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Abdelmageed S, Horak VJ, Virtanen PS, Lam SK, Burchiel KJ, Raskin JS. A Well-Being Well-Check for Neurosurgery: Evidence-Based Suggestions for Our Specialty Based on a Systematic Review. World Neurosurg 2024; 185:351-358.e2. [PMID: 38403016 DOI: 10.1016/j.wneu.2024.02.093] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND The path through neurosurgery is rigorous. Many neurosurgeons may experience burnout, depression, or suicide throughout training and practice. We review the literature to help foster a culture of awareness and self-care and arm trainees with coping skills to reduce burnout and, thus, suicidality during all phases of their medical careers. METHODS A systematic search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using 4 databases. 7 studies were included. RESULTS Overlying themes of interventions were to increase balance, mindfulness, and physical fitness. The most common interventions included in programs were educational and physical activity. We suggest a comprehensive wellness program emphasizing interventions from 4 wellness dimensions-physical, spiritual, mental, and emotional. CONCLUSIONS Many neurosurgeons experience burnout, leading to a lack of satisfaction and early retirement; this necessitates a discipline-wide acknowledgment of endemic burnout among neurosurgeons. Systemic changes are needed to refine the training process and prioritize physician well-being- this cannot be left to chance.
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Affiliation(s)
- Sunny Abdelmageed
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Victoria Jane Horak
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA; Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Piiamaria S Virtanen
- Department of Neurological Surgery, Section of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Siler DA, Mota C, Morrison S, Burchiel KJ, Madden C. 503 Stimulation of the Paraventricular Nucleus Activates Brown Adipose Tissue via Local GABA Release: A Novel Target for the Treatment of Obesity. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_503] [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: 03/18/2023] Open
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Mota CMD, Siler DA, Burchiel KJ, Madden CJ. Acute deep brain stimulation of the paraventricular nucleus of the hypothalamus increases brown adipose tissue thermogenesis in rats. Neurosci Lett 2023; 799:137130. [PMID: 36792026 PMCID: PMC10069326 DOI: 10.1016/j.neulet.2023.137130] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/15/2023]
Abstract
Brown adipose tissue (BAT) activity is controlled by the sympathetic nervous system. Activation of BAT has shown significant promise in preclinical studies to elicit weight loss. Since the hypothalamic paraventricular nucleus (PVN) contributes to the regulation of BAT thermogenic activity, we sought to determine the effects of electrical stimulation of the PVN as a model of deep brain stimulation (DBS) for increasing BAT sympathetic nerve activity (SNA). The rostral raphe pallidus area (rRPa) was also chosen as a target for DBS since it contains the sympathetic premotor neurons for BAT. Electrical stimulation (100 µA, 100 µs, 100 Hz, for 5 min at a 50 % duty cycle) of the PVN increased BAT SNA and BAT thermogenesis. These effects were prevented by a local nanoinjection of bicuculline, a GABAA receptor antagonist. We suggest that electrical stimulation of the PVN elicited local release of GABA, which inhibited BAT sympathoinhibitory neurons in PVN, thereby releasing a restraint on BAT SNA. Electrical stimulation of the rRPa inhibited BAT thermogenesis and this was prevented by a local nanoinjection of bicuculline, suggesting that local release of GABA suppressed BAT SNA. Electrical stimulation of the PVN activates BAT metabolism via a mechanism that may include activation of local GABAA receptors. These findings contribute to our understanding of the mechanisms underlying the effects of DBS in the regulation of fat metabolism and provide a foundation for further DBS studies targeting hypothalamic circuits regulating BAT thermogenesis as a therapy for obesity.
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Affiliation(s)
- Clarissa M D Mota
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, United States
| | - Dominic A Siler
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, United States
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, United States
| | - Christopher J Madden
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, United States.
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Holland MT, Jiao J, Mantovani A, Anderson S, Mitchell KA, Safarpour D, Burchiel KJ. Identifying the therapeutic zone in globus pallidus deep brain stimulation for Parkinson's disease. J Neurosurg 2023; 138:329-336. [PMID: 35901683 DOI: 10.3171/2022.5.jns22152] [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: 01/28/2022] [Accepted: 05/19/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The globus pallidus internus (GPI) has been demonstrated to be an effective surgical target for deep brain stimulation (DBS) treatment in patients with medication-refractory Parkinson's disease (PD). The ability of neurosurgeons to define the area of greatest therapeutic benefit within the globus pallidus (GP) may improve clinical outcomes in these patients. The objective of this study was to determine the best DBS therapeutic implantation site within the GP for effective treatment in PD patients. METHODS The authors performed a retrospective review of 56 patients who underwent bilateral GP DBS implantation at their institution during the period from January 2015 to January 2020. Each implanted contact was anatomically localized. Patients were followed for stimulation programming for at least 6 months. The authors reviewed preoperative and 6-month postsurgery clinical outcomes based on data from the Unified Parkinson's Disease Rating Scale Part III (UPDRS III), dyskinesia scores, and levodopa equivalent daily dose (LEDD). RESULTS Of the 112 leads implanted, the therapeutic cathode was most frequently located in the lamina between the GPI external segment (GPIe) and the GP externus (GPE) (n = 40). Other common locations included the GPE (n = 24), the GPIe (n = 15), and the lamina between the GPI internal segment (GPIi) and the GPIe (n = 14). In the majority of patients (73%) a monopolar programming configuration was used. At 6 months postsurgery, UPDRS III off medications (OFF) and on stimulation (ON) scores significantly improved (z = -4.02, p < 0.001), as did postsurgery dyskinesia ON scores (z = -4.08, p < 0.001) and postsurgery LEDD (z = -4.7, p < 0.001). CONCLUSIONS Though the ventral GP (pallidotomy target) has been a commonly used target for GP DBS, a more dorsolateral target may be more effective for neuromodulation strategies. The assessment of therapeutic contact locations performed in this study showed that the lamina between GPI and GPE used in most patients is the optimal central stimulation target. This information should improve preoperative GP targeting.
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Affiliation(s)
- Marshall T Holland
- 1Department of Neurological Surgery, University of Alabama at Birmingham, Alabama; and
| | | | - Alessandra Mantovani
- 3Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | | | - Katherine A Mitchell
- 3Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | | | - Kim J Burchiel
- 3Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Mousavi SH, Gehling P, Burchiel KJ. The Long-Term Outcome of Radiofrequency Ablation in Multiple Sclerosis-Related Symptomatic Trigeminal Neuralgia. Neurosurgery 2022; 90:293-299. [PMID: 35113822 DOI: 10.1227/neu.0000000000001817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/04/2021] [Accepted: 09/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Radiofrequency lesioning (RFL) is used to surgically manage trigeminal neuralgia (TN) secondary to multiple sclerosis (MS). However, the long-term outcome of RFL has not been established. OBJECTIVE To investigate the long-term clinical outcome of RFL in MS-related TN (symptomatic trigeminal neuralgia [STN]). METHODS During a 23-yr period, institutional data were available for 51 patients with STN who underwent at least one RFL procedure to treat facial pain. Patient outcome was evaluated at a mean follow-up of 69 mo (95% confidence interval; range 52-86 mo). No pain with no medication (NPNM) was the primary long-term outcome measure. RESULTS After an initial RFL procedure, immediate pain relief was achieved in 50 patients (98%), and NPNM as assessed at 1, 3, and 6 yr was 86%, 52%, and 22%, respectively. At the last clinical visit after an initial RFL, 23 patients (45%) with pain recurrence underwent repeat RFL; NPNM at 1, 3, and 6 yr after a repeat RFL was 85%, 58%, and 32%, respectively. There was no difference in pain outcome after an initial and repeat RFL ( P = .77). Ten patients with pain recurrence underwent additional RFL procedures. Two patients developed mastication muscle weakness, one patient experienced a corneal abrasion, which resolved with early ophthalmological interventions, and one patient experienced bothersome numbness. CONCLUSION RFL achieves NPNM status in STN and can be repeated with similar efficacy.
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Affiliation(s)
- Seyed H Mousavi
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Paxton Gehling
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
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Selden NR, Barbaro NM, Barrow DL, Batjer HH, Branch CL, Burchiel KJ, Byrne RW, Dacey RG, Day AL, Dempsey RJ, Derstine P, Friedman AH, Giannotta SL, Grady MS, Harsh GR, Harbaugh RE, Mapstone TB, Muraszko KM, Origitano TC, Orrico KO, Popp AJ, Sagher O, Selman WR, Zipfel GJ. Neurosurgery residency and fellowship education in the United States: 2 decades of system development by the One Neurosurgery Summit organizations. J Neurosurg 2021; 136:565-574. [PMID: 34359022 DOI: 10.3171/2020.10.jns203125] [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: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 11/06/2022]
Abstract
The purpose of this report is to chronicle a 2-decade period of educational innovation and improvement, as well as governance reform, across the specialty of neurological surgery. Neurological surgery educational and professional governance systems have evolved substantially over the past 2 decades with the goal of improving training outcomes, patient safety, and the quality of US neurosurgical care. Innovations during this period have included the following: creating a consensus national curriculum; standardizing the length and structure of neurosurgical training; introducing educational outcomes milestones and required case minimums; establishing national skills, safety, and professionalism courses; systematically accrediting subspecialty fellowships; expanding professional development for educators; promoting training in research; and coordinating policy and strategy through the cooperation of national stakeholder organizations. A series of education summits held between 2007 and 2009 restructured some aspects of neurosurgical residency training. Since 2010, ongoing meetings of the One Neurosurgery Summit have provided strategic coordination for specialty definition, neurosurgical education, public policy, and governance. The Summit now includes leadership representatives from the Society of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Board of Neurological Surgery, the Review Committee for Neurological Surgery of the Accreditation Council for Graduate Medical Education, the American Academy of Neurological Surgery, and the AANS/CNS Joint Washington Committee. Together, these organizations have increased the effectiveness and efficiency of the specialty of neurosurgery in advancing educational best practices, aligning policymaking, and coordinating strategic planning in order to meet the highest standards of professionalism and promote public health.
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Affiliation(s)
- Nathan R Selden
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Nicholas M Barbaro
- 2Department of Neurosurgery, University of Texas, Dell Medical School, Austin, Texas
| | - Daniel L Barrow
- 3Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - H Hunt Batjer
- 4Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Charles L Branch
- 5Department of Neurosurgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Kim J Burchiel
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Richard W Byrne
- 6Department of Neurosurgery, Rush University, Chicago, Illinois
| | - Ralph G Dacey
- 7Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Arthur L Day
- 8Department of Neurosurgery, University of Texas Houston Health Science Center, Houston, Texas
| | - Robert J Dempsey
- 9Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
| | - Pamela Derstine
- 10Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Allan H Friedman
- 11Department of Neurosurgery, Duke University Health System, Durham, North Carolina
| | - Steven L Giannotta
- 12Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - M Sean Grady
- 13Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Griffith R Harsh
- 14Department of Neurological Surgery, University of California Davis, Sacramento, California
| | - Robert E Harbaugh
- 15Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Timothy B Mapstone
- 16Department of Neurosurgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Karin M Muraszko
- 17Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Origitano
- 18Neuroscience and Spine Institute, Kalispell Regional Healthcare, Kalispell, Montana
| | | | - A John Popp
- 20Department of Neurosurgery, Albany Medical College and Albany Medical Center Hospital, Albany, New York; and
| | - Oren Sagher
- 17Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Warren R Selman
- 21Department of Neurosurgery, University Hospitals Cleveland and Case Western Reserve University, Cleveland, Ohio
| | - Gregg J Zipfel
- 7Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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Burchiel KJ. Commentary: Surgical Relevance of the Suprameatal Tubercle During Superior Petrosal Vein-Sparing Trigeminal Nerve Microvascular Decompression. Oper Neurosurg (Hagerstown) 2021; 20:E417. [PMID: 33822202 DOI: 10.1093/ons/opab080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kim J Burchiel
- Oregon Health & Science University, Portland, Oregon, USA
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Holland MT, Mansfield K, Mitchell A, Burchiel KJ. Hidden Error in Optical Stereotactic Navigation Systems and Strategy to Maximize Accuracy. Stereotact Funct Neurosurg 2021; 99:369-376. [PMID: 33744897 DOI: 10.1159/000514053] [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: 10/15/2020] [Accepted: 12/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Optical neuronavigation has been established as a reliable and effective adjunct to many neurosurgical procedures. Operations such as asleep deep brain stimulation (aDBS) benefit from the potential increase in accuracy that these systems offer. Built into these technologies is a degree of tolerated error that may exceed the presumed accuracy resulting in suboptimal outcomes. OBJECTIVE The objective of this study was to identify an underlying source of error in neuronavigation and determine strategies to maximize accuracy. METHODS A Medtronic Stealth system (Stealth Station 7 hardware, S8 software, version 3.1.1) was used to simulate an aDBS procedure with the Medtronic Nexframe system. Multiple configurations and orientations of the Nexframe-Nexprobe system components were examined to determine potential sources of, and to quantify navigational error, in the optical navigation system. Virtual entry point and target variations were recorded and analyzed. Finally, off-plan error was recorded with the AxiEM system and visual observation on a phantom head. RESULTS The most significant source of error was found to be the orientation of the reference marker plate configurations to the camera system, with the presentation of the markers perpendicular to the camera line of site being the most accurate position. Entry point errors ranged between 0.134 ± 0.048 and 1.271 ± 0.0986 mm in a complex, reproducible pattern dependent on the orientation of the Nexprobe reference plate. Target errors ranged between 0.311 ± 0.094 and 2.159 ± 0.190 mm with a similarly complex, repeatable pattern. Representative configurations were tested for physical error at target with errors ranging from 1.2 mm to 1.4 mm. Throughout data acquisition, no orientation was indicated as outside the acceptable tolerance by the Stealth software. CONCLUSIONS Use of optical neuronavigation is expected to increase in frequency and variety of indications. Successful implementation of this technology depends on understanding the tolerances built into the system. In situations that depend on extremely high precision, surgeons should familiarize themselves with potential sources of error so that systems may be optimized beyond the manufacturer's built-in tolerances. We recommend that surgeons align the navigation reference plate and any optical instrument's reference plate spheres in the plane perpendicular to the line of site of the camera to maximize accuracy.
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Affiliation(s)
- Marshall T Holland
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Ann Mitchell
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA,
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Schwalb JM, Burchiel KJ, Patil PG, Aziz TZ. Introduction. Surgery for pain. Neurosurgical Focus: Video 2020. [PMCID: PMC9542595 DOI: 10.3171/2020.7.focvid2048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jason M. Schwalb
- Department of Neurosurgery and Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Kim J. Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Parag G. Patil
- Departments of Neurological Surgery, Neurology, Anesthesiology, and Biomedical Engineering, University of Michigan, Ann Arbor, Michigan; and
| | - Tipu Z. Aziz
- Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
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Hardaway FA, Holste K, Ozturk G, Pettersson D, Pollock JM, Burchiel KJ, Raslan AM. Sex-dependent posterior fossa anatomical differences in trigeminal neuralgia patients with and without neurovascular compression: a volumetric MRI age- and sex-matched case-control study. J Neurosurg 2020; 132:631-638. [PMID: 30717058 DOI: 10.3171/2018.9.jns181768] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 06/25/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The pathophysiology of trigeminal neuralgia (TN) in patients without neurovascular compression (NVC) is not completely understood. The objective of this retrospective study was to evaluate the hypothesis that TN patients without NVC differ from TN patient with NVC with respect to brain anatomy and demographic characteristics. METHODS Six anatomical brain measurements from high-resolution brain MR images were tabulated; anterior-posterior (AP) prepontine cistern length, cerebellopontine angle (CPA) cistern volume, nerve-to-nerve distance, symptomatic nerve length, pons volume, and posterior fossa volume were assessed on OsiriX. Brain MRI anatomical measurements from 232 patients with either TN type 1 or TN type 2 (TN group) were compared with measurements obtained in 100 age- and sex-matched healthy controls (control group). Two-way ANOVA tests were conducted on the 6 measurements relative to group and NVC status. Bonferroni adjustments were used to correct for multiple comparisons. A nonhierarchical k-means cluster analysis was performed on the TN group using age and posterior fossa volume as independent variables. RESULTS Within the TN group, females were found to be younger than males and less likely to have NVC. The odds ratio (OR) of females not having NVC compared to males was 2.7 (95% CI 1.3-5.5, p = 0.017). Patients younger than 30 years were much less likely to have NVC compared to older patients (OR 4.9, 95% CI 1.3-18.4, p = 0.017). The mean AP prepontine cistern length and symptomatic nerve length were smaller in the TN group than in the control group (5.3 vs 6.5 mm and 8.7 vs 9.7 mm, respectively; p < 0.001). The posterior fossa volume was significantly smaller in TN patients without NVC compared to those with NVC. A TN group cluster analysis suggested a sex-dependent difference that was not observed in those without NVC. Factorial ANOVA and post hoc testing found that findings in males without NVC were significantly different from those in controls or male TN patients with NVC and similar to those in females (female controls as well as female TN patients with or without NVC). CONCLUSIONS Posterior fossa volume in males was larger than posterior fossa volume in females. This finding, along with the higher incidence of TN in females, suggests that smaller posterior fossa volume might be an independent factor in the pathophysiology of TN, which warrants further study.
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Affiliation(s)
| | | | | | - David Pettersson
- 2Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey M Pollock
- 2Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon
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Abstract
Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.
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12
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Magown P, Ko AL, Burchiel KJ. The Spectrum of Trigeminal Neuralgia Without Neurovascular Compression. Neurosurgery 2020; 85:E553-E559. [PMID: 31329945 DOI: 10.1093/neuros/nyz048] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 05/10/2018] [Accepted: 01/29/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In trigeminal neuralgia type 1 (TN1), neurovascular compression (NVC) is often assumed to be the pain initiating mechanism. NVC can be surgically addressed by microvascular decompression (MVD). However, some patients with TN1 present without NVC (WONVC). OBJECTIVE To characterize and analyze the clinical spectrum of a TN1 patient population WONVC. METHODS A retrospective chart review of patients presenting with TN1 between 2007 and 2017 was performed. Patients who were potential candidates for MVD surgery underwent high-resolution imaging with 3-dimensional (3D) reconstruction to address the presence, or absence, of NVC. Demographic data about the populations with NVC (WNVC) and WONVC were collected. RESULTS Of 242 patients with TN1, 32% did not have NVC. Patients WONVC were on average 10.6 yr younger than those WNVC. TN1 onset in patients WONVC was more frequent below 48.7 yr, and the opposite was found in patients WNVC. Compared to patients WNVC, those WONVC were predominantly female (odds ratio 4.8), on average were 4 yr younger at symptom onset (34.7 yr) and 7.8 yr younger at first clinic visit, and had a 3.7 yr shorter symptom duration. CONCLUSION Patients presenting with TN1 WONVC were predominantly females in their mid-30s with short symptom duration. In the absence of NVC, this subgroup of TN1 patients has limited surgical options, and potentially a longer condition duration that must be managed medically or surgically. This population WONVC might provide insights into the true pathophysiology of TN1.
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Affiliation(s)
- Philippe Magown
- Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrew L Ko
- Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Kim J Burchiel
- Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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13
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Burchiel KJ, Kinsman M, Mansfield K, Mitchell A. Verification of the Deep Brain Stimulation Electrode Position Using Intraoperative Electromagnetic Localization. Stereotact Funct Neurosurg 2020; 98:37-42. [PMID: 32018272 DOI: 10.1159/000505494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 07/03/2019] [Accepted: 12/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electromagnetic (EM) localization has typically been used to direct shunt catheters into the ventricle. The objective of this study was to determine if this method of EM tracking could be used in a deep brain stimulation (DBS) electrode cannula to accurately predict the eventual location of the electrode contacts. METHODS The Medtronic AxiEMTM system was used to generate the cannula tip location directed to the planned target site. Prior to clinical testing, a series of phantom modelling observations were made. RESULTS Phantom trials (n = 23) demonstrated that the cannula tip could be accurately located at the target site with an error of between 0.331 ± 0.144 and 0.6 ± 0.245 mm, depending on the orientation of the delivery system to the axis of the phantom head. Intraoperative EM localization of the DBS cannula was performed in 84 trajectories in 48 patients. The average difference between the planned target and the EM stylet location at the cannula tip was 1.036 ± 0.543 mm. The average error between the planned target coordinates and the actual target electrode location (by CT) was 1.431 ± 0.607 and 1.145 ± 0.636 mm for the EM stylet location in the cannula (p = 0.00312), indicating that EM localization reflected the position of the target electrode more accurately than the planned target. CONCLUSIONS EM localization can be used to verify the position of DBS electrodes intraoperatively with a high accuracy.
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Affiliation(s)
- Kim J Burchiel
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA,
| | - Michael Kinsman
- Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kevin Mansfield
- Department of Neurosurgery, Mercy Clinic, Springfield, Missouri, USA
| | - Ann Mitchell
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Rao AJ, Bullis C, Holste KG, Teton Z, Burchiel KJ, Raslan AM. Balancing Operative Efficiency and Surgical Education: A Functional Neurosurgery Model. Oper Neurosurg (Hagerstown) 2019; 17:622-631. [PMID: 30997509 DOI: 10.1093/ons/opz048] [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: 08/21/2018] [Accepted: 02/19/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation. OBJECTIVE To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations. METHODS For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience. RESULTS A sampling of each operation (n = 36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety. CONCLUSION This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care.
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Affiliation(s)
- Abigail J Rao
- Department of Neurosurgery, University of California-Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon.,Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
| | - Carli Bullis
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Katherine G Holste
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Zoe Teton
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Hardaway FA, Raslan AM, Burchiel KJ. Deep Brain Stimulation-Related Infections: Analysis of Rates, Timing, and Seasonality. Neurosurgery 2019; 83:540-547. [PMID: 29048556 DOI: 10.1093/neuros/nyx505] [Citation(s) in RCA: 20] [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: 05/08/2017] [Accepted: 09/15/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Infection is one of the most common complications of deep brain stimulation (DBS). Long-term infection rates beyond the immediate postoperative period are rarely evaluated. OBJECTIVE To study short- and long-term DBS-related infection rates; to evaluate any potential seasonality associated with DBS-related infections. METHODS We retrospectively reviewed all DBS surgeries performed in a 5-yr period at 1 hospital by a single surgeon. Infection rates and clinical characteristics were analyzed. Postoperative "infections" were defined as occurring within 6 mo of implantation of DBS hardware, while "erosions" were defined as transcutaneous exposure of hardware at ≥6 mo after implantation. Based on the date of surgery preceding an infection, rates of infection were calculated on a monthly and seasonal basis and compared using Chi square and logistic regression analyses. RESULTS A total of 443 patients underwent 592 operations; 311 patients underwent primary DBS placement with 632 electrodes. Primary DBS placement infection incidence was 2.6%. DBS procedure infection and infection rate by electrode were 2.9% and 3.2%, respectively. Infectious complications presented later than 6 mo postoperatively in 38% of infected patients Summer (July-September) infection rate was significantly higher than other seasons (P = .002). The odds ratio of an infection related to a surgery performed in August was found to be 4.15 compared to other months (P = .021). CONCLUSION There is a persistent risk of DBS infection and erosion beyond the first year of DBS implantation. Start of the academic year was associated with increased infection rate at our institution.
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Affiliation(s)
- Fran A Hardaway
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon
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Burchiel KJ, Mitchell A, Mansfield KJ. Improving Accuracy for Optical Navigation in Asleep Deep Brain Stimulation Electrode Implantation. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_456] [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: 11/12/2022] Open
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17
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Affiliation(s)
- Philippe Magown
- Division of Functional Neurosurgery Department of Neurological Surgery Oregon Health and Science University Portland, Oregon
| | - Andrew L Ko
- Division of Functional and Restorative Neurosurgery Department of Neurological Surgery University of Washington Seattle, Washington
| | - Kim J Burchiel
- Division of Functional Neurosurgery Department of Neurological Surgery Oregon Health and Science University Portland, Oregon
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Holste KG, Hardaway FA, Raslan AM, Burchiel KJ. Pain-free and pain-controlled survival after sectioning the nervus intermedius in nervus intermedius neuralgia: a single-institution review. J Neurosurg 2019; 131:352-359. [DOI: 10.3171/2018.3.jns172495] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/06/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVENervus intermedius neuralgia (NIN) or geniculate neuralgia is a rare facial pain condition consisting of sharp, lancinating pain deep in the ear and can occur alongside trigeminal neuralgia (TN). Studies on the clinical presentation, intraoperative findings, and ultimately postoperative outcomes are extremely limited. The aim of this study was to examine the clinical presentation and surgical findings, and determine pain-free survival after sectioning of the nervus intermedius (NI).METHODSThe authors conducted a retrospective chart review and survey of patients who were diagnosed with NIN at one institution and who underwent neurosurgical interventions. Pain-free survival was determined through chart review and phone interviews using a modified facial pain and quality of life questionnaire and represented as Kaplan-Meier curves.RESULTSThe authors found 15 patients with NIN who underwent microsurgical intervention performed by two surgeons from 2002 to 2016 at a single institution. Fourteen of these patients underwent sectioning of the NI, and 8 of 14 had concomitant TN. Five patients had visible neurovascular compression (NVC) of the NI by the anterior inferior cerebellar artery in most cases where NVC was found. The most common postoperative complaints were dizziness and vertigo, diplopia, ear fullness, tinnitus, and temporary facial nerve palsy. Thirteen of the 14 patients reportedly experienced pain relief immediately after surgery. The mean length of follow-up was 6.41 years (range 8 months to 14.5 years). Overall recurrence of any pain was 42% (6 of 14), and 4 patients (isolated NIN that received NI sectioning alone) reported their pain was the same or worse than before surgery at longest follow-up. The median pain-free survival was 4.82 years ± 14.85 months. The median pain-controlled survival was 6.22 years ± 15.78 months.CONCLUSIONSIn this retrospective review, sectioning of the NI produced no major complications, such as permanent facial weakness or deafness, and was effective for patients when performed in addition to other procedures. After sectioning of the NI, patients experienced 4.8 years pain free and experienced 6.2 years of less pain than before surgery. Alone, sectioning of the NI was not effective. The pathophysiology of NIN is not entirely understood. It appears that neurovascular compression plays only a minor role in the syndrome and there is a high degree of overlap with TN.
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Teton ZE, Blatt D, Holste K, Raslan AM, Burchiel KJ. Utilization of 3D imaging reconstructions and assessment of symptom-free survival after microvascular decompression of the facial nerve in hemifacial spasm. J Neurosurg 2019; 133:425-432. [PMID: 31299649 DOI: 10.3171/2019.4.jns183207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/15/2018] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hemifacial spasm (HFS), largely caused by neurovascular compression (NVC) of the facial nerve, is a rare condition characterized by paroxysmal, unilateral, involuntary contraction of facial muscles. It has long been suggested that these symptoms are due to compression at the transition zone of the facial nerve. The aim of this study was to examine symptom-free survival and long-term quality of life (QOL) in HFS patients who underwent microvascular decompression (MVD). A secondary aim was to examine the benefit of utilizing fused MRI and MRA post hoc 3D reconstructions to better characterize compression location at the facial nerve root exit zone (fREZ). METHODS The authors retrospectively analyzed patients with HFS who underwent MVD at a single institution, combined with a modified HFS-7 telephone questionnaire. Kaplan-Meier analysis was used to determine event-free survival, and the Wilcoxon signed-rank test was used to compare pre- and postoperative HFS-7 scores. RESULTS Thirty-five patients underwent MVD for HFS between 2002 and 2018 with subsequent 3D reconstructions of preoperative images. The telephone questionnaire response rate was 71% (25/35). If patients could not be reached by telephone, then the last clinic follow-up date was recorded and any recurrence noted. Twenty-four patients (69%) were symptom free at longest follow-up. The mean length of follow-up was 2.4 years (1 month to 8 years). The mean symptom-free survival time was 44.9 ± 5.8 months, and the average symptom-control survival was 69.1 ± 4.9 months. Four patients (11%) experienced full recurrence. Median HFS-7 scores were reduced by 18 points after surgery (Z = -4.013, p < 0.0001). Three-dimensional reconstructed images demonstrated that NVC most commonly occurred at the attached segment (74%, 26/35) of the facial nerve within the fREZ and least commonly occurred at the traditionally implicated transition zone (6%, 2/35). CONCLUSIONS MVD is a safe and effective treatment that significantly improves QOL measures for patients with HFS. The vast majority of patients (31/35, 89%) were symptom free or reported only mild symptoms at longest follow-up. Symptom recurrence, if it occurred, was within the first 2 years of surgery, which has important implications for patient expectations and informed consent. Three-dimensional image reconstruction analysis determined that culprit compression most commonly occurs proximally along the brainstem at the attached segment. The success of this procedure is dependent on recognizing this pattern and decompressing appropriately. Three-dimensional reconstructions were found to provide much clearer characterization of this area than traditional preoperative imaging. Therefore, the authors suggest that use of these reconstructions in the preoperative setting has the potential to help identify appropriate surgical candidates, guide operative planning, and thus improve outcome in patients with HFS.
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Affiliation(s)
| | | | - Katherine Holste
- 1School of Medicine and
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Ahmed M Raslan
- 3Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Kim J Burchiel
- 3Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
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Teton ZE, Blatt D, AlBakry A, Obayashi J, Ozturk G, Hamzaoglu V, Magown P, Selden NR, Burchiel KJ, Raslan AM. Natural history of neuromodulation devices and therapies: a patient-centered survival analysis. J Neurosurg 2019; 132:1385-1391. [PMID: 31003217 DOI: 10.3171/2019.2.jns182450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite rapid development and expansion of neuromodulation technologies, knowledge about device and/or therapy durability remains limited. The aim of this study was to evaluate the long-term rate of hardware and therapeutic failure of implanted devices for several neuromodulation therapies. METHODS The authors performed a retrospective analysis of patients' device and therapy survival data (Kaplan-Meier survival analysis) for deep brain stimulation (DBS), vagus nerve stimulation (VNS), and spinal cord stimulation (SCS) at a single institution (years 1994-2015). RESULTS During the study period, 450 patients underwent DBS, 383 VNS, and 128 SCS. For DBS, the 5- and 10-year initial device survival was 87% and 73%, respectively, and therapy survival was 96% and 91%, respectively. For VNS, the 5- and 10-year initial device survival was 90% and 70%, respectively, and therapy survival was 99% and 97%, respectively. For SCS, the 5- and 10-year initial device survival was 50% and 34%, respectively, and therapy survival was 74% and 56%, respectively. The average initial device survival for DBS, VNS, and SCS was 14 years, 14 years, and 8 years while mean therapy survival was 18 years, 18 years, and 12.5 years, respectively. CONCLUSIONS The authors report, for the first time, comparative device and therapy survival rates out to 15 years for large cohorts of DBS, VNS, and SCS patients. Their results demonstrate higher device and therapy survival rates for DBS and VNS than for SCS. Hardware failures were more common among SCS patients, which may have played a role in the discontinuation of therapy. Higher therapy survival than device survival across all modalities indicates continued therapeutic benefit beyond initial device failures, which is important to emphasize when counseling patients.
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Hardaway FA, Gustafsson HC, Holste K, Burchiel KJ, Raslan AM. A novel scoring system as a preoperative predictor for pain-free survival after microsurgery for trigeminal neuralgia. J Neurosurg 2019; 132:217-224. [PMID: 30684937 DOI: 10.3171/2018.9.jns181208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 05/03/2018] [Accepted: 09/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pain relief following microvascular decompression (MVD) for trigeminal neuralgia (TN) may be related to pain type, degree of neurovascular conflict, arterial compression, and location of compression. The objective of this study was to construct a predictive pain-free scoring system based on clinical and radiographic factors that can be used to preoperatively prognosticate long-term outcomes for TN patients following surgical intervention (MVD or internal neurolysis [IN]). It was hypothesized that contributing factors would include pain type, presence of an artery or vein, neurovascular conflict severity, and compression location (root entry zone). METHODS At the authors' institution 275 patients with type 1 or type 2 TN (TN1 or TN2) underwent MVD or IN following preoperative high-resolution brain MRI studies. Outcome data were obtained retrospectively by chart review and/or phone follow-up. Characteristics of neurovascular conflict were obtained from preoperative MRI studies. Factors that resulted in a probability value of < 0.05 on univariate logistic regression analyses were entered into a multivariate Cox regression analysis in a backward stepwise fashion. For the multivariate analysis, significance at the 0.15 level was used. A prognostic system was then devised with 4 possible scores (0, 1, 2, or 3) and pain-free survival analyses conducted. RESULTS Univariate predictors of pain-free survival were pain type (p = 0.013), presence of any vessel (p = 0.042), and neurovascular compression severity (p = 0.038). Scores of 0, 1, 2, and 3 were found to be significantly different in regard to pain-free survival (log rank, p = 0.005). At 5 and 10 years there were 36%, 43%, 61%, and 69%, and 36%, 43%, 56%, and 67% pain-free survival rates in groups 0, 1, 2, and 3, respectively. While TN2 patients had worse outcomes regardless of score, a subgroup analysis of TN1 patients with higher neurovascular conflict (score of 3) had significantly better outcomes than TN1 patients without severe neurovascular conflict (score of 1) (log rank, p = 0.005). Regardless of pain type, those patients with severe neurovascular conflict were more likely to have arterial compression (99%) compared to those with low neurovascular conflict (p < 0.001). CONCLUSIONS Pain-free survival was predicted by a scoring system based on preoperative clinical and radiographic findings. Higher scores predicted significantly better pain relief than lower scores. TN1 patients with severe neurovascular conflict had the best long-term pain-free outcome.
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Teton ZE, Holste KG, Hardaway FA, Burchiel KJ, Raslan AM. Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia. J Neurosurg 2019; 132:232-238. [PMID: 30641844 DOI: 10.3171/2018.8.jns18239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Glossopharyngeal neuralgia (GN) is a rare pain condition in which patients experience paroxysmal, lancinating throat pain. Multiple surgical approaches have been used to treat this condition, including microvascular decompression (MVD), and sectioning of cranial nerve (CN) IX and the upper rootlets of CN X, or a combination of the two. The aim of this study was to examine the long-term quality of life and pain-free survival after MVD and sectioning of the CN X/IX complex. METHODS A combined retrospective chart review and a quality-of-life telephone survey were performed to collect demographic and long-term outcome data. Quality of life was assessed by means of a questionnaire based on a combination of the Barrow Neurological Institute pain intensity scoring criteria and the Brief Pain Inventory-Facial. Kaplan-Meier analysis was performed to determine pain-free survival. RESULTS Of 18 patients with GN, 17 underwent sectioning of the CN IX/X complex alone or sectioning and MVD depending on the presence of a compressing vessel. Eleven of 17 patients had compression of CN IX/X by the posterior inferior cerebellar artery, 1 had compression by a vertebral artery, and 5 had no compression. One patient (6%) experienced no immediate pain relief. Fifteen (88%) of 17 patients were pain free at the last follow-up (mean 9.33 years, range 5.16-13 years). One patient (6%) experienced throat pain relapse at 3 months. The median pain-free survival was 7.5 years ± 10.6 months. Nine of 18 patients were contacted by telephone. Of the 17 patients who underwent sectioning of the CN IX/X complex, 13 (77%) patients had short-term complaints: dysphagia (n = 4), hoarseness (n = 4), ipsilateral hearing loss (n = 4), ipsilateral taste loss (n = 2), and dizziness (n = 2) at 2 weeks. Nine patients had persistent side effects at latest follow-up. Eight of 9 telephone respondents reported that they would have the surgery over again. CONCLUSIONS Sectioning of the CN IX/X complex with or without MVD of the glossopharyngeal nerve is a safe and effective surgical therapy for GN with initial pain freedom in 94% of patients and an excellent long-term pain relief (mean 7.5 years).
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Affiliation(s)
- Kim J Burchiel
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
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24
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Mohammed M, Madden CJ, Burchiel KJ, Morrison SF. Preoptic area cooling increases the sympathetic outflow to brown adipose tissue and brown adipose tissue thermogenesis. Am J Physiol Regul Integr Comp Physiol 2018; 315:R609-R618. [PMID: 29897823 DOI: 10.1152/ajpregu.00113.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Modest cold exposures are likely to activate autonomic thermogenic mechanisms due to activation of cutaneous thermal afferents, whereas central thermosensitive neurons set the background tone on which this afferent input is effective. In addition, more prolonged or severe cold exposures that overwhelm cold defense mechanisms would directly activate thermosensitive neurons within the central nervous system. Here, we examined the involvement of the canonical brown adipose tissue (BAT) sympathoexcitatory efferent pathway in the response to direct local cooling of the preoptic area (POA) in urethane-chloralose-anesthetized rats. With skin temperature and core body temperature maintained between 36 and 39°C, cooling POA temperature by ~1-4°C evoked increases in BAT sympathetic nerve activity (SNA), BAT temperature, expired CO2, and heart rate. POA cooling-evoked responses were inhibited by nanoinjections of ionotropic glutamate receptor antagonists or the GABAA receptor agonist muscimol into the median POA or by nanoinjections of ionotropic glutamate receptor antagonists into the dorsomedial hypothalamic nucleus (bilaterally) or into the raphe pallidus nucleus. These results demonstrate that direct cooling of the POA can increase BAT SNA and thermogenesis via the canonical BAT sympathoexcitatory efferent pathway, even in the face of warm thermal input from the skin and body core.
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Affiliation(s)
- Mazher Mohammed
- Department of Neurological Surgery, Oregon Health & Science University , Portland, Oregon
| | - Christopher J Madden
- Department of Neurological Surgery, Oregon Health & Science University , Portland, Oregon
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University , Portland, Oregon
| | - Shaun F Morrison
- Department of Neurological Surgery, Oregon Health & Science University , Portland, Oregon
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Ko AL, Magown P, Ozpinar A, Hamzaoglu V, Burchiel KJ. Asleep Deep Brain Stimulation Reduces Incidence of Intracranial Air during Electrode Implantation. Stereotact Funct Neurosurg 2018; 96:83-90. [PMID: 29847829 DOI: 10.1159/000488150] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 02/10/2015] [Accepted: 03/05/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Asleep deep brain stimulation (aDBS) implantation replaces microelectrode recording for image-guided implantation, shortening the operative time and reducing cerebrospinal fluid egress. This may decrease pneumocephalus, thus decreasing brain shift during implantation. OBJECTIVE To compare the incidence and volume of pneumocephalus during awake (wkDBS) and aDBS procedures. METHODS A retrospective review of bilateral DBS cases performed at Oregon Health & Science University from 2009 to 2017 was undertaken. Postimplantation imaging was reviewed to determine the presence and volume of intracranial air and measure cortical brain shift. RESULTS Among 371 patients, pneumocephalus was noted in 66% of wkDBS and 15.6% of aDBS. The average volume of air was significantly higher in wkDBS than aDBS (8.0 vs. 1.8 mL). Volumes of air greater than 7 mL, which have previously been linked to brain shift, occurred significantly more frequently in wkDBS than aDBS (34 vs 5.6%). wkDBS resulted in significantly larger cortical brain shifts (5.8 vs. 1.2 mm). CONCLUSIONS We show that aDBS reduces the incidence of intracranial air, larger air volumes, and cortical brain shift. Large volumes of intracranial air have been correlated to shifting of brain structures during DBS procedures, a variable that could impact accuracy of electrode placement.
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Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, University of Washington Medical Center and Harborview Medical Center, Seattle, Washington, USA
| | - Philippe Magown
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Alp Ozpinar
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vural Hamzaoglu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
Deep brain stimulation (DBS) has become an established treatment for medically refractory movement disorders including Parkinson's disease, essential tremor, and dystonia. The field of DBS continues to evolve with advances in patient selection, target identification, electrode and pulse generator technology, and the development of more effective stimulation paradigms such as closed-loop stimulation. Furthermore, as the safety and efficacy of DBS improves through better hardware design and deeper understanding of its mechanisms of action, the indications for DBS will continue to expand to cover a wider range of disorders. Finally, the recent approval of MR-guided focused ultrasound for the treatment of essential tremor and potentially other movement disorders heralds a resurgence in lesion creation as a viable alternative to DBS for selected patients.
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Burchiel KJ, Zetterman RK, Ludmerer KM, Philibert I, Brigham TP, Malloy K, Arrighi JA, Ashley SW, Bienstock JL, Carek PJ, Correa R, Forstein DA, Gaiser RR, Gold JP, Keepers GA, Kennedy BC, Kirk LM, Kothari A, Langdale LA, Shayne PH, Stain SC, Woods SK, Wyatt-Johnson C, Nasca TJ. The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development in a Safe, Humane Environment. J Grad Med Educ 2017; 9:692-696. [PMID: 29270256 PMCID: PMC5734321 DOI: 10.4300/jgme-d-17-00317.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Brodsky MA, Anderson S, Murchison C, Seier M, Wilhelm J, Vederman A, Burchiel KJ. Clinical outcomes of asleep vs awake deep brain stimulation for Parkinson disease. Neurology 2017; 89:1944-1950. [DOI: 10.1212/wnl.0000000000004630] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 08/04/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:To compare motor and nonmotor outcomes at 6 months of asleep deep brain stimulation (DBS) for Parkinson disease (PD) using intraoperative imaging guidance to confirm electrode placement vs awake DBS using microelectrode recording to confirm electrode placement.Methods:DBS candidates with PD referred to Oregon Health & Science University underwent asleep DBS with imaging guidance. Six-month outcomes were compared to those of patients who previously underwent awake DBS by the same surgeon and center. Assessments included an “off”-levodopa Unified Parkinson’s Disease Rating Scale (UPDRS) II and III, the 39-item Parkinson's Disease Questionnaire, motor diaries, and speech fluency.Results:Thirty participants underwent asleep DBS and 39 underwent awake DBS. No difference was observed in improvement of UPDRS III (+14.8 ± 8.9 vs +17.6 ± 12.3 points, p = 0.19) or UPDRS II (+9.3 ± 2.7 vs +7.4 ± 5.8 points, p = 0.16). Improvement in “on” time without dyskinesia was superior in asleep DBS (+6.4 ± 3.0 h/d vs +1.7 ± 1.2 h/d, p = 0.002). Quality of life scores improved in both groups (+18.8 ± 9.4 in awake, +8.9 ± 11.5 in asleep). Improvement in summary index (p = 0.004) and subscores for cognition (p = 0.011) and communication (p < 0.001) were superior in asleep DBS. Speech outcomes were superior in asleep DBS, both in category (+2.77 ± 4.3 points vs −6.31 ± 9.7 points (p = 0.0012) and phonemic fluency (+1.0 ± 8.2 points vs −5.5 ± 9.6 points, p = 0.038).Conclusions:Asleep DBS for PD improved motor outcomes over 6 months on par with or better than awake DBS, was superior with regard to speech fluency and quality of life, and should be an option considered for all patients who are candidates for this treatment.Clinicaltrials.gov identifier:NCT01703598.Classification of evidence:This study provides Class III evidence that for patients with PD undergoing DBS, asleep intraoperative CT imaging–guided implantation is not significantly different from awake microelectrode recording–guided implantation in improving motor outcomes at 6 months.
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Ko AL, Ibrahim A, Magown P, Macallum R, Burchiel KJ. Factors Affecting Stereotactic Accuracy in Image-Guided Deep Brain Stimulator Electrode Placement. Stereotact Funct Neurosurg 2017; 95:315-324. [DOI: 10.1159/000479527] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/11/2017] [Indexed: 11/19/2022]
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Hardaway F, Gustafsson H, Holste K, Burchiel KJ, Raslan AMT. 127 A Novel Scoring System for Preoperative Prediction for Pain-Free Survival After Microsurgery for Trigeminal Neuralgia. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Holste K, Raslan AMT, Burchiel KJ. 130 Pain Free Survival After Microvascular Decompression and Sectioning of the Vagoglossopharyngeal Nerve Complex in Glossopharyngeal Neuralgia. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.130] [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: 11/12/2022] Open
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Abstract
ABBREVIATIONS AD, Alzheimer diseaseDBS, Deep brain stimulationFDA, Food and Drug AdministrationMER, Microelectrode recording.
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Affiliation(s)
- Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Affiliation(s)
- Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Jacob RL, Geddes J, McCartney S, Burchiel KJ. Cost analysis of awake versus asleep deep brain stimulation: a single academic health center experience. J Neurosurg 2016; 124:1517-23. [DOI: 10.3171/2015.5.jns15433] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The objective of this study was to compare the cost of deep brain stimulation (DBS) performed awake versus asleep at a single US academic health center and to compare costs across the University HealthSystem Consortium (UHC) Clinical Database.
METHODS
Inpatient and outpatient demographic and hospital financial data for patients receiving a neurostimulator lead implant (from the first quarter of 2009 to the second quarter of 2014) were collected and analyzed. Inpatient charges included those associated with International Classification of Diseases, Ninth Revision (ICD-9) procedure code 0293 (implantation or replacement of intracranial neurostimulator lead). Outpatient charges included all preoperative charges ≤ 30 days prior to implant and all postoperative charges ≤ 30 days after implant. The cost of care based on reported charges and a cost-to-charge ratio was estimated. The UHC database was queried (January 2011 to March 2014) with the same ICD-9 code. Procedure cost data across like hospitals (27 UHC hospitals) conducting similar DBS procedures were compared.
RESULTS
Two hundred eleven DBS procedures (53 awake and 158 asleep) were performed at a single US academic health center during the study period. The average patient age ( ± SD) was 65 ± 9 years old and 39% of patients were female. The most common primary diagnosis was Parkinson’s disease (61.1%) followed by essential and other forms of tremor (36%). Overall average DBS procedure cost was $39,152 ± $5340. Asleep DBS cost $38,850 ± $4830, which was not significantly different than the awake DBS cost of $40,052 ± $6604. The standard deviation for asleep DBS was significantly lower (p ≤ 0.05). In 2013, the median cost for a neurostimulator implant lead was $34,052 at UHC-affiliated hospitals that performed at least 5 procedures a year. At Oregon Health & Science University, the median cost was $17,150 and the observed single academic health center cost for a neurostimulator lead implant was less than the expected cost (ratio 0.97).
CONCLUSIONS
In this single academic medical center cost analysis, DBS performed asleep was associated with a lower cost variation relative to the awake procedure. Furthermore, costs compared favorably to UHC-affiliated hospitals. While asleep DBS is not yet standard practice, this center exclusively performs asleep DBS at a lower cost than comparable institutions.
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Affiliation(s)
| | | | - Shirley McCartney
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kim J. Burchiel
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Gupta K, Burchiel KJ. Atypical facial pain in multiple sclerosis caused by spinal cord seizures: a case report and review of the literature. J Med Case Rep 2016; 10:101. [PMID: 27095098 PMCID: PMC4837532 DOI: 10.1186/s13256-016-0891-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 12/02/2015] [Accepted: 03/30/2016] [Indexed: 11/24/2022] Open
Abstract
Background Pain is a very commonly reported symptom and often drives patients to seek medical attention; however, it can prove a very difficult diagnostic conundrum and even more challenging to treat effectively. Accurately determining the primary pain generator is key, as certain conditions have efficacious medical and surgical treatments. We present a rare case of a man with multiple sclerosis presenting with spinal cord seizures causing dermatomal pain. While pain has been reported in the context of motor symptoms attributed to spinal cord seizures in a small number of spinal cord conditions, this case represents the first report of pain exclusively associated with spinal cord demyelination in multiple sclerosis. Case presentation We present the case of a 60-year-old Caucasian male patient with multiple sclerosis who reported a 5-year history of progressive pain in his left retroauricular region and superior left shoulder. He described this pain as sharp, episodic, and unrelenting and he was referred for consideration for surgical treatment of trigeminal neuralgia. He had no evidence of trigeminal nerve root pathology on magnetic resonance imaging, but did show dorsolateral spinal cord demyelination at the C3–4 level. His symptoms therefore represent an unusual presentation of spinal cord seizures. Conclusions Spinal cord seizures are rarely reported in multiple sclerosis and typically present with focal motor seizures. These have been reported to present with cramping dysesthesia and pruritus, though rarely with primary pain. Knowledge of uncommon pain presentations is critical for the increasing number of primary care physicians caring for patients with such chronic neurological diseases as it will guide management and referral patterns. This knowledge is also important for the treating neurologists and neurosurgeons. Neurosurgical intervention for trigeminal neuralgia poses considerable surgical risk, and it should be avoided where possible. Identifying the primary pain generator is, therefore, critical for accurate diagnosis and management.
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Affiliation(s)
- Kunal Gupta
- Department of Neurological Surgery CR-137, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Kim J Burchiel
- Department of Neurological Surgery CR-137, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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Sitti I, Acar G, Zisakis AK, Özdemir M, Acar F, Burchiel KJ. Effect of Subthalamic Nucleus Stimulation on Pedunculopontine Nucleus Neural Activity. Stereotact Funct Neurosurg 2016; 94:54-9. [PMID: 26977617 DOI: 10.1159/000442892] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 11/30/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The pedunculopontine nucleus has recently been proposed as an alternative target for deep brain stimulation for the treatment of medically intractable Parkinson's disease. The suggested indication for pedunculopontine nucleus deep brain stimulation is severe and medically intractable axial symptoms such as gait and postural impairment. OBJECTIVE Our goal in this study was to describe the effects of subthalamic nucleus stimulation on pedunculopontine nucleus electrophysiological activity. METHODS Fourteen male Wistar rats were divided into a sham stimulation group and an experimental group. In both groups, electrodes were implanted bilaterally into the subthalamic nucleus and into the right pedunculopontine nucleus. Microelectrode recordings were carried out in both groups prior to and during subthalamic nucleus stimulation. RESULTS Subthalamic nucleus stimulation produced no clear inhibition of neuronal firing in the pedunculopontine nucleus. However, we found that stimulation of the subthalamic nucleus at 60 Hz produces some entrainment of pedunculopontine nucleus neuronal firing and a shift of subthalamic nucleus firing patterns to more tonic and random patterns. These results are consistent with the effects of deep brain stimulation on neuronal activity in the subthalamic nucleus and globus pallidus internus. CONCLUSION The result of this study provides additional evidence to improve our understanding of the mechanism of subthalamic nucleus-deep brain stimulation, and its physiological consequences.
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Affiliation(s)
- Ilkay Sitti
- Department of Neurosurgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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Ko AL, Burchiel KJ. Response. J Neurosurg 2015; 123:1613-1614. [PMID: 26953365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Ko AL, Ozpinar A, Raskin JS, Magill ST, Raslan AM, Burchiel KJ. Correlation of preoperative MRI with the long-term outcomes of dorsal root entry zone lesioning for brachial plexus avulsion pain. J Neurosurg 2015; 124:1470-8. [PMID: 26406799 DOI: 10.3171/2015.2.jns142572] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 11/06/2022]
Abstract
OBJECT Lesioning of the dorsal root entry zone (DREZotomy) is an effective treatment for brachial plexus avulsion (BPA) pain. The role of preoperative assessment with MRI has been shown to be unreliable for determining affected levels; however, it may have a role in predicting pain outcomes. Here, DREZotomy outcomes are reviewed and preoperative MRI is examined as a possible prognostic factor. METHODS A retrospective review was performed of an institutional database of patients who had undergone brachial plexus DREZ procedures since 1995. Preoperative MRI was examined to assess damage to the DREZ or dorsal horn, as evidenced by avulsion of the DREZ or T2 hyperintensity within the spinal cord. Phone interviews were conducted to assess the long-term pain outcomes. RESULTS Between 1995 and 2012, 27 patients were found to have undergone cervical DREZ procedures for BPA. Of these, 15 had preoperative MR images of the cervical spine available for review. The outcomes were graded from 1 to 4 as poor (no significant relief), good (more than 50% pain relief), excellent (more than 75% pain relief), or pain free, respectively. Overall, DREZotomy was found to be a safe, efficacious, and durable procedure for relief of pain due to BPA. The initial success rate was 73%, which declined to 66% at a median follow-up time of 62.5 months. Damage to the DREZ or dorsal horn was significantly correlated with poorer outcomes (p = 0.02). The average outcomes in patients without MRI evidence of DREZ or dorsal horn damage was significantly higher than in patients with such damage (3.67 vs 1.75, t-test; p = 0.001). A longer duration of pain prior to operation was also a significant predictor of treatment success (p = 0.004). CONCLUSIONS Overall, the DREZotomy procedure has a 66% chance of achieving meaningful pain relief on long-term follow-up. Successful pain relief is associated with the lack of damage to the DREZ and dorsal horn on preoperative MRI.
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Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Alp Ozpinar
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
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St George RJ, Carlson-Kuhta P, King LA, Burchiel KJ, Horak FB. Compensatory stepping in Parkinson's disease is still a problem after deep brain stimulation randomized to STN or GPi. J Neurophysiol 2015; 114:1417-23. [PMID: 26108960 DOI: 10.1152/jn.01052.2014] [Citation(s) in RCA: 18] [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: 12/30/2014] [Accepted: 06/19/2015] [Indexed: 11/22/2022] Open
Abstract
The effects of deep brain stimulation (DBS) on balance in people with Parkinson's disease (PD) are not well established. This study examined whether DBS randomized to the subthalamic nucleus (STN; n = 11) or globus pallidus interna (GPi; n = 10) improved compensatory stepping to recover balance after a perturbation. The standing surface translated backward, forcing subjects to take compensatory steps forward. Kinematic and kinetic responses were recorded. PD-DBS subjects were tested off and on their levodopa medication before bilateral DBS surgery and retested 6 mo later off and on DBS, combined with off and on levodopa medication. Responses were compared with PD-control subjects (n = 8) tested over the same timescale and 17 healthy control subjects. Neither DBS nor levodopa improved the stepping response. Compensatory stepping in the best-treated state after surgery (DBS+DOPA) was similar to the best-treated state before surgery (DOPA) for the PD-GPi group and the PD-control group. For the PD-STN group, there were more lateral weight shifts, a delayed foot-off, and a greater number of steps required to recover balance in DBS+DOPA after surgery compared with DOPA before surgery. Within the STN group five subjects who did not fall during the experiment before surgery fell at least once after surgery, whereas the number of falls in the GPi and PD-control groups were unchanged. DBS did not improve the compensatory step response needed to recover from balance perturbations in the GPi group and caused delays in the preparation phase of the step in the STN group.
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Affiliation(s)
- R J St George
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon; Human Motor Control Laboratory, School of Medicine, University of Tasmania, Hobart, Australia
| | - P Carlson-Kuhta
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon
| | - L A King
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon
| | - K J Burchiel
- Department of Neurosurgery, Oregon Health and Science University, Beaverton, Oregon
| | - F B Horak
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon; Department of Veterans Affairs Portland Health Care System, Portland, Oregon; and
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Ko AL, Lee A, Raslan AM, Ozpinar A, McCartney S, Burchiel KJ. Trigeminal neuralgia without neurovascular compression presents earlier than trigeminal neuralgia with neurovascular compression. J Neurosurg 2015; 123:1519-27. [PMID: 26047411 DOI: 10.3171/2014.11.jns141741] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). To characterize what may be distinct patient populations, the authors examined age at onset in patients with TN with and without NVC. METHODS A retrospective review of patients undergoing posterior fossa surgery for Type I TN at Oregon Health & Science University from 2009 to 2013 was undertaken. Charts were reviewed, and imaging and operative data were collected for patients with and without NVC. Mean, median, and the empirical cumulative distribution of onset age were determined. Statistical analysis was performed using Student t-test, Wilcoxon and Kolmogorov-Smirnoff tests, and Kaplan-Meier analysis. Multivariate analysis was performed using a Cox proportional hazards model. RESULTS The charts of 219 patients with TN were reviewed. There were 156 patients who underwent posterior fossa exploration and microvascular decompression or internal neurolysis: 129 patients with NVC and 27 without NVC. Mean age at symptoms onset for patients with and without NVC was 51.1 and 42.6 years, respectively. This difference (8.4 years) was significant (t-test: p = 0.007), with sufficient power to detect an effect size of 8.2 years. Median age between groups with and without NVC was 53.25 and 41.2 years, respectively (p = 0.003). Histogram analysis revealed a bimodal age at onset in patients without NVC, and cumulative distribution of age at onset revealed an earlier presentation of symptoms (p = 0.003) in patients without NVC. Chi-square analysis revealed a trend toward female predominance in patients without NVC, which was not significant (p = 0.08). Multivariate analysis revealed that age at onset was related to NVC but not sex, symptom side or distribution, or patient response to medical treatment. CONCLUSIONS NVC is neither sufficient nor necessary for the development of TN. Patients with TN without NVC may represent a distinct population of younger, predominantly female patients. Further research into the pathophysiology underlying this debilitating disease is needed.
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Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Albert Lee
- Department of Neurological Surgery, University of Indiana, Indianapolis, Indiana
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Alp Ozpinar
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Shirley McCartney
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
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Ko AL, Ozpinar A, Lee A, Raslan AM, McCartney S, Burchiel KJ. Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression. J Neurosurg 2015; 122:1048-57. [PMID: 25679283 DOI: 10.3171/2014.12.jns14469] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or "nerve combing," as a treatment for TN without NVC. METHODS This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. RESULTS A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. CONCLUSIONS This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.
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Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
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Raslan AM, Burchiel KJ. Letters to the editor: value-based neurosurgery and microvascular decompression. J Neurosurg 2014; 121:495-7. [PMID: 24972131 DOI: 10.3171/2014.4.jns14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ragel BT, Piedra M, Klimo P, Burchiel KJ, Waldo H, McCartney S, Selden NR. An ACGME Duty Hour Compliant 3-Person Night Float System for Neurological Surgery Residency Programs. J Grad Med Educ 2014; 6:315-9. [PMID: 24949139 PMCID: PMC4054734 DOI: 10.4300/jgme-d-13-00172.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/15/2013] [Accepted: 01/01/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted the 24+6-hour work schedule and 80-hour workweek, and in 2011, it enhanced work hour and supervision standards. INNOVATION In response, Oregon Health & Science University's (OHSU) neurological surgery residency instituted a 3-person night float system. METHODS We analyzed work hour records and operative experience for 1 year before and after night float implementation in a model that shortened a combined introductory research and basic clinical neurosciences rotation from 12 to 6 months. We analyzed residents' perception of the system using a confidential survey. The ACGME 2011 work hour standards were applied to both time periods. RESULTS AFTER NIGHT FLOAT IMPLEMENTATION, THE NUMBER OF DUTY HOUR VIOLATIONS WAS REDUCED: 28-hour shift (11 versus 235), 8 hours off between shifts (2 versus 20), 80 hours per week (0 versus 17), and total violations (23 versus 275). Violations increased only for the less than 4 days off per 4-week interval rule (10 versus 3). No meaningful difference was seen in the number of operative cases performed per year at any postgraduate year (PGY) training level: PGY-2 (336 versus 351), PGY-3 (394 versus 354), PGY-4 (803 versus 802), PGY-5 (1075 versus 1040), PGY-7 (947 versus 913), and total (3555 versus 3460). Residents rated the new system favorably. CONCLUSIONS To meet 2011 ACGME duty hour standards, the OHSU neurological surgery residency instituted a 3-person night float system. A nearly complete elimination of work hour violations did not affect overall resident operative experience.
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Lee A, McCartney S, Burbidge C, Raslan AM, Burchiel KJ. Trigeminal neuralgia occurs and recurs in the absence of neurovascular compression. J Neurosurg 2014; 120:1048-54. [DOI: 10.3171/2014.1.jns131410] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Vascular compression of the trigeminal nerve is the most common factor associated with the etiology of trigeminal neuralgia (TN). Microvascular decompression (MVD) has proven to be the most successful and durable surgical approach for this disorder. However, not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.
Methods
The authors performed a retrospective review of cases of TN Type 1 (TN1) or Type 2 (TN2) involving patients 18 years or older who underwent evaluation (and surgery when indicated) at Oregon Health & Science University between July 2006 and February 2013. Surgical and imaging findings were correlated.
Results
The review identified a total of 257 patients with TN (219 with TN1 and 38 with TN2) who underwent high-resolution MRI and MR angiography with 3D reconstruction of combined images using OsiriX. Imaging data revealed that the occurrence of TN1 and TN2 without NVC was 28.8% and 18.4%, respectively. A subgroup of 184 patients underwent surgical exploration. Imaging findings were highly correlated with surgical findings, with a sensitivity of 96% for TN1 and TN2 and a specificity of 90% for TN1 and 66% for TN2.
Conclusions
Magnetic resonance imaging detects NVC with a high degree of sensitivity. However, despite a diagnosis of TN1 or TN2, a significant number of patients have no NVC. Trigeminal neuralgia clearly occurs and recurs in the absence of NVC.
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St George RJ, Carlson-Kuhta P, Nutt JG, Hogarth P, Burchiel KJ, Horak FB. The effect of deep brain stimulation randomized by site on balance in Parkinson's disease. Mov Disord 2014; 29:949-53. [PMID: 24532106 DOI: 10.1002/mds.25831] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [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: 08/02/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The effect of the surgical site of DBS on balance and gait in Parkinson's Disease (PD) is uncertain. This is the first double-blind study of subjects randomized to either the STN (N = 14) or GPi (N = 14) who were assessed on a range of clinical balance measures. METHODS Balance testing occurred before and 6 months postsurgery. A control PD group was tested over the same period without surgery (N = 9). All subjects were tested on and off medication and DBS subjects were also tested on and off DBS. The Postural Instability and Gait Disability items of the UPDRS and additional functional tests, which we call the Balance and Gait scale, were assessed. Activities of Balance Confidence and Activities of Daily Living questionnaires were also recorded. RESULTS Balance was not different between the best-treated states before and after DBS surgery for both sites. Switching DBS on improved balance scores, and scores further improved with medication, compared to the off state. The GPi group showed improved performance in the postsurgery off state and better ratings of balance confidence after surgery, compared to the STN group. CONCLUSIONS Clinical measures of balance function for both the STN and GPi sites showed that balance did not improve beyond the best medically treated state before surgery. Both clinical balance testing in the off/off state and self-reported balance confidence after surgery showed better performance in the GPi than the STN group.
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Affiliation(s)
- Rebecca J St George
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
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McCartney S, Weltin M, Burchiel KJ. Use of an Artificial Neural Network for Diagnosis of Facial Pain Syndromes: An Update. Stereotact Funct Neurosurg 2014; 92:44-52. [DOI: 10.1159/000353188] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 05/07/2013] [Indexed: 01/27/2023]
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Raslan AM, Burchiel KJ. Response. J Neurosurg 2013; 119:1353-1354. [PMID: 24344456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Affiliation(s)
- Ashwin Viswanathan
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
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Thompson EM, Burchiel KJ, Raslan AM. Percutaneous trigeminal tractotomy–nucleotomy with use of intraoperative computed tomography and general anesthesia: report of 2 cases. Neurosurg Focus 2013; 35:E5. [DOI: 10.3171/2013.6.focus13218] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For confirming the correct location of the radiofrequency electrode before creation of a lesion, percutaneous CT-guided trigeminal tractotomy–nucleotomy is most commonly performed with the patient prone and awake. However, for patients whose facial pain and hypersensitivity are so severe that the patients are unable to rest their face on a support (as required with prone positioning), awake CT-guided tractotomy-nucleotomy might not be feasible. The authors describe 2 such patients, for whom percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia was successful. One patient was a 79-year-old man with profound left facial postherpetic neuralgia, who was unable to tolerate awake CT-guided tractotomy-nucleotomy, and the other was a 45-year-old woman with intractable hemicranial pain that developed after a right frontal lesionectomy for epilepsy. Each patient underwent a percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia. No complications occurred, and each patient reported excellent pain relief for up to 6 and 3 months after surgery, respectively. Percutaneous intraoperative CT-guided tractotomy-nucleotomy performed on anesthetized patients is effective for facial postherpetic neuralgia and postoperative hemicranial neuralgia.
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