access to the ureter and renal pelvis for diagnosis and treatment has become a reality. We did fluorescence ureteroscopy using oral 5-ALA to diagnose upper tract urothelial tumours for four patients. Here we describe this technique and assess its feasibility to diagnose ureteric and renal pelvicalyceal tumours. MATERIALS AND METHODS: A prospective pilot study was performed to assess the feasibility of PDD using oral 5-amino levulinic acid (ALA) for upper urinary tract tumours. RESULTS: Four patients underwent PDD guided flexible ureteroscopy of the upper urinary tract. Obvious exophytic tumour seen on white light was also seen as red fluorescence on blue light. All areas with red fluorescence were biopsied (including additional areas not seen on white light) and were confirmed to be transitional cell carcinoma. CONCLUSION: Photodynamic diagnosis using oral 5-ALA and subsequent treatment of upper tract urothelial tumours is safe and feasible with additional advantages of detecting lesions not visualised on conventional white light endoscopy.

Cerebral metastases occur in 15-40% of cancers and their incidence is increasing. We have studied the use of fluorescence image-guided surgery and repetitive photodynamic therapy in 14 metastatic brain cancers. METHODS: Case note review of prospectively collected data on patients who were treated with PDT at the time of surgery for brain metastases. Patients were consented for the surgery and PDT. Patients were given 2mg/kg body weight of Photofrin((R)) IV 48h before the surgery and 20mg/kg 5-aminolevulenic acid orally 3h before surgery. Following resection of the tumor using fluorescence, microsurgical and image guidance techniques, the post-excision cavity is filled with a balloon using 0.32% intralipid solution and up to five consecutive PDT treatments were given using 100J/cm(2) Diode Laser 630nm. Patients were followed up clinically and by brain imaging every 3 months till their death. RESULTS: Seven were lung in origin and seven of variable sources. One patient with lung metastases died of unrelated cause while the remaining six had remained free from brain disease till their death. Two of the remaining seven patients died of local brain recurrence, one bowel after 4 weeks and one of unknown primary after 70 weeks. CONCLUSION: Adjuvant repetitive PDT seems to offer an excellent local control of metastatic brain carcinomas with about 79% of patients succumb to the primary and only two out of fourteen died of brain recurrence with the best results obtained in lung cancer.

INTRODUCTION: The main goals of transsphenoidal pituitary surgery are total removal of pituitary adenomas (PAs) and preservation of normal pituitary functions. Achieving these goals is dependent upon the precise localisation of PAs during surgery, particularly secreting microadenomas. However, some microadenomas are invisible on preoperative imaging and during surgery, leading some surgeons to perform total hypophysectomy in many patients to achieve cure at the expense of panhypopituitrism. We have examined optical detection systems to identify PAs intraoperatively. This paper reports our preliminary findings. METHODS: A prospective observational study design. TECHNIQUE: Patients were given 20 mg/kg body weight 5-aminolevulinic acid (ALA) mixed in 30 ml of orange juice, orally 3 h before surgery. Surgery was performed in the supine position, under image guidance, through the right nostril using Storz 0 degree endoscope assisted with microsurgery as required. The endoscope was attached to photodiagnostic filters (PD) allowing switching the light from white to blue at the flick of a foot pedal. After the dura of the floor of the sella was incised a laser probe was inserted into the pituitary gland to identify the ALA-induced protoporphyrin IX spectroscopy at 632 nm, using an optical biopsy system (OBS). Once the adenoma was identified by the OBS it was exposed and examined by the PD system to detect fluorescence. The PA was removed and its type was confirmed by histopathology and correlated to the OBS and PD system findings. PATIENTS: Thirty consecutive patients were studied: 14 were non-functioning macroadenomas (NFA), 12 were secreting PAs and 4 pituitary cysts. The secreting PAs were GH (2), ACTH (3), prolactin (2) and gonadotrophins (5). Six were microadenomas (3 ACTH, 1 GH, 2 prolactin) and 20 were macroadenomas, of which 12 were invading macroadenomas. Twenty-four of these were examined by the OBS and the PD systems and six were examined by the PD system only. The true positive (sensitivity) of the PD and OBS systems were 80.8%(21/26) and 95.5%(21/22) respectively. The true negative (specificity) of PD and OBS were 75%(3/4) and 100%(2/2) respectively. The false negative rate of PD was 19.2%(5/26) and for OBS was 4.5%(1/22), while the false positive rate for PD was 25%(1/4) and for OBS was 0. CONCLUSION: Intraoperative optical identification of pituitary adenomas is a feasible and reliable way to localize pituitary adenomas during transsphenoidal surgery and it may lead to improved cure rate and preservation of normal pituitary functions.

Metastatic brain melanoma occurs in about 3.5% of patients suffering from malignant melanoma. It has disabling effects on cognition, memory, language and mobility. We studied the use of fluorescence image-guided resection and repetitive Photodynamic Therapy in six consecutive metastatic brain melanomas. Three were males and the mean age of the group was 52.8 years. RESULTS: All six patients (100%) remained free of brain disease till death, 50% died of malignant melanoma elsewhere, and 50% died of unrelated causes. CONCLUSION: Adjuvant fluorescence image-guided resection and repetitive Photodynamic Therapy offers an excellent local control of metastatic brain melanoma.

Fluorescence image-guided surgery (FIGS) and fluorescence-guided resection (FGR) are surgical techniques used to maximise tumor excision and minimise collateral damage. FIGS and FGR combine preoperative photosensitizer-administration and fluorescence detection during surgery, by illumination of the surgical field using the appropriate wavelength and observing the fluorescence via a long-pass filter that allows fluorescent tumor to be seen by the surgeon. Commercially available technology has led to gross total resection of enhancing brain tumors in 65% of patients compared to merely 35% under standard white light surgery. This is a step-by-step synopsis of the techniques of FIGS in brain.

Intracranial tumours are an excellent target for photodiagnosis (PD), fluorescence guided resection (FGR) and photodynamic therapy (PDT), because the tumour to brain ratio of photosensitizers' concentration is very high. However, several attempts of proving the value of PDT in the most malignant type of brain tumours, gliobastoma multeforme (GBM) failed to demonstrate any significant worthwhile survival advantage in the past because of the very nature of this cancer and several compounding factors that led to this apparent disappointing outcome; variations in the photosensitizer and light dosages, variations in the photosensitizer administration to treatment time-intervals, and variations in photosensitizers used are just few to mention in this article. However, after a very long gestation period of brain PD, FGR and PDT, three randomized controlled trials (RCT) in brain PD, FGR and PDT were concluded by 2007. The first trial demonstrated that time to tumour progression (TTP) was significantly longer in patients who had PD and FGR compared to standard surgical resection but this difference did not translate into survival advantage in GBM due to the variability in the management of recurrent tumours and significant residual tumour cells left after FGR in about a third of patients leading to GBM relapse. The second trial compared single shot PDT in GBM and standard therapy. Neither the treatment nor the control group received PD or FGR. Again this RCT did not provide any survival advantage in patients who had had PDT due to the fact that standard surgical resection had left significant residual tumour in a large number of patients canceling any potential benefit from PDT. The last trial compared combined PD, FGR and repetitive PDT and standard therapy and confirmed that TTP was significantly longer in the treatment group and demonstrated that the treatment group had significant survival advantage in GBM. In conclusion, PD, FGR and PDT need to be combined to be effective in brain tumours and in the future, we will see more and more scientific evidence accumulating in support of brain PD, FGR and PDT. The next decade will see further refinement and evolution of the techniques and technology employed and expansion of the indications of brain PD, FGR and PDT.