1
|
Campbell BA, Favi Bocca L, Tiefenbach J, Hogue O, Nagel SJ, Rammo R, Escobar Sanabria D, Machado AG, Baker KB. Myogenic and cortical evoked potentials vary as a function of stimulus pulse geometry delivered in the subthalamic nucleus of Parkinson's disease patients. Front Neurol 2023; 14:1216916. [PMID: 37693765 PMCID: PMC10484227 DOI: 10.3389/fneur.2023.1216916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction The therapeutic efficacy of deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD) may be limited for some patients by the presence of stimulation-related side effects. Such effects are most often attributed to electrical current spread beyond the target region. Prior computational modeling studies have suggested that changing the degree of asymmetry of the individual phases of the biphasic, stimulus pulse may allow for more selective activation of neural elements in the target region. To the extent that different neural elements contribute to the therapeutic vs. side-effect inducing effects of DBS, such improved selectivity may provide a new parameter for optimizing DBS to increase the therapeutic window. Methods We investigated the effect of six different pulse geometries on cortical and myogenic evoked potentials in eight patients with PD whose leads were temporarily externalized following STN DBS implant surgery. DBS-cortical evoked potentials were quantified using peak to peak measurements and wavelets and myogenic potentials were quantified using RMS. Results We found that the slope of the recruitment curves differed significantly as a function of pulse geometry for both the cortical- and myogenic responses. Notably, this effect was observed most frequently when stimulation was delivered using a monopolar, as opposed to a bipolar, configuration. Discussion Manipulating pulse geometry results in differential physiological effects at both the cortical and neuromuscular level. Exploiting these differences may help to expand DBS' therapeutic window and support the potential for incorporating pulse geometry as an additional parameter for optimizing therapeutic benefit.
Collapse
Affiliation(s)
- Brett A. Campbell
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
| | - Leonardo Favi Bocca
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
| | - Jakov Tiefenbach
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
| | - Olivia Hogue
- Center for Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - David Escobar Sanabria
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, United States
| | - Andre G. Machado
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - Kenneth B. Baker
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
| |
Collapse
|
2
|
Baek H, Chen J, Lockwood D, Obusez E, Poturalski M, Nagel SJ, Jones SE. Feasibility of Magnetic Resonance-Compatible Accelerometers to Monitor Tremor Fluctuations During Magnetic Resonance-Guided Focused Ultrasound Thalamotomy: Technical Note. Oper Neurosurg (Hagerstown) 2023; 24:641-650. [PMID: 36827201 DOI: 10.1227/ons.0000000000000638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/30/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is used to treat essential tremor and tremor-dominant Parkinson disease. Feedback is collected throughout the procedure to verify the location of the target and completeness of response; however, variability in clinical judgments may underestimate or overestimate treatment response. OBJECTIVE To objectively quantify joint motion after each sonication using accelerometers secured to the contralateral upper extremity in an effort to optimize MRgFUS treatment. METHODS Before the procedure, 3 accelerometers were secured to the patient's arm, forearm, and index finger. Throughout the procedure, tremor motion was regularly recorded during postural and kinetic tremor testing and individual joint angle measures were modeled. The joint angle from each accelerometer was compared with baseline measurements to assess changes in angles. Subsequent adjustments to the target location and sonication energy were made at the discretion of the neurosurgeon and neuroradiologist. RESULTS Intraoperative accelerometer measurements of hand tremor from 18 patients provided quantified data regarding joint angle reduction: 87.3%, 94.2%, and 86.7% for signature writing, spiral drawing, and line drawing tests, respectively. Target adjustment based on accelerometer monitoring of the angle at each joint added substantial value toward achieving optimal tremor reduction. CONCLUSION Real-time accelerometer recordings collected during MRgFUS thalamotomy offered objective quantification of changes in joint angle after each sonication, and these findings were consistent with clinical judgments of tremor response. These results suggest that this technique could be used for fine adjustment of the location of sonication energy and number of sonications to consistently achieve optimal tremor reduction.
Collapse
Affiliation(s)
- Hongchae Baek
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | | | | | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | |
Collapse
|
3
|
Campbell BA, Favi Bocca L, Escobar Sanabria D, Almeida J, Rammo R, Nagel SJ, Machado AG, Baker KB. The impact of pulse timing on cortical and subthalamic nucleus deep brain stimulation evoked potentials. Front Hum Neurosci 2022; 16:1009223. [PMID: 36204716 PMCID: PMC9532054 DOI: 10.3389/fnhum.2022.1009223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
The impact of pulse timing is an important factor in our understanding of how to effectively modulate the basal ganglia thalamocortical (BGTC) circuit. Single pulse low-frequency DBS-evoked potentials generated through electrical stimulation of the subthalamic nucleus (STN) provide insight into circuit activation, but how the long-latency components change as a function of pulse timing is not well-understood. We investigated how timing between stimulation pulses delivered in the STN region influence the neural activity in the STN and cortex. DBS leads implanted in the STN of five patients with Parkinson's disease were temporarily externalized, allowing for the delivery of paired pulses with inter-pulse intervals (IPIs) ranging from 0.2 to 10 ms. Neural activation was measured through local field potential (LFP) recordings from the DBS lead and scalp EEG. DBS-evoked potentials were computed using contacts positioned in dorsolateral STN as determined through co-registered post-operative imaging. We quantified the degree to which distinct IPIs influenced the amplitude of evoked responses across frequencies and time using the wavelet transform and power spectral density curves. The beta frequency content of the DBS evoked responses in the STN and scalp EEG increased as a function of pulse-interval timing. Pulse intervals <1.0 ms apart were associated with minimal to no change in the evoked response. IPIs from 1.5 to 3.0 ms yielded a significant increase in the evoked response, while those >4 ms produced modest, but non-significant growth. Beta frequency activity in the scalp EEG and STN LFP response was maximal when IPIs were between 1.5 and 4.0 ms. These results demonstrate that long-latency components of DBS-evoked responses are pre-dominantly in the beta frequency range and that pulse interval timing impacts the level of BGTC circuit activation.
Collapse
Affiliation(s)
- Brett A. Campbell
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Leonardo Favi Bocca
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - David Escobar Sanabria
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Julio Almeida
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Richard Rammo
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Andre G. Machado
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Kenneth B. Baker
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
- *Correspondence: Kenneth B. Baker
| |
Collapse
|
4
|
Golubovsky JL, Liao J, Hogue O, Pucci F, Rammo R, Lipman J, Aminian A, Nagel SJ. Complications Associated With Ventriculoperitoneal Shunt Surgery for Normal Pressure Hydrocephalus Using Stereotactic Navigation and Abdominal Laparoscopy: A Single-Institution Case Series. Oper Neurosurg (Hagerstown) 2022; 23:188-193. [PMID: 35972080 DOI: 10.1227/ons.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Normal pressure hydrocephalus (NPH) is characterized by cerebral ventriculomegaly and the triad of magnetic gait, urinary incontinence, and cognitive impairment. Treatment includes ventriculoperitoneal (VP) shunt surgery. OBJECTIVE To evaluate complication rates in a cohort of patients undergoing VP shunt surgery with stereotactic proximal catheter navigation and laparoscopic distal catheter placement. METHODS This study was a retrospective consecutive cohort analysis of 117 patients with NPH undergoing VP shunt placement using both stereotactic navigation and laparoscopy from 2015 to 2020. Patients with obstructive hydrocephalus and those with central nervous system infection, intraventricular hemorrhage, Ommaya reservoirs, or undergoing shunt revision at initial encounter were excluded. Variables included demographics and comorbidities, NPH symptoms, operative details, radiographic outcomes, and rates of complications, readmissions, and reoperations within 1, 3, and 12 months. Impact of demographics and comorbidities on complication rates was assessed using Fisher exact tests. RESULTS Zero patients required reoperation within 30 days. One intracranial hemorrhage was detected on immediate postoperative head computed tomography. Four patients ultimately required revision: 2 for catheter repositioning to alleviate abdominal pain, 1 ligation for a colectomy, and 1 removal for shunt infection. Patients with cardiac or other neurological comorbidities had higher rates of readmission and complications. Systemic complications totaled 12% in the first 30 days. CONCLUSION The combination of intraoperative stereotactic navigation and laparoscopic assistance leads to low rates of serious complications and reoperations for VP shunt implantation in patients with NPH. These changes to surgical technique are easy to implement and may reduce the risk for this common operation.
Collapse
Affiliation(s)
- Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - James Liao
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olivia Hogue
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francesco Pucci
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard Rammo
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ali Aminian
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Baek H, Lockwood D, Mason EJ, Obusez E, Poturalski M, Rammo R, Nagel SJ, Jones SE. Clinical Intervention Using Focused Ultrasound (FUS) Stimulation of the Brain in Diverse Neurological Disorders. Front Neurol 2022; 13:880814. [PMID: 35614924 PMCID: PMC9124976 DOI: 10.3389/fneur.2022.880814] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Various surgical techniques and pharmaceutical treatments have been developed to improve the current technologies of treating brain diseases. Focused ultrasound (FUS) is a new brain stimulation modality that can exert a therapeutic effect on diseased brain cells, with this effect ranging from permanent ablation of the pathological neural circuit to transient excitatory/inhibitory modulation of the neural activity depending on the acoustic energy of choice. With the development of intraoperative imaging technology, FUS has become a clinically available noninvasive neurosurgical option with visual feedback. Over the past 10 years, FUS has shown enormous potential. It can deliver acoustic energy through the physical barrier of the brain and eliminate abnormal brain cells to treat patients with Parkinson's disease and essential tremor. In addition, FUS can help introduce potentially beneficial therapeutics at the exact brain region where they need to be, bypassing the brain's function barrier, which can be applied for a wide range of central nervous system disorders. In this review, we introduce the current FDA-approved clinical applications of FUS, ranging from thermal ablation to blood barrier opening, as well as the emerging applications of FUS in the context of pain control, epilepsy, and neuromodulation. We also discuss the expansion of future applications and challenges. Broadening FUS technologies requires a deep understanding of the effect of ultrasound when targeting various brain structures in diverse disease conditions in the context of skull interface, anatomical structure inside the brain, and pathology.
Collapse
Affiliation(s)
- Hongchae Baek
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Daniel Lockwood
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Emmanuel Obusez
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Stephen E. Jones
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- *Correspondence: Stephen E. Jones
| |
Collapse
|
6
|
Williams MA, Nagel SJ, Golomb J, Jensen H, Dasher NA, Holubkov R, Edwards RJ, Luciano MG, Zwimpfer TJ, Katzen H, Moghekar A, Wisoff JH, McKhann GM, Hamilton MG. Safety and effectiveness of the assessment and treatment of idiopathic normal pressure hydrocephalus in the Adult Hydrocephalus Clinical Research Network. J Neurosurg 2022; 137:1-13. [PMID: 35276651 DOI: 10.3171/2022.1.jns212782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to describe the processes and outcomes associated with patients at five sites in the Adult Hydrocephalus Clinical Research Network (AHCRN) who had undergone evaluation and treatment for suspected idiopathic normal pressure hydrocephalus (iNPH) and had 1-year postoperative follow-up. METHODS Subjects with possible iNPH who had been prospectively enrolled in the AHCRN registry between November 19, 2014, and December 31, 2018, were evaluated by CSF drainage via either lumbar puncture or external lumbar drainage, consistent with recommendations of the international iNPH guidelines. Standardized clinical evaluations of gait, cognition, urinary symptoms, depression, and functional outcomes were conducted at baseline, before and after CSF drainage, and at 4-month intervals after shunt surgery. Complications of CSF drainage and shunt surgery were recorded. RESULTS Seventy-four percent (424/570) of patients with possible iNPH had CSF drainage, and 46% of them (193/424) underwent shunt surgery. The mean change in gait velocity with CSF drainage was 0.18 m/sec in patients who underwent shunt surgery versus 0.08 m/sec in patients who did not. For shunt surgery patients, gait velocity increased by 54% from 0.67 m/sec before CSF drainage to 0.96 m/sec 8-12 months after surgery, and 80% of patients had an increase of at least 0.1 m/sec by the first postoperative visit. Evaluation of cognition, urinary symptoms, depression, and functional outcomes also revealed improvement after shunt surgery. Of 193 patients who had undergone shunt surgery, 176 (91%) had no complications and 17 (9%) had 28 complications. Eleven patients (6%) had 14 serious complications that resulted in the need for surgery or an extended hospital stay. The 30-day reoperation rate was 3%. CONCLUSIONS Using criteria recommended by the international iNPH guidelines, the authors found that evaluation and treatment of iNPH are safe and effective. Testing with CSF drainage and treatment with shunt surgery are associated with a high rate of sustained improvement and a low rate of complications for iNPH in the 1st year after shunt surgery. Patients who had undergone shunt surgery for iNPH experienced improvement in gait, cognitive function, bladder symptoms, depression, and functional outcome measures. Gait velocity, which is an easily measured, objective, continuous variable, should be used as a standard outcome measure to test a patient's response to CSF drainage and shunt surgery in iNPH.
Collapse
Affiliation(s)
- Michael A Williams
- 1Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Sean J Nagel
- 2Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | - James Golomb
- 3Department of Neurology, New York University School of Medicine, New York, New York
| | - Hailey Jensen
- 4Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nickolas A Dasher
- 5Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard Holubkov
- 4Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard J Edwards
- 6Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom
| | - Mark G Luciano
- 7Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Thomas J Zwimpfer
- 8Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather Katzen
- 9Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Abhay Moghekar
- 10Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeffrey H Wisoff
- 11Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital at NYU Langone Health, New York, New York
| | - Guy M McKhann
- 12Department of Neurological Surgery, Columbia University School of Medicine, New York, New York; and
| | - Mark G Hamilton
- 13Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
7
|
Wu C, Nagel SJ, Agarwal R, Pötter-Nerger M, Hamel W, Sharan AD, Connolly AT, Cheeran B, Larson PS. Reduced Risk of Reoperations With Modern Deep Brain Stimulator Systems: Big Data Analysis From a United States Claims Database. Front Neurol 2021; 12:785280. [PMID: 34925219 PMCID: PMC8675885 DOI: 10.3389/fneur.2021.785280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/29/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: There have been significant improvements in the design and manufacturing of deep brain stimulation (DBS) systems, but no study has considered the impact of modern systems on complications. We sought to compare the relative occurrence of reoperations after de novo implantation of modern and traditional DBS systems in patients with Parkinson's disease (PD) or essential tremor (ET) in the United States. Design: Retrospective, contemporaneous cohort study. Setting: Multicenter data from the United States Centers for Medicare and Medicaid Services administrative claims database between 2016 and 2018. Participants: This population-based sample consisted of 5,998 patients implanted with a DBS system, of which 3,869 patients had a de novo implant and primary diagnosis of PD or ET. Follow-up of 3 months was available for 3,810 patients, 12 months for 3,561 patients, and 24 months for 1,812 patients. Intervention: Implantation of a modern directional (MD) or traditional omnidirectional (TO) DBS system. Primary and Secondary Outcome Measures: We hypothesized that MD systems would impact complication rates. Reoperation rate was the primary outcome. Associated diagnoses, patient characteristics, and implanting center details served as covariates. Kaplan–Meier analysis was performed to compare rates of event-free survival and regression models were used to determine covariate influences. Results: Patients implanted with modern systems were 36% less likely to require reoperation, largely due to differences in acute reoperations and intracranial lead reoperations. Risk reduction persisted while accounting for practice differences and implanting center experience. Risk reduction was more pronounced in patients with PD. Conclusions: In the first multicenter analysis of device-related complications including modern DBS systems, we found that modern systems are associated with lower reoperation rates. This risk profile should be carefully considered during device selection for patients undergoing DBS for PD or ET. Prospective studies are needed to further investigate underlying causes.
Collapse
Affiliation(s)
- Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, PA, United States
| | - Sean J Nagel
- Department of Neurological Surgery, Center for Neuro-Restoration, Cleveland Clinic, Cleveland, OH, United States
| | | | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurological Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashwini D Sharan
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, PA, United States
| | | | | | - Paul S Larson
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
8
|
Zwimpfer TJ, Salterio N, Williams MA, Holubkov R, Katzen H, Luciano MG, Moghekar A, Nagel SJ, Wisoff JH, Golomb J, McKhann GM, Edwards RJ, Hamilton MG. Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus. J Neurosurg 2021; 136:887-894. [PMID: 34534954 DOI: 10.3171/2021.3.jns203424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus. METHODS Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included. RESULTS A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19-79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7-1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1-1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0-0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6-1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1-1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2-0.6 m/sec, p < 0.001). The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23-27) that improved to 26/30 (IQR 24-28) post-ETV. The median within-patient change was +1 point (IQR 0-2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22-27), which improved to 26/30 (IQR 25-28) post-ETV. The median within-patient change was +2 points (IQR 1-3 points, p = 0.007), which is both statistically and clinically significant. CONCLUSIONS Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.
Collapse
Affiliation(s)
- Thomas J Zwimpfer
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas Salterio
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A Williams
- 2Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington
| | - Richard Holubkov
- 3Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Heather Katzen
- 4Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Abhay Moghekar
- 6Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Sean J Nagel
- 7Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | | | - James Golomb
- 9Neurology, New York University School of Medicine, New York, New York
| | - Guy M McKhann
- 10Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Richard J Edwards
- 11Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom; and
| | - Mark G Hamilton
- 12Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | |
Collapse
|
9
|
Koh EJ, Golubovsky JL, Rammo R, Momin A, Walter B, Fernandez HH, Machado A, Nagel SJ. Estimating the Risk of Deep Brain Stimulation in the Modern Era: 2008 to 2020. Oper Neurosurg (Hagerstown) 2021; 21:277-290. [PMID: 34392372 DOI: 10.1093/ons/opab261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly. OBJECTIVE To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery. METHODS PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients. RESULTS The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%. CONCLUSION This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.
Collapse
Affiliation(s)
- Eun Jeong Koh
- Department of Neurosurgery, Jeonbuk National University Medical School, Jeonju, Jeonbuk, Republic of Korea
| | - Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arbaz Momin
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Benjamin Walter
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hubert H Fernandez
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
10
|
Rammo RA, Ozinga SJ, White A, Nagel SJ, Machado AG, Pallavaram S, Cheeran BJ, Walter BL. Directional Stimulation in Parkinson's Disease and Essential Tremor: The Cleveland Clinic Experience. Neuromodulation 2021; 25:829-835. [PMID: 33733515 DOI: 10.1111/ner.13374] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/18/2021] [Accepted: 02/01/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess use of directional stimulation in Parkinson's disease and essential tremor patients programmed in routine clinical care. MATERIALS AND METHODS Patients with Parkinson's disease or essential tremor implanted at Cleveland Clinic with a directional deep brain stimulation (DBS) system from November 2017 to October 2019 were included in this retrospective case series. Omnidirectional was compared against directional stimulation using therapeutic current strength, therapeutic window percentage, and total electrical energy delivered as outcome variables. RESULTS Fifty-seven Parkinson's disease patients (36 males) were implanted in the subthalamic nucleus (105 leads) and 33 essential tremor patients (19 males) were implanted in the ventral intermediate nucleus of the thalamus (52 leads). Seventy-four percent of patients with subthalamic stimulation (65% of leads) and 79% of patients with thalamic stimulation (79% of leads) were programmed with directional stimulation for their stable settings. Forty-six percent of subthalamic leads and 69% of thalamic leads were programmed on single segment activation. There was no correlation between the length of microelectrode trajectory through the STN and use of directional stimulation. CONCLUSIONS Directional programming was more common than omnidirectional programming. Substantial gains in therapeutic current strength, therapeutic window, and total electrical energy were found in subthalamic and thalamic leads programmed on directional stimulation.
Collapse
Affiliation(s)
- Richard A Rammo
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alexandra White
- Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sean J Nagel
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Benjamin L Walter
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
11
|
Woodroffe RW, Pearson AC, Pearlman AM, Howard MA, Nauta HJW, Nagel SJ, Hori YS, Machado AG, Almeida Frizon L, Helland L, Holland MT, Gillies GT, Wilson S. Spinal Cord Stimulation for Visceral Pain: Present Approaches and Future Strategies. Pain Med 2020; 21:2298-2309. [PMID: 32719876 DOI: 10.1093/pm/pnaa108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The introduction of successful neuromodulation strategies for managing chronic visceral pain lag behind what is now treatment of choice in refractory chronic back and extremity pain for many providers in the United States and Europe. Changes in public policy and monetary support to identify nonopioid treatments for chronic pain have sparked interest in alternative options. In this review, we discuss the scope of spinal cord stimulation (SCS) for visceral pain, its limitations, and the potential role for new intradural devices of the type that we are developing in our laboratories, which may be able to overcome existing challenges. METHODS A review of the available literature relevant to this topic was performed, with particular focus on the pertinent neuroanatomy and uses of spinal cord stimulation systems in the treatment of malignant and nonmalignant gastrointestinal, genitourinary, and chronic pelvic pain. RESULTS To date, there have been multiple off-label reports testing SCS for refractory gastrointestinal and genitourinary conditions. Though some findings have been favorable for these organs and systems, there is insufficient evidence to make this practice routine. The unique configuration and layout of the pelvic pain pathways may not be ideally treated using traditional SCS implantation techniques, and intradural stimulation may be a viable alternative. CONCLUSIONS Despite the prevalence of visceral pain, the application of neuromodulation therapies, a standard approach for other painful conditions, has received far too little attention, despite promising outcomes from uncontrolled trials. Detailed descriptions of visceral pain pathways may offer several clues that could be used to implement devices tailored to this unique anatomy.
Collapse
Affiliation(s)
- Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy C Pearson
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy M Pearlman
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Haring J W Nauta
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - S J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Y S Hori
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Logan Helland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Marshall T Holland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| |
Collapse
|
12
|
Herring EZ, Shin JH, Nagel SJ, Krishnaney AA. Novel Strategy of Ventral Dural Repair for Idiopathic Thoracic Spinal Cord Herniation: Report of Outcomes and Review of Techniques. Oper Neurosurg (Hagerstown) 2020; 17:21-31. [PMID: 30517700 DOI: 10.1093/ons/opy244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 07/28/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Idiopathic ventral thoracic spinal cord herniation is a rare condition that usually presents with progressive myelopathy or Brown-Séquard syndrome. More than 100 cases have been reported with significant variance in surgical treatment strategies and likewise, significant variance in patient outcomes. Although laminectomy has often been used, to date, there is no consensus regarding the optimal surgical approach or strategy for ventral dural repair. OBJECTIVE To report and illustrate a novel approach to repair the ventral dural defect with more than 2 yr of clinical follow-up. The specific approach and graft used are both detailed. METHODS A retrospective chart review of all known cases of idiopathic spinal cord herniation at the Cleveland Clinic over the last 15 yr was performed. Postoperative outcome scores (including the Japanese Orthopedic Association score, European Myelopathy score, and Nurick) were calculated preoperatively and postoperatively. RESULTS A total of 5 patients were identified. Four of five patients improved clinically after surgery and 1 patient remained unchanged at last follow-up (average 23.2 mo, range 12-60 mo). There were no complications. All patients had postoperative magnetic resonance imaging demonstrating realignment of the spinal cord and no recurrence of tethering. CONCLUSION A unilateral dorsolateral, transpedicular approach combined with laminectomy provides excellent exposure for ventral or ventrolateral dural defects associated with idiopathic spinal cord herniation and minimizes spinal cord manipulation. A collagen matrix graft used as an onlay between the spinal cord and ventral dural defect is a safe and effective option for ventral dural repair.
Collapse
Affiliation(s)
- Eric Z Herring
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean J Nagel
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | | |
Collapse
|
13
|
Nagel SJ, Hsieh J, Machado AG, Frizon LA, Howard MA, Gillies GT, Wilson S. Biomarker Optimization of Spinal Cord Stimulation Therapies. Neuromodulation 2020; 24:3-12. [PMID: 32881257 DOI: 10.1111/ner.13252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We are in the process of designing and testing an intradural stimulation device that will shorten the distance between the location of the electrode array and the targeted neural tissue, thus improving the efficacy of electrical current delivery. Identifying a biomarker that accurately reflects the response to this intervention is highly valued because of the potential to optimize interventional parameters or predict a response before it is clinically measurable. In this report, we summarize the findings pertaining to the study of biomarkers so that we and others will have an up-to-date reference that critically evaluates the current approaches and select one or several for testing during the development of our device. MATERIALS AND METHODS We have conducted a broad survey of the existing literature to catalogue the biomarkers that could be coupled to intradural spinal cord stimulation. We describe in detail some of the most promising biomarkers, existing limitations, and suitability to managing chronic pain. RESULTS Chronic, intractable pain is an all-encompassing condition that is incurable. Many treatments for managing chronic pain are nonspecific in action and intermittently administered; therefore, patients are particularly susceptible to large fluctuations in pain control over the course of a day. The absence of a reliable biomarker challenges assessment of therapeutic efficacy and contributes to either incomplete and inconsistent pain relief or, alternatively, intolerable side effects. Fluctuations in metabolites or inflammatory markers, signals captured during dynamic imaging, and genomics will likely have a role in governing how a device is modulated. CONCLUSIONS Efforts to identify one or more biomarkers are well underway with some preliminary evidence supporting their efficacy. This has far-reaching implications, including improved outcomes, fewer adverse events, harmonization of treatment and individuals, performance gains, and cost savings. We anticipate that novel biomarkers will be used widely to manage chronic pain.
Collapse
Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Hsieh
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo A Frizon
- Department of Neurosurgery, Hospital Marcelino Champagnat, Curitiba, PR, Brazil
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| |
Collapse
|
14
|
Frizon LA, Yamamoto EA, Nagel SJ, Simonson MT, Hogue O, Machado AG. Deep Brain Stimulation for Pain in the Modern Era: A Systematic Review. Neurosurgery 2020; 86:191-202. [PMID: 30799493 DOI: 10.1093/neuros/nyy552] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 01/25/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been considered for patients with intractable pain syndromes since the 1950s. Although there is substantial experience reported in the literature, the indications are contested, especially in the United States where it remains off-label. Historically, the sensory-discriminative pain pathways were targeted. More recently, modulation of the affective sphere of pain has emerged as a plausible alternative. OBJECTIVE To systematically review the literature from studies that used contemporary DBS technology. Our aim is to summarize the current evidence of this therapy. METHODS A systematic search was conducted in the MEDLINE, EMBASE, and Cochrane libraries through July 2017 to review all studies using the current DBS technology primarily for pain treatment. Study characteristics including patient demographics, surgical technique, outcomes, and complications were collected. RESULTS Twenty-two articles were included in this review. In total, 228 patients were implanted with a definitive DBS system for pain. The most common targets used were periaqueductal/periventricular gray matter region, ventral posterior lateral/posterior medial thalamus, or both. Poststroke pain, phantom limb pain, and brachial plexus injury were the most common specific indications for DBS. Outcomes varied between studies and across chronic pain diagnoses. Two different groups of investigators targeting the affective sphere of pain have demonstrated improvements in quality of life measures without significant reductions in pain scores. CONCLUSION DBS outcomes for chronic pain are heterogeneous thus far. Future studies may focus on specific pain diagnosis rather than multiple syndromes and consider randomized placebo-controlled designs. DBS targeting the affective sphere of pain seems promising and deserves further investigation.
Collapse
Affiliation(s)
- Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Erin A Yamamoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Olivia Hogue
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
15
|
Abbatemarco JR, Griffin A, Jones NG, Hartman J, McKee K, Wang Z, Nagel SJ, Machado AG, Bethoux F. Long-term outcomes of intrathecal baclofen in ambulatory multiple sclerosis patients: A single-center experience. Mult Scler 2020; 27:933-941. [PMID: 32662728 DOI: 10.1177/1352458520936912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intrathecal baclofen (ITB) is traditionally reserved for non-ambulatory patients. OBJECTIVE To investigate outcomes of ITB in ambulatory multiple sclerosis (MS) patients. METHODS Changes in outcome measures were estimated by a mixed effect model, while the complication rate was calculated using a logistic regression. Predictors of non-ambulatory status were identified by Cox model. RESULTS In all, 256 patients received an ITB test injection and 170 underwent ITB surgery. Aggregate Modified Ashworth Scale (MAS) scores for the ambulatory ITB cohort decreased from 13.5 ± 6.96 to 4.54 ± 4.18 at 5 years (p < 0.001). There was no significant change in walking speed 1 year post ITB surgery (0.45 m/second ± 0.30 vs 0.38 m/second ± 0.39, p = 0.80) with 77.8% of patients remaining ambulatory which decreased to 41.7% at year 5. Longer MS disease duration (hazard ratio (HR): 1.04; 95% confidence interval (CI): 1.01-1.07; p = 0.018) and lower hip flexor strength (HR: 0.40; 95% CI: 0.27-0.57; p < 0.001) predicted non-ambulatory status after surgery. Complications were more likely in the ambulatory cohort (odds ratio (OR): 3.30, 95% CI: 2.17-5.02; p = 0.017). CONCLUSION ITB is effective for ambulatory MS patients without compromising short-term walking speed, although a higher complication rate was observed in this cohort.
Collapse
Affiliation(s)
- Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Austin Griffin
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Noble G Jones
- Department of Internal Medicine, Duke University, Durham, NC, USA/Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, West Orange, NJ, USA
| | - Jennifer Hartman
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Keith McKee
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Zhini Wang
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sean J Nagel
- Department of Neurosurgery, Center for Neurological Restoration, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Andre G Machado
- Department of Neurosurgery, Center for Neurological Restoration, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Francois Bethoux
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA/Department of Physical Medicine & Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
16
|
Nunn AC, Jones HE, Morosanu CO, Singleton WGB, Williams MA, Nagel SJ, Luciano MG, Zwimpfer TJ, Holubkov R, Wisoff JH, McKhann GM, Hamilton MG, Edwards RJ. Extended lumbar drainage in idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis of diagnostic test accuracy. Br J Neurosurg 2020; 35:285-291. [PMID: 32643967 DOI: 10.1080/02688697.2020.1787948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND When appropriately selected, a high proportion of patients with suspected idiopathic normal pressure hydrocephalus (iNPH) will respond to cerebrospinal fluid diversion with a shunt. Extended lumbar drainage (ELD) is regarded as the most accurate test for this condition, however, varying estimates of its accuracy are found in the current literature. Here, we review the literature in order to provide summary estimates of sensitivity, specificity, positive- and negative predictive value for this test through meta-analysis of suitably rigorous studies. METHODS Studies involving a population of NPH patients with predominantly idiopathic aetiology (>80%) in which the intention of the study was to shunt patients regardless of the outcome of ELD were included in the review. Various literature databases were searched to identify diagnostic test accuracy studies addressing ELD in the diagnosis of iNPH. Those studies passing screening and eligibility were assessed using the QUADAS-2 tool and data extracted for bivariate random effects meta-analysis. RESULTS Four small studies were identified. They showed disparate results concerning diagnostic test accuracy. The summary estimates for sensitivity and specificity were 94% (CI 41-100%) and 85% (CI 33-100%), respectively. The summary estimates of positive and negative predictive value were both 90% (CIs 65-100% and 48-100%, respectively). CONCLUSION Large, rigorous studies addressing the diagnostic accuracy of ELD are lacking, and little robust evidence exists to support the use of ELD in diagnostic algorithms for iNPH. Therefore, a large cohort study, or ideally an RCT, is needed to determine best practice in selecting patients for shunt surgery.
Collapse
Affiliation(s)
- Adam C Nunn
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Michael A Williams
- Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA.,Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA
| | - Sean J Nagel
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Mark G Luciano
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thomas J Zwimpfer
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Richard Holubkov
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jeffrey H Wisoff
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital at NYU Langone Health, New York, NY, USA
| | - Guy M McKhann
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Neurological Surgery, Columbia University School of Medicine, New York, NY, USA
| | - Mark G Hamilton
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary School of Medicine, Calgary, Canada
| | - Richard J Edwards
- Department of Neurosurgery, Southmead Hospital, Bristol, UK.,Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA
| |
Collapse
|
17
|
Mureb M, Golub D, Benjamin C, Gurewitz J, Strickland BA, Zada G, Chang E, Urgošík D, Liščák R, Warnick RE, Speckter H, Eastman S, Kaufmann AM, Patel S, Feliciano CE, Carbini CH, Mathieu D, Leduc W, Nagel SJ, Hori YS, Hung YC, Ogino A, Faramand A, Kano H, Lunsford LD, Sheehan J, Kondziolka D. Earlier radiosurgery leads to better pain relief and less medication usage for trigeminal neuralgia patients: an international multicenter study. J Neurosurg 2020:1-8. [PMID: 32619989 DOI: 10.3171/2020.4.jns192780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 04/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Trigeminal neuralgia (TN) is a chronic pain condition that is difficult to control with conservative management. Furthermore, disabling medication-related side effects are common. This study examined how stereotactic radiosurgery (SRS) affects pain outcomes and medication dependence based on the latency period between diagnosis and radiosurgery. METHODS The authors conducted a retrospective analysis of patients with type I TN at 12 Gamma Knife treatment centers. SRS was the primary surgical intervention in all patients. Patient demographics, disease characteristics, treatment plans, medication histories, and outcomes were reviewed. RESULTS Overall, 404 patients were included. The mean patient age at SRS was 70 years, and 60% of the population was female. The most common indication for SRS was pain refractory to medications (81%). The median maximum radiation dose was 80 Gy (range 50-95 Gy), and the mean follow-up duration was 32 months. The mean number of medications between baseline (pre-SRS) and the last follow-up decreased from 1.98 to 0.90 (p < 0.0001), respectively, and this significant reduction was observed across all medication categories. Patients who received SRS within 4 years of their initial diagnosis achieved significantly faster pain relief than those who underwent treatment after 4 years (median 21 vs 30 days, p = 0.041). The 90-day pain relief rate for those who received SRS ≤ 4 years after their diagnosis was 83.8% compared with 73.7% in patients who received SRS > 4 years after their diagnosis. The maximum radiation dose was the strongest predictor of a durable pain response (OR 1.091, p = 0.003). Early intervention (OR 1.785, p = 0.007) and higher maximum radiation dose (OR 1.150, p < 0.0001) were also significant predictors of being pain free (a Barrow Neurological Institute pain intensity score of I-IIIA) at the last follow-up visit. New sensory symptoms of any kind were seen in 98 patients (24.3%) after SRS. Higher maximum radiation dose trended toward predicting new sensory deficits but was nonsignificant (p = 0.075). CONCLUSIONS TN patients managed with SRS within 4 years of diagnosis experienced a shorter interval to pain relief with low risk. SRS also yielded significant decreases in adjunct medication utilization. Radiosurgery should be considered earlier in the course of treatment for TN.
Collapse
Affiliation(s)
- Monica Mureb
- 1Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Danielle Golub
- 1Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Carolina Benjamin
- 1Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Jason Gurewitz
- 1Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | | | | | - Eric Chang
- 3Radiation Oncology, University of Southern California, Los Angeles, California
| | - Dušan Urgošík
- 4Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liščák
- 4Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Ronald E Warnick
- 5Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio
| | - Herwin Speckter
- 6Centro Gamma Knife Dominicano, CEDIMAT, Santo Domingo, Dominican Republic
| | - Skyler Eastman
- 7Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anthony M Kaufmann
- 7Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Samir Patel
- 8Department of Oncology, Division of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Caleb E Feliciano
- 9Department of Neurosurgery, University of Puerto Rico, School of Medicine, San Juan, Puerto Rico
| | - Carlos H Carbini
- 10Administración de Servicios Médicos de Puerto Rico, Centro Gamma Knife de Puerto Rico y El Caribe, San Juan, Puerto Rico
| | - David Mathieu
- 11Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada
| | | | -
- 11Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada
| | - Sean J Nagel
- 12Center for Neuro-Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Yusuke S Hori
- 12Center for Neuro-Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Yi-Chieh Hung
- 13Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Akiyoshi Ogino
- 14Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Faramand
- 14Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- 14Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 14Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason Sheehan
- 13Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Douglas Kondziolka
- 1Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| |
Collapse
|
18
|
Williams MA, Nagel SJ, Luciano MG, Relkin N, Zwimpfer TJ, Katzen H, Holubkov R, Moghekar A, Wisoff JH, McKhann GM, Golomb J, Edwards RJ, Hamilton MG. The clinical spectrum of hydrocephalus in adults: report of the first 517 patients of the Adult Hydrocephalus Clinical Research Network registry. J Neurosurg 2020; 132:1773-1784. [DOI: 10.3171/2019.2.jns183538] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors describe the demographics and clinical characteristics of the first 517 patients enrolled in the Adult Hydrocephalus Clinical Research Network (AHCRN) during its first 2 years.METHODSAdults ≥ 18 years were nonconsecutively enrolled in a registry at 6 centers. Four categories of adult hydrocephalus were defined: transition (treated before age 18 years), unrecognized congenital (congenital pattern, not treated before age 18 years), acquired (secondary to known risk factors, treated or untreated), and suspected idiopathic normal pressure hydrocephalus (iNPH) (≥ age 65 years, not previously treated). Data include etiology, symptoms, examination findings, neuropsychology screening, comorbidities, treatment, complications, and outcomes. Standard evaluations were administered to all patients by trained examiners, including the Montreal Cognitive Assessment, the Symbol Digit Modalities Test, the Beck Depression Inventory–II, the Overactive Bladder Questionnaire Short Form symptom bother, the 10-Meter Walk Test, the Boon iNPH gait scale, the Lawton Activities of Daily Living/Instrumental Activities of Daily Living (ADL/IADL) questionnaire, the iNPH grading scale, and the modified Rankin Scale.RESULTSOverall, 517 individuals were enrolled. Age ranged from 18.1 to 90.7 years, with patients in the transition group (32.7 ± 10.0 years) being the youngest and those in the suspected iNPH group (76.5 ± 5.2 years) being the oldest. The proportion of patients in each group was as follows: 16.6% transition, 26.5% unrecognized congenital, 18.2% acquired, and 38.7% suspected iNPH. Excluding the 86 patients in the transition group, who all had received treatment, 79.4% of adults in the remaining 3 groups had not been treated at the time of enrollment. Patients in the suspected iNPH group had the poorest performance in cognitive evaluations, and those in the unrecognized congenital group had the best performance. The same pattern was seen in the Lawton ADL/IADL scores. Gait velocity was lowest in patients in the suspected iNPH group. Categories that had the most comorbidities (suspected iNPH) or etiologies of hydrocephalus that directly cause neurological injury (transition, acquired) had greater degrees of impairment compared to unrecognized congenital, which had the fewest comorbidities or etiologies associated with neurological injury.CONCLUSIONSThe clinical spectrum of hydrocephalus in adults comprises more than iNPH or acquired hydrocephalus. Only 39% of patients had suspected iNPH, whereas 43% had childhood onset (i.e., those in the transition and unrecognized congenital groups). The severity of symptoms and impairment was worsened when the etiology of the hydrocephalus or complications of treatment caused additional neurological injury or when multiple comorbidities were present. However, more than half of patients in the transition, unrecognized congenital, and acquired hydrocephalus groups had minimal or no impairment. Excluding the transition group, nearly 80% of patients in the AHCRN registry were untreated at the time of enrollment. A future goal for the AHCRN is to determine whether patients with unrecognized congenital and acquired hydrocephalus need treatment and which patients in the suspected iNPH cohort actually have possible hydrocephalus and should undergo further diagnostic testing. Future prospective research is needed in the diagnosis, treatment, outcomes, quality of life, and macroeconomics of all categories of adult hydrocephalus.
Collapse
Affiliation(s)
- Michael A. Williams
- 1Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Sean J. Nagel
- 2Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Mark G. Luciano
- 3Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Norman Relkin
- 4Department of Neurology, Weill Cornell School of Medicine, New York, New York
| | - Thomas J. Zwimpfer
- 5Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather Katzen
- 6Department of Neurology, University of Miami Miller School of Medicine, Florida
| | - Richard Holubkov
- 7Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Abhay Moghekar
- 8Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeffrey H. Wisoff
- 9Division of Pediatric Neurosurgery, Hassenfeld Children’s Hospital at NYU Langone Health
| | - Guy M. McKhann
- 10Department of Neurological Surgery, Columbia University School of Medicine
| | - James Golomb
- 11Department of Neurology, New York University School of Medicine, New York, New York,
| | - Richard J. Edwards
- 12Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom; and
| | - Mark G. Hamilton
- 13Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
19
|
Hori YS, Sharma A, Nagel SJ. Insidious abdominal wall pseudocyst following ventriculoperitoneal shunting. Interdisciplinary Neurosurgery 2020. [DOI: 10.1016/j.inat.2019.100597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
20
|
Golubovsky JL, Li H, Momin A, Shao J, Lee MY, Frizon LA, Hogue O, Walter B, Machado AG, Nagel SJ. Predictors of second-sided deep brain stimulation for Parkinson's disease. J Neurosurg 2020:1-7. [PMID: 32059181 DOI: 10.3171/2019.12.jns19638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 12/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parkinson's disease (PD) is a progressive neurological movement disorder that is commonly treated with deep brain stimulation (DBS) surgery in advanced stages. The purpose of this study was to investigate factors that affect time to placement of a second-sided DBS lead for PD when a unilateral lead is initially placed for asymmetrical presentation. The decision whether to initially perform unilateral or bilateral DBS is largely based on physician and/or patient preference. METHODS This study was a retrospective cohort analysis of patients with PD undergoing initial unilateral DBS for asymmetrical disease between January 1999 and December 2017 at the authors' institution. Patients treated with DBS for essential tremor or other conditions were excluded. Variables collected included demographics at surgery, time since diagnosis, Unified Parkinson's Disease Rating Scale motor scores (UPDRS-III), patient-reported quality-of-life outcomes, side of operation, DBS target, intraoperative complications, and date of follow-up. Paired t-tests were used to assess mean changes in UPDRS-III. Cox proportional hazards analysis and the Kaplan-Meier method were used to determine factors associated with time to second lead insertion over 5 years. RESULTS The final cohort included 105 patients who underwent initial unilateral DBS for asymmetrical PD; 59% of patients had a second-sided lead placed within 5 years with a median time of 34 months. Factors found to be significantly associated with early second-sided DBS included patient age 65 years or younger, globus pallidus internus (GPi) target, and greater off-medication reduction in UPDRS-III score following initial surgery. Older age was also found to be associated with a smaller preoperative UPDRS-III levodopa responsiveness score and with a smaller preoperative to postoperative medication-off UPDRS-III change. CONCLUSIONS Younger patients, those undergoing GPi-targeted unilateral DBS, and patients who responded better to the initial DBS were more likely to undergo early second-sided lead placement. Therefore, these patients, and patients who are more responsive to medication preoperatively (as a proxy for DBS responsiveness), may benefit from consideration of initial bilateral DBS.
Collapse
Affiliation(s)
- Joshua L Golubovsky
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute
| | - Hong Li
- 2Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic; and
| | - Arbaz Momin
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute
| | - Jianning Shao
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute
| | - Maxwell Y Lee
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute
| | | | - Olivia Hogue
- 2Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic; and
| | - Benjamin Walter
- 3Center for Neurological Restoration, and.,Departments of4Neurology and
| | - André G Machado
- 3Center for Neurological Restoration, and.,5Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sean J Nagel
- 3Center for Neurological Restoration, and.,5Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
21
|
Frizon LA, Gopalakrishnan R, Hogue O, Floden D, Nagel SJ, Baker KB, Isolan GR, Stefani MA, Machado AG. Cortical thickness in visuo-motor areas is related to motor outcomes after STN DBS for Parkinson's disease. Parkinsonism Relat Disord 2020; 71:17-22. [PMID: 31978672 DOI: 10.1016/j.parkreldis.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/07/2019] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is a widely accepted therapy for Parkinson's disease. While outcome predictors such as levodopa-response are well established, there remains a need for objective and unbiased predictors in clinical practice. We performed an exploratory study to examine whether cortical thickness, derived from preoperative MRI, correlates with postoperative outcome. METHODS Using freesurfer, we retrospectively measured cortical thickness on the preoperative MRI of 38 patients who underwent bilateral STN-DBS for PD during a 4-year period. The Unified Parkinson Disease Rating motor (UPDRS III) and experiences of daily living subscales (UPDRS II) were collected at baseline and six months after surgery. As an initial analysis, a series of partial correlations was conducted to evaluate the association between postoperative outcome scores and average cortical thickness from predefined regions of interest, adjusting for candidate confounders, without correcting for multiple comparisons. A confirmatory vertex-wise analysis was performed using a cluster-wise correction for multiple comparisons. RESULTS Based on the ROI analysis, the strongest correlation with motor outcome was found to be with the left lateral-occipital cortex. Patients with greater cortical thickness in this area presented with greater improvements in motor scores. This relationship was also supported by the vertex-wise analysis. Greater cortical thickness in frontal and temporal regions may be correlated with greater post-operative improvements in UPDRS II, but this was not confirmed in the vertex-wise analysis. CONCLUSIONS Our data indicate that greater cortical thickness in visuo-motor areas is correlated with motor outcomes after DBS for PD. Further prospective investigations are needed to confirm our findings and better-investigate potential image biomarkers.
Collapse
Affiliation(s)
- Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Raghavan Gopalakrishnan
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olivia Hogue
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Darlene Floden
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth B Baker
- Department of Neuroscience, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gustavo R Isolan
- Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Marco A Stefani
- Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
22
|
Hori Y, Machado A, Nagel SJ. Preoperative Radiological Finding at the Lumbar Spinal Level Is a Novel Predictive Factor for Postoperative Outcome After Spinal Cord Stimulation in Patients With Failed Back Surgery Syndrome. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
23
|
Nagel SJ, Frizon L, Maiti T, Machado AG, Gillies GT, Helland L, Woodroffe RW, Howard MA, Wilson S. Contemporary Approaches to Preventing and Treating Infections of Novel Intrathecal Neurostimulation Devices. World Neurosurg 2019; 128:e397-e408. [DOI: 10.1016/j.wneu.2019.04.165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 02/04/2023]
|
24
|
Maldonado-Naranjo AL, Golubovsky JL, Frizon LA, Hogue O, Lobel DA, Machado AG, Steinmetz MP, Nagel SJ. The Role of Additional Spine Surgery in the Management of Failed Back Surgery Syndrome, Complex Regional Pain Syndrome, and Intractable Pain in the Setting of Previous or Concurrent Spinal Cord Stimulation: Indications and Outcomes. World Neurosurg 2019; 125:e416-e423. [DOI: 10.1016/j.wneu.2019.01.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
|
25
|
Anderson DJ, Kipke DR, Nagel SJ, Lempka SF, Machado AG, Holland MT, Gillies GT, Howard MA, Wilson S. Intradural Spinal Cord Stimulation: Performance Modeling of a New Modality. Front Neurosci 2019; 13:253. [PMID: 30941012 PMCID: PMC6434968 DOI: 10.3389/fnins.2019.00253] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 03/04/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction: Intradural spinal cord stimulation (SCS) may offer significant therapeutic benefits for those with intractable axial and extremity pain, visceral pain, spasticity, autonomic dysfunction and related disorders. A novel intradural electrical stimulation device, limited by the boundaries of the thecal sac, CSF and spinal cord was developed to test this hypothesis. In order to optimize device function, we have explored finite element modeling (FEM). Methods: COMSOL®Multiphysics Electrical Currents was used to solve for fields and currents over a geometric model of a spinal cord segment. Cathodic and anodic currents are applied to the center and tips of the T-cross component of the electrode array to shape the stimulation field and constrain charge-balanced cathodic pulses to the target area. Results: Currents from the electrode sites can move the effective stimulation zone horizontally across the cord by a linear step method, which can be diversified considerably to gain greater depth of penetration relative to standard epidural SCS. It is also possible to prevent spread of the target area with no off-target action potential. Conclusion: Finite element modeling of a T-shaped intradural spinal cord stimulator predicts significant gains in field depth and current shaping that are beyond the reach of epidural stimulators. Future studies with in vivo models will investigate how this approach should first be tested in humans.
Collapse
Affiliation(s)
- David J Anderson
- NeuroNexus Technologies, Ann Arbor, MI, United States.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Daryl R Kipke
- NeuroNexus Technologies, Ann Arbor, MI, United States
| | - Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
| | - Marshall T Holland
- Department of Neurosurgery, University of Iowa Hospitals & Clinics, Iowa City, IA, United States
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, United States
| | - Mathew A Howard
- Department of Neurosurgery, University of Iowa Hospitals & Clinics, Iowa City, IA, United States
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals & Clinics, Iowa City, IA, United States
| |
Collapse
|
26
|
Nagel SJ, Helland L, Woodroffe RW, Frizon LA, Holland MT, Machado AG, Yamaguchi S, Gillies GT, Howard MA, Wilson S. Durotomy Surrogate and Seals for Intradural Spinal Cord Stimulators: Apparatus and Review of Clinical Methods and Materials. Neuromodulation 2019; 22:916-929. [DOI: 10.1111/ner.12913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/14/2018] [Accepted: 11/14/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Sean J. Nagel
- Neurological SurgeryCleveland Clinic Cleveland, OH USA
| | - Logan Helland
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | - Royce W. Woodroffe
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | | | - Marshall T. Holland
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | | | - Satoshi Yamaguchi
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | - George T. Gillies
- Department of Mechanical and Aerospace EngineeringUniversity of Virginia Charlottesville VA USA
| | - Matthew A. Howard
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | - Saul Wilson
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| |
Collapse
|
27
|
Xiong DD, Ye W, Xiao R, Miller JA, Mroz TE, Steinmetz MP, Nagel SJ, Machado AG. Patient-reported allergies predict postoperative outcomes and psychosomatic markers after spine surgery. Spine J 2019; 19:121-130. [PMID: 29800707 DOI: 10.1016/j.spinee.2018.05.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/13/2018] [Accepted: 05/17/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes. PURPOSE The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery. STUDY DESIGN/SETTING This is a retrospective cohort study at a single tertiary care institution. PATIENT SAMPLE The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014. OUTCOME MEASURES The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission. METHODS Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes. RESULTS A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1-58.2 for cervical patients and 79.4-58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05-4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03-1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10). CONCLUSIONS Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year.
Collapse
Affiliation(s)
- David D Xiong
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Wenda Ye
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Roy Xiao
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Jacob A Miller
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Radiation Oncology, Stanford Medicine, Stanford, CA, USA
| | - Thomas E Mroz
- Department of Neurological Surgery, Cleveland Clinic, 9500 Euclid Ave, S-31, Cleveland, OH 44195, USA; Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Michael P Steinmetz
- Department of Neurological Surgery, Cleveland Clinic, 9500 Euclid Ave, S-31, Cleveland, OH 44195, USA; Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Sean J Nagel
- Department of Neurological Surgery, Cleveland Clinic, 9500 Euclid Ave, S-31, Cleveland, OH 44195, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Andre G Machado
- Department of Neurological Surgery, Cleveland Clinic, 9500 Euclid Ave, S-31, Cleveland, OH 44195, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| |
Collapse
|
28
|
Matias CM, Frizon LA, Nagel SJ, Lobel DA, Machado AG. Deep brain stimulation outcomes in patients implanted under general anesthesia with frame-based stereotaxy and intraoperative MRI. J Neurosurg 2018; 129:1572-1578. [DOI: 10.3171/2017.7.jns171166] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors’ aim in this study was to evaluate placement accuracy and clinical outcomes in patients who underwent implantation of deep brain stimulation devices with the aid of frame-based stereotaxy and intraoperative MRI after induction of general anesthesia.METHODSThirty-three patients with movement disorders (27 with Parkinson’s disease) underwent implantation of unilateral or bilateral deep brain stimulation systems (64 leads total). All patients underwent the implantation procedure with standard frame-based techniques under general anesthesia and without microelectrode recording. MR images were acquired immediately after the procedure and fused to the preoperative plan to verify accuracy. To evaluate clinical outcome, different scales were used to assess quality of life (EQ-5D), activities of daily living (Unified Parkinson’s Disease Rating Scale [UPDRS] part II), and motor function (UPDRS part III during off- and on-medication and off- and on-stimulation states). Accuracy was assessed by comparing the coordinates (x, y, and z) from the preoperative plan and coordinates from the tip of the lead on intraoperative MRI and postoperative CT scans.RESULTSThe EQ-5D score improved or remained stable in 71% of the patients. When in the off-medication/on-stimulation state, all patients reported significant improvement in UPDRS III score at the last follow-up (p < 0.001), with a reduction of 25.2 points (46.3%) (SD 14.7 points and 23.5%, respectively). There was improvement or stability in the UPDRS II scores for 68% of the Parkinson’s patients. For 2 patients, the stereotactic error was deemed significant based on intraoperative MRI findings. In these patients, the lead was removed and replaced after correcting for the error during the same procedure. Postoperative lead revision was not necessary in any of the patients. Based on findings from the last intraoperative MRI study, the mean difference between the tip of the electrode and the planned target was 0.82 mm (SD 0.5 mm, p = 0.006) for the x-axis, 0.67 mm (SD 0.5 mm, p < 0.001) for the y-axis, and 0.78 mm (SD 0.7 mm, p = 0.008) for the z-axis. On average, the euclidian distance was 1.52 mm (SD 0.6 mm). In patients who underwent bilateral implantation, accuracy was further evaluated comparing the first implanted side and the second implanted side. There was a significant mediolateral (x-axis) difference (p = 0.02) in lead accuracy between the first (mean 1.02 mm, SD 0.57 mm) and the second (mean 0.66 mm, SD 0.50 mm) sides. However, no significant difference was found for the y- and z-axes (p = 0.10 and p = 0.89, respectively).CONCLUSIONSFrame-based DBS implantation under general anesthesia with intraoperative MRI verification of lead location is safe, accurate, precise, and effective compared with standard implantation performed using awake intraoperative physiology. More clinical trials are necessary to directly compare outcomes of each technique.
Collapse
Affiliation(s)
- Caio M. Matias
- 2Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Leonardo A. Frizon
- 1Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio; and
| | - Sean J. Nagel
- 1Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio; and
| | - Darlene A. Lobel
- 1Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio; and
| | - André G. Machado
- 1Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio; and
| |
Collapse
|
29
|
Achey RL, Yamamoto E, Sexton D, Hammer C, Lee BS, Butler RS, Thompson NR, Nagel SJ, Machado AG, Lobel DA. Prediction of depression and anxiety via patient-assessed tremor severity, not physician-reported motor symptom severity, in patients with Parkinson’s disease or essential tremor who have undergone deep brain stimulation. J Neurosurg 2018; 129:1562-1571. [DOI: 10.3171/2017.8.jns1733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 08/28/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDeep brain stimulation (DBS) is an effective therapy for movement disorders such as idiopathic Parkinson’s disease (PD) and essential tremor (ET). However, some patients who demonstrate benefit on objective motor function tests do not experience postoperative improvement in depression or anxiety, 2 important components of quality of life (QOL). Thus, to examine other possible explanations for the lack of a post-DBS correlation between improved objective motor function and decreased depression or anxiety, the authors investigated whether patient perceptions of motor symptom severity might contribute to disease-associated depression and anxiety.METHODSThe authors performed a retrospective chart review of PD and ET patients who had undergone DBS at the Cleveland Clinic in the period from 2009 to 2013. Patient demographics, diagnosis (PD, ET), motor symptom severity, and QOL measures (Primary Care Evaluation of Mental Disorders 9-item Patient Health Questionnaire [PHQ-9] for depression, Generalized Anxiety Disorder 7-item Scale [GAD-7], and patient-assessed tremor scores) were collected at 4 time points: preoperatively, postoperatively, 1-year follow-up, and 2-year follow-up. Multivariable prediction models with solutions for fixed effects were constructed to assess the correlation of predictor variables with PHQ-9 and GAD-7 scores. Predictor variables included age, sex, visit time, diagnosis (PD vs ET), patient-assessed tremor, physician-reported tremor, Unified Parkinson’s Disease Rating Scale part III (UPDRS-III) score, and patient-assessed tremor over time.RESULTSSeventy PD patients and 17 ET patients were included in this analysis. Mean postoperative and 1-year follow-up UPDRS-III and physician-reported tremor scores were significantly decreased compared with preoperative scores (p < 0.0001). Two-year follow-up physician-reported tremor was also significantly decreased from preoperative scores (p < 0.0001). Only a diagnosis of PD (p = 0.0047) and the patient-assessed tremor rating (p < 0.0001) were significantly predictive of depression. A greater time since surgery, in general, significantly decreased anxiety scores (p < 0.0001) except when a worsening of patient-assessed tremor was reported over the same time period (p < 0.0013).CONCLUSIONSPatient-assessed tremor severity alone was predictive of depression in PD and ET following DBS. This finding suggests that a patient’s perception of illness plays a greater role in depression than objective physical disability regardless of the time since surgical intervention. In addition, while anxiety may be attenuated by DBS, patient-assessed return of tremor over time can increase anxiety, highlighting the importance of long-term follow-up for behavioral health features in chronic neurological disorders. Together, these data suggest that the patient experience of motor symptoms plays a role in depression and anxiety—a finding that warrants consideration when evaluating, treating, and following movement disorder patients who are candidates for DBS.
Collapse
Affiliation(s)
- Rebecca L. Achey
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Erin Yamamoto
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Daniel Sexton
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Christine Hammer
- 2Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Bryan S. Lee
- 3Department of Neurosurgery, Neurological Institute
| | | | | | - Sean J. Nagel
- 5Center for Neurological Restoration, Department of Neurosurgery, Neurological Institute
| | - Andre G. Machado
- 5Center for Neurological Restoration, Department of Neurosurgery, Neurological Institute
- 6Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio; and
| | - Darlene A. Lobel
- 5Center for Neurological Restoration, Department of Neurosurgery, Neurological Institute
- 6Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio; and
| |
Collapse
|
30
|
Wilson S, Nagel SJ, Frizon LA, Fredericks DC, DeVries-Watson NA, Gillies GT, Howard MA. The Hemisection Approach in Large Animal Models of Spinal Cord Injury: Overview of Methods and Applications. J INVEST SURG 2018; 33:240-251. [PMID: 30380340 DOI: 10.1080/08941939.2018.1492048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Translating basic science research into a safe and effective therapy for spinal cord injury (SCI) requires suitable large animal models for testing both implantable devices and biologic approaches to better approximate human anatomy and function. Hemisection lesions, routinely used for investigational purposes in small animals, are less frequently described in large animals that might be appropriate for translational studies. Size constraints of small animals (mice and rats) limits the predictability of the findings when scaled up. Our goal is to review the status of hemisection SCI in large animals across species and time to prepare for the testing of a novel intradural spinal cord stimulation device for control of spasticity in an ovine model. Methods and Results: We surveyed the literature on hemisection in quadrupeds and nonhuman primates, and catalogued the species, protocols and outcomes of the experimental work in this field. Feline, lapine, canine, simian, porcine, ovine and bovine models were the primary focal points. There is a consistent body of literature reporting use of the hemisection approach in large animals, but with differences in surgical technique depending on the goals and nature of the individual studies. While the injuries are not always consistent, the experimental variability is generally lower than that of the contusion-based approach. In general, as the body size of the animal increases, animal care requirements and the associated costs follow. In most cases, this is inversely correlated with the number of animals used in hemisection models. Conclusions: The hemisection approach to modeling SCI is straightforward compared with other methods such as the contusive impact and enables the transection of isolated ascending and descending tracts and segment specific cell bodies. This has certain advantages in models investigating post-injury axonal regrowth. However, this approach is not generally in line with the patho-physiologies encountered in SCI patients. Even so, the ability to achieve more control over the level of injury makes it a useful adjunct to contusive and ischemic approaches, and suggests a useful role in future translational studies.
Collapse
Affiliation(s)
- S Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - S J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - L A Frizon
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - D C Fredericks
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - N A DeVries-Watson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - G T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - M A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| |
Collapse
|
31
|
Williams MA, Luciano MG, Nagel SJ, Relkin N, Zwimpfer TJ, Katzen H, Holubkov R, Hamilton MG. 357 Demographics and Characteristics of Hydrocephalus in Adults. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
32
|
Frizon LA, Sabharwal NC, Maiti T, Golubovsky J, May F, Shao J, Machado AG, Nagel SJ. Removal of Intrathecal Catheters Used in Drug Delivery Systems. Neuromodulation 2018; 21:665-668. [DOI: 10.1111/ner.12799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Leonardo A. Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | | | - Tanmoy Maiti
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | | | - Francis May
- Cleveland Clinic Lerner College of Medicine; Cleveland OH USA
| | - Jianning Shao
- Cleveland Clinic Lerner College of Medicine; Cleveland OH USA
| | - Andre G. Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Sean J. Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| |
Collapse
|
33
|
Shao J, Frizon L, Machado AG, McKee K, Bethoux F, Hartman J, Nagel SJ. Occlusion of the Ascenda Catheter in a Patient with Pump Twiddler's Sydrome: A Case Report. Anesth Pain Med 2018; 8:e65312. [PMID: 30027067 PMCID: PMC6045776 DOI: 10.5812/aapm.65312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/05/2018] [Accepted: 04/22/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction Intrathecal baclofen (ITB) therapy is an effective way to manage spasticity in numerous conditions, including multiple sclerosis, stroke, and cerebral palsy. While pump failure is a common complication of ITB, improvements in device design have led to reduction of complications. In particular, the Ascenda catheter from Medtronic, Inc. was designed to resist kinking and associated complications; indeed, no incidences of catheter twisting or occlusion have been reported in literature prior to this case. Case Report We report a case of a 32-year old gentleman who presented to the clinic with symptoms of baclofen withdrawal 19 months after he had a programmable pump implanted for spasticity. During the diagnostic evaluation it was discovered that the patients pump had flipped in his abdominal pocket. He was taken to surgery to reorient the pump, during which time it was noted the catheter was tightly coiled on itself occluding flow. The twisted catheter was excised and replaced with a new segment.His symptoms subsequently resolved. Conclusions Although catheter occlusions have subsided since the approval of the Ascenda catheter, pump twiddler's syndrome remains a risk factor for this complication. This is the first report describing this syndrome in a patient with the Ascenda catheter.
Collapse
Affiliation(s)
- Jianning Shao
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
- Corresponding author: Jianning Shao, B.A., Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 44195, 9980 Carnegie Ave, Cleveland, OH. Tel: +1-8474360396, Fax: +1-216444.1015, E-mail:
| | - Leonardo Frizon
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Andre G. Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Keith McKee
- Mellen Center, Cleveland Clinic, Cleveland, OH
| | | | | | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
34
|
Frizon LA, Nagel SJ, May FJ, Shao J, Maldonado-Naranjo AL, Fernandez HH, Machado AG. Outcomes following deep brain stimulation lead revision or reimplantation for Parkinson's disease. J Neurosurg 2018; 130:1-6. [PMID: 29932378 DOI: 10.3171/2018.1.jns171660] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe number of patients who benefit from deep brain stimulation (DBS) for Parkinson's disease (PD) has increased significantly since the therapy was first approved by the FDA. Suboptimal outcomes, infection, or device failure are risks of the procedure and may require lead removal or repositioning. The authors present here the results of their series of revision and reimplantation surgeries.METHODSThe data were reviewed from all DBS intracranial lead removals, revisions, or reimplantations among patients with PD over a 6-year period at the authors' institution. The indications for these procedures were categorized as infection, suboptimal outcome, and device failure. Motor outcomes as well as lead location were analyzed before removal and after reimplant or revision.RESULTSThe final sample included 25 patients who underwent 34 lead removals. Thirteen patients had 18 leads reimplanted after removal. There was significant improvement in the motor scores after revision surgery among the patients who had the lead revised for a suboptimal outcome (p = 0.025). The mean vector distance of the new lead location compared to the previous location was 2.16 mm (SD 1.17), measured on an axial plane 3.5 mm below the anterior commissure-posterior commissure line. When these leads were analyzed by subgroup, the mean distance was 1.67 mm (SD 0.83 mm) among patients treated for infection and 2.73 mm (SD 1.31 mm) for those with suboptimal outcomes.CONCLUSIONSPatients with PD who undergo reimplantation surgery due to suboptimal outcome may experience significant benefits. Reimplantation after surgical infection seems feasible and overall safe.
Collapse
Affiliation(s)
- Leonardo A Frizon
- 1Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
- 2Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Sean J Nagel
- 1Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Francis J May
- 1Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Jianning Shao
- 1Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
| | | | - Hubert H Fernandez
- 1Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Andre G Machado
- 1Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
| |
Collapse
|
35
|
Herring EZ, Frizon LA, Hogue O, Mejia JU, Rosenquist R, Bolash RB, Machado AG, Nagel SJ. Long-term Outcomes Using Intrathecal Drug Delivery Systems in Complex Regional Pain Syndrome. Pain Medicine 2018; 20:515-520. [DOI: 10.1093/pm/pny104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Eric Z Herring
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Jay U Mejia
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Andre G Machado
- Center for Neurological Restoration
- Department of Neurosurgery, Cleveland Clinc, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration
- Department of Neurosurgery, Cleveland Clinc, Cleveland, Ohio, USA
| |
Collapse
|
36
|
Abbatemarco JR, Willis MA, Wilson RG, Nagel SJ, Machado AG, Bethoux FA. Case Series: Intrathecal Baclofen Therapy in Stiff-Person Syndrome. Neuromodulation 2018. [DOI: 10.1111/ner.12765] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Mary Alissa Willis
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, The Cleveland Clinic Foundation; Cleveland OH USA
| | - Robert G. Wilson
- Department of Neurology; Cleveland Clinic Foundation; Cleveland OH USA
| | - Sean J. Nagel
- Department of Neurosurgery; Cleveland Clinic Foundation; Cleveland OH USA
| | - Andre G. Machado
- Department of Neurosurgery; Cleveland Clinic Foundation; Cleveland OH USA
| | - Francois A. Bethoux
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, The Cleveland Clinic Foundation; Cleveland OH USA
| |
Collapse
|
37
|
Xu J, Nault RJ, Maldonado-Naranjo A, Frizon LA, John K, Holman K, Nagel SJ. Disseminated cerebral toxoplasmosis in a patient with chronic lymphocytic leukemia. J Clin Neurosci 2018; 50:127-128. [PMID: 29428267 DOI: 10.1016/j.jocn.2018.01.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
Infections are one of the most common causes of mortality in immunocompromised patients. In patients diagnosed with hematologic malignancies, treatment with stem cell transplants (SCT) or T-cell suppressing chemotherapy increases the risk of central nervous system (CNS) infections, of which toxoplasmosis is the most common. We report the case of a 63 year-old woman with chronic lymphocytic leukemia (CLL) that presented with gait instability and visual changes. Intracranial lesions were noted on initial neuro-imaging. A rapid decline in the patient's mental status warranted an urgent biopsy of the lesions that revealed tachyzoites consistent with toxoplasmosis. In the presence of diffuse brain lesions that lack a metastatic pattern or contrast enhancement, a common approach is to perform biopsy only after a battery of non-invasive testing. This diagnostic delay may take several days, exposing the patient to a rapidly fatal infection. This report illustrates the utility of early brain biopsy in high-risk patients with hematologic malignancies and CNS lesions.
Collapse
Affiliation(s)
- Jordan Xu
- Case Western Reserve Univerisity School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, United States
| | - Rod J Nault
- Case Western Reserve Univerisity School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, United States
| | - Andres Maldonado-Naranjo
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, 9600 Euclid Ave, Cleveland, OH 44195, United States
| | - Leonardo A Frizon
- Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic Foundation 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Kuruvilla John
- Department of Neurology, Neurological Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates.
| | - Katherine Holman
- Department of Infectious Disease, Respiratory Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Sean J Nagel
- Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic Foundation 9500 Euclid Ave, Cleveland, OH 44195, United States
| |
Collapse
|
38
|
Nagel SJ, Reddy CG, Frizon LA, Chardon MK, Holland M, Machado AG, Gillies GT, Howard MA, Wilson S. Spinal dura mater: biophysical characteristics relevant to medical device development. J Med Eng Technol 2018; 42:128-139. [PMID: 29569970 PMCID: PMC7053539 DOI: 10.1080/03091902.2018.1435745] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Understanding the relevant biophysical properties of the spinal dura mater is essential to the design of medical devices that will directly interact with this membrane or influence the contents of the intradural space. We searched the literature and reviewed the pertinent characteristics for the design, construction, testing, and imaging of novel devices intended to perforate, integrate, adhere or reside within or outside of the spinal dura mater. The spinal dura mater is a thin tubular membrane composed of collagen and elastin fibres that varies in circumference along its length. Its mechanical properties have been well-described, with the longitudinal tensile strength exceeding the transverse strength. Data on the bioelectric, biomagnetic, optical and thermal characteristics of the spinal dura are limited and sometimes taken to be similar to those of water. While various modalities are available to visualise the spinal dura, magnetic resonance remains the best modality to segment its structure. The reaction of the spinal dura to imposition of a foreign body or other manipulations of it may compromise its biomechanical and immune-protective benefits. Therefore, dural sealants and replacements are of particular clinical, research and commercial interest. In conclusion, existing devices that are in clinical use for spinal cord stimulation, intrathecal access or intradural implantation largely adhere to traditional designs and their attendant limitations. However, if future devices are built with an understanding of the dura's properties incorporated more fully into the designs, there is potential for improved performance.
Collapse
Affiliation(s)
- Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Chandan G. Reddy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Leonardo A. Frizon
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Matthieu K. Chardon
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marshall Holland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Andre G. Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Matthew A. Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| |
Collapse
|
39
|
Frizon LA, Shao J, Maldonado-Naranjo AL, Lobel DA, Nagel SJ, Fernandez HH, Machado AG. The Safety and Efficacy of Using the O-Arm Intraoperative Imaging System for Deep Brain Stimulation Lead Implantation. Neuromodulation 2017; 21:588-592. [DOI: 10.1111/ner.12744] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/12/2017] [Accepted: 11/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Leonardo A. Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Jianning Shao
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | | | - Darlene A. Lobel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Sean J. Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Hubert H. Fernandez
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Andre G. Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; Cleveland OH USA
| |
Collapse
|
40
|
Lee BS, Jones J, Lang M, Achey R, Dai L, Lobel DA, Nagel SJ, Machado AG, Bethoux F. Early outcomes after intrathecal baclofen therapy in ambulatory patients with multiple sclerosis. J Neurosurg 2017; 129:1056-1062. [PMID: 29192855 DOI: 10.3171/2017.5.jns162925] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multiple sclerosis (MS) is a chronic autoimmune disease that causes demyelination and axonal loss. Walking difficulties are a common and debilitating symptom of MS; they are usually caused by spastic paresis of the lower extremities. Although intrathecal baclofen (ITB) therapy has been reported to be an effective treatment for spasticity in MS, there is limited published evidence regarding its effects on ambulation. The goal of this study was to characterize ITB therapy outcomes in ambulatory patients with MS. METHODS Data from 47 ambulatory patients with MS who received ITB therapy were analyzed retrospectively. Outcome measures included Modified Ashworth Scale, Spasm Frequency Scale, Numeric Pain Rating Scale, and the Timed 25-Foot Walk. Repeated-measures ANOVA was used to test for changes in outcome measures between baseline and posttreatment (6 months and 1 year). Significance was set at p < 0.05. Descriptive data are expressed as the mean ± SD, and results of the repeated-measures ANOVA tests and the Wilcoxon rank-sum test are expressed as the mean ± SEM. RESULTS There was a statistically significant reduction in the following variables: 1) aggregate lower-extremity Modified Ashworth Scale scores (from 14.8 ± 1.0 before ITB therapy to 5.8 ± 0.8 at 6 months posttreatment and 6.4 ± 0.9 at 1 year [p < 0.05]); 2) Numeric Pain Rating Scale scores (4.4 ± 0.5 before ITB, 2.8 ± 0.5 at 6 months, and 2.4 ± 0.4 at 1 year [p < 0.05]); 3) spasm frequency (45.7% of the patients reported a spasm frequency of ≥ 1 event per hour before ITB therapy, whereas 15.6% and 4.3% of the patients reported the same at 6 months and 1 year posttreatment, respectively [p < 0.05]); and 4) the number of oral medications taken for spasticity (p < 0.05). Of the 47 patients, 34 remained ambulatory at 6 months, and 32 at 1 year posttreatment. There was no statistically significant change in performance on the Timed 25-Foot Walk test over time for those patients who remained ambulatory. CONCLUSIONS In this retrospective study, the authors found that ITB therapy is effective in reducing spasticity and related symptoms in ambulatory patients with MS. Because the use of ITB therapy is increasing in ambulatory patients with MS, randomized, prospective studies are important to help provide a more useful characterization of the effects of ITB therapy on ambulation.
Collapse
Affiliation(s)
- Bryan S Lee
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic
| | - Jaes Jones
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - Min Lang
- 3School of Medicine, Case Western Reserve University
| | - Rebecca Achey
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - Lu Dai
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - Darlene A Lobel
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic.,4Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; and
| | - Sean J Nagel
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic.,4Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; and
| | - Andre G Machado
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic.,4Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; and
| | - Francois Bethoux
- 4Center for Neurological Restoration, Neurological Institute, Cleveland Clinic; and.,5Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
41
|
Nagel SJ, Reddy CG, Frizon LA, Holland MT, Machado AG, Gillies GT, Howard MA. Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation. Neuromodulation 2017; 21:625-640. [DOI: 10.1111/ner.12693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Sean J. Nagel
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - Chandan G. Reddy
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | | | - Marshall T. Holland
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Andre G. Machado
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering; University of Virginia; Charlottesville VA USA
| | - Matthew A. Howard
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| |
Collapse
|
42
|
Angelov L, Mohammadi AM, Bennett EE, Abbassy M, Elson P, Chao ST, Montgomery JS, Habboub G, Vogelbaum MA, Suh JH, Murphy ES, Ahluwalia MS, Nagel SJ, Barnett GH. Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm. J Neurosurg 2017; 129:366-382. [PMID: 28937324 DOI: 10.3171/2017.3.jns162532] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%-62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy. METHODS Fifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board-approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient. RESULTS Among 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23-83 years), 23 patients (43%) had non-small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12-18 Gy) and 15 Gy (range 12-15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm3 (range 2.4-31.3 cm3) and 7.0 cm3 (range 1.0-29.7 cm3). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm3 (range 0.1-23.1 cm3). The median change in volume compared with baseline was a decrease of 54.9% (range -98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3-7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively. CONCLUSIONS 2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) and 6-month (88%) LC rates and an overall AE rate of 11%. Prospective studies with larger cohorts and longer follow-up are necessary to assess the durability and toxicities of 2-SSRS.
Collapse
Affiliation(s)
- Lilyana Angelov
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | - Alireza M Mohammadi
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | | | - Mahmoud Abbassy
- 4Department of Neurosurgery, Alexandria University, Alexandria, Egypt
| | - Paul Elson
- 3Quantitative Health Sciences, Taussig Cancer Institute, and
| | - Samuel T Chao
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Joshua S Montgomery
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute
| | | | - Michael A Vogelbaum
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | - John H Suh
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Erin S Murphy
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Manmeet S Ahluwalia
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute
| | - Sean J Nagel
- 2Department of Neurosurgery, Neurological Institute
| | - Gene H Barnett
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| |
Collapse
|
43
|
Frizon LA, Hogue O, Wathen C, Yamamoto EA, Sabharwal NC, Jones J, Volovetz J, Maldonado-Naranjo A, Lobel DA, Machado A, Nagel SJ. 321 Subsequent Pulse Generator Replacement Surgery does not Increase the Infection Rate in Patients with Deep Brain Stimulator Systems. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
44
|
Maldonado-Naranjo AL, Frizon LA, Sabharwal NC, Xiao R, Hogue O, Lobel DA, Machado AG, Nagel SJ. Rate of Complications Following Spinal Cord Stimulation Paddle Electrode Removal. Neuromodulation 2017; 21:513-519. [PMID: 28833931 DOI: 10.1111/ner.12643] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/13/2017] [Accepted: 06/26/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) is a safe, reversible surgical treatment for complex regional pain syndrome and failed back surgery syndrome refractory to conventional medical management. Paddle electrodes are routinely used for the permanent implant because of the reduced risk of migration, lower energy requirements, and expanded coverage options. The risks associated with paddle lead removal are not well defined in the literature. METHODS We retrospectively reviewed the outcomes of all patients at the Cleveland Clinic who underwent removal of SCS paddle electrodes between 2009 and 2016. RESULTS We identified 68 patients during this interval who had a paddle electrode removed. The most common reason for removal was loss of coverage or effect (75%), followed by infection (13.24%), and the need for magnetic resonance imaging for diagnostic purposes (8.82%). Postoperative complications occurred in eight patients (11.75%), two of which were classified as major (2.94%). One of these patients developed a postoperative cerebrospinal fluid leak, and another suffered a large suprafascial hematoma. Both patients underwent reoperation. Minor complications were reported in six patients (8.82%) and included wound dehiscence, infection, and prolonged ileus in one case. On average, patients who developed complications lost 20 mL more blood during surgery than those who did not develop complications (p = 0.006). CONCLUSION One of the benefits of SCS therapy is the reversibility of the procedure. However, removal is not without some risk though the overall risk of minor or major complication is low. Patients who are considering removal should be counseled appropriately. Prophylactic removal is not recommended. However, when removal is needed, surgeons and pain specialists must be familiar with these complications and their management.
Collapse
Affiliation(s)
| | - Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Navin C Sabharwal
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Roy Xiao
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olivia Hogue
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Darlene A Lobel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
45
|
Frizon LA, Hogue O, Wathen C, Yamamoto E, Sabharwal NC, Jones J, Volovetz J, Maldonado-Naranjo AL, Lobel DA, Machado AG, Nagel SJ. Subsequent Pulse Generator Replacement Surgery Does Not Increase the Infection Rate in Patients With Deep Brain Stimulator Systems: A Review of 1537 Unique Implants at a Single Center. Neuromodulation 2017; 20:444-449. [DOI: 10.1111/ner.12605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/23/2017] [Accepted: 03/14/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Leonardo A. Frizon
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Olivia Hogue
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Connor Wathen
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Erin Yamamoto
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Navin C. Sabharwal
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Jaes Jones
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Josephine Volovetz
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | | | - Darlene A. Lobel
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Andre G. Machado
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| | - Sean J. Nagel
- Center for Neurological Restoration; Neurological Institute, Cleveland Clinic; Cleveland OH USA
| |
Collapse
|
46
|
Nagel SJ, Wilson S, Johnson MD, Machado A, Frizon L, Chardon MK, Reddy CG, Gillies GT, Howard MA. Spinal Cord Stimulation for Spasticity: Historical Approaches, Current Status, and Future Directions. Neuromodulation 2017; 20:307-321. [PMID: 28370802 DOI: 10.1111/ner.12591] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/08/2016] [Accepted: 01/03/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Millions of people worldwide suffer with spasticity related to irreversible damage to the brain or spinal cord. Typical antecedent events include stroke, traumatic brain injury, and spinal cord injury, although insidious onset is also common. Regardless of the cause, the resulting spasticity leads to years of disability and reduced quality of life. Many treatments are available to manage spasticity; yet each is fraught with drawbacks including incomplete response, high cost, limited duration, dose-limiting side effects, and periodic maintenance. Spinal cord stimulation (SCS), a once promising therapy for spasticity, has largely been relegated to permanent experimental status. METHODS In this review, our goal is to document and critique the history and assess the development of SCS as a treatment of lower limb spasticity. By incorporating recent discoveries with the insights gained from the early pioneers in this field, we intend to lay the groundwork needed to propose testable hypotheses for future studies. RESULTS SCS has been tested in over 25 different conditions since a potentially beneficial effect was first reported in 1973. However, the lack of a fully formed understanding of the pathophysiology of spasticity, archaic study methodology, and the early technological limitations of implantable hardware limit the validity of many studies. SCS offers a measure of control for spasticity that cannot be duplicated with other interventions. CONCLUSIONS With improved energy-source miniaturization, tailored control algorithms, novel implant design, and a clearer picture of the pathophysiology of spasticity, we are poised to reintroduce and test SCS in this population.
Collapse
Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Michael D Johnson
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andre Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo Frizon
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Matthieu K Chardon
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chandan G Reddy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| |
Collapse
|
47
|
Nagel SJ, Machado AG, Gale JT, Lobel DA, Pandya M. Preserving cortico-striatal function: deep brain stimulation in Huntington's disease. Front Syst Neurosci 2015; 9:32. [PMID: 25814939 PMCID: PMC4356075 DOI: 10.3389/fnsys.2015.00032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 02/18/2015] [Indexed: 11/13/2022] Open
Abstract
Huntington's disease (HD) is an incurable neurodegenerative disease characterized by the triad of chorea, cognitive dysfunction and psychiatric disturbances. Since the discovery of the HD gene, the pathogenesis has been outlined, but to date a cure has not been found. Disease modifying therapies are needed desperately to improve function, alleviate suffering, and provide hope for symptomatic patients. Deep brain stimulation (DBS), a proven therapy for managing the symptoms of some neurodegenerative movement disorders, including Parkinson's disease, has been reported as a palliative treatment in select cases of HD with debilitating chorea with variable success. New insights into the mechanism of action of DBS suggest it may have the potential to circumvent other manifestations of HD including cognitive deterioration. Furthermore, because DBS is already widely used, reversible, and has a risk profile that is relatively low, new studies can be initiated. In this article we contend that new clinical trials be considered to test the effects of DBS for HD.
Collapse
Affiliation(s)
- Sean J Nagel
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neurosurgery, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| | - Andre G Machado
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neurosurgery, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| | - John T Gale
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neuroscience, Cleveland Clinic, Lerner Research Institute Cleveland, Ohio, USA
| | - Darlene A Lobel
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neurosurgery, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| | - Mayur Pandya
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Psychiatry, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| |
Collapse
|
48
|
Abstract
Percutaneous spinal cord stimulation has a clinical benefit in selected patients with chronic neuropathic pain related to failed back surgery syndrome and complex regional pain syndrome. Patients with other peripheral neuropathic pain syndromes may also respond favorably. The cause of the chronic pain must be established to rule out remediable causes. Drug abuse or aberrant drug-related behaviors should be assessed before proceeding. A psychological evaluation identifies patients who may not benefit. Risk factors for infection should be corrected where possible. This safe, reversible treatment should be considered early for patients with intractable peripheral neuropathic pain.
Collapse
Affiliation(s)
- Sean J Nagel
- Department of Neurosurgery, Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA.
| | - Scott F Lempka
- Department of Neurosurgery, Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA; Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106-1702, USA
| | - Andre G Machado
- Department of Neurosurgery, Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA
| |
Collapse
|
49
|
Abstract
This article provides an integrated review of the basic anatomy and physiology of the pain processing pathways. The transmission and parcellation of noxious stimuli from the peripheral nervous system to the central nervous system is discussed. In addition, the inhibitory and excitatory systems that regulate pain along with the consequences of dysfunction are considered.
Collapse
Affiliation(s)
- Sarah Bourne
- Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Avenue, S4, Cleveland, OH 44195, USA
| | - Andre G Machado
- Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA
| | - Sean J Nagel
- Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA.
| |
Collapse
|
50
|
Matias CM, Amit A, Lempka SF, Ozinga JG, Nagel SJ, Lobel DA, Machado AG. Long-term Outcomes After Replacement of Percutaneous Leads With Paddle Leads in a Retrospective Cohort of Patients With Spinal Cord Stimulation Systems. Neurosurgery 2014; 75:430-6; discussion 436. [DOI: 10.1227/neu.0000000000000460] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Although the long-term outcomes for spinal cord stimulation (SCS) have been reported, long-term outcomes of patients who underwent revisions of the SCS with paddle leads are lacking.
OBJECTIVE:
To report the long-term outcomes of 39 patients who had percutaneous SCS revised with a new paddle lead.
METHODS:
Baseline and follow-up mail-in questionnaires assessed pain and disability levels with numerical rating scales, somatotopical overlap between SCS-related paresthesias and areas of chronic pain, and overall satisfaction. Analysis was performed with regard to age, sex, diagnosis, duration of disease, number of surgical revisions, complications, and interval between surgeries.
RESULTS:
After surgical revision, 20 patients (50%) had at least a 3-point reduction in the numerical rating scale. Greater pain reduction was correlated with better coverage (P = .001). Coverage area was greater in patients with a single revision than in patients with multiple revisions (P = .01). Good satisfaction was reported by 25 patients (62.5%) who indicated that they would undergo the procedure again in order to achieve the same results. These patients had significantly greater pain reduction (P = .001) and better coverage (P = .002) than patients who reported otherwise. No other major complication occurred.
CONCLUSION:
Revision of percutaneous SCS systems with implantation of a new paddle lead is safe and more effective in patients who have undergone not more than 1 prior revision.
Collapse
Affiliation(s)
- Caio M. Matias
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| | - Amit Amit
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| | - Scott F. Lempka
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| | - John G. Ozinga
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| | - Darlene A. Lobel
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| | - Andre G. Machado
- Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio
| |
Collapse
|