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Tugend M, Washington E, Sekula RF. Outcomes of Trigeminal Ganglion Sparing Surgical Resection of Nonacoustic Cerebellopontine Angle Tumors Causing Trigeminal Neuralgia. World Neurosurg 2024:S1878-8750(24)00548-5. [PMID: 38583565 DOI: 10.1016/j.wneu.2024.03.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE Tumors may be responsible for up to 5% of trigeminal neuralgia cases. Predictors of long-term pain relief after surgical resection of various cerebellopontine angle tumor types are not well understood. Previous studies found that size and extent of resection predict long-term pain status, although resection of tumor involving the trigeminal ganglion may be associated with high morbidity. This study evaluated predictors of TN pain freedom after resection of a nonacoustic CPA tumor, with avoidance of any portion involving the TG. METHODS In a retrospective cohort study, we evaluated clinical outcomes and complications after surgical resection of nonacoustic CPA tumors with purposeful avoidance of the TG causing trigeminal neuralgia. The primary outcome was pain-freedom. We performed logistic regression analyses to examine the relationship between pain-freedom at last follow-up and age, side of symptoms, preoperative symptom duration, tumor diameter, tumor type, and concurrent neurovascular compression (NVC). RESULTS Of 18 patients with nonacoustic CPA tumors causing TN treated with surgical resection, 83.3% were pain-free at last follow-up (mean 44.6 months). Age (P = 0.12), side (P = 0.41), preoperative symptom duration (P = 0.85), tumor diameter (P = 0.29), tumor type (P = 0.37), and NVC presence (P = 0.075) were not associated with long-term pain freedom. CONCLUSIONS This study provides additional evidence that various tumor types causing TN may safely undergo surgical resection and decompression of the trigeminal nerve to treat TN. This study presents a cohort of patients that underwent resection of a nonacoustic CPA tumor, with purposeful avoidance of the TG to minimize complications, demonstrating high rates of long-term pain freedom.
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Affiliation(s)
- Margaret Tugend
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Evan Washington
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA.
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Branstetter BF, Sekula RF. The Sagittal Angle of the Trigeminal Nerve at the Porus Trigeminus is a Radiologic Predictor of Surgical Outcome in Microvascular Decompression for Classical Trigeminal Neuralgia. Neurosurgery 2024; 94:524-528. [PMID: 37706752 DOI: 10.1227/neu.0000000000002671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/11/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Classical trigeminal neuralgia (cTN) is a painful disease. Microvascular decompression (MVD) provides immediate and durable relief in many patients. A variety of positive and negative prognostic biomarkers for MVD have been identified. The sagittal angle of the trigeminal nerve at the porus trigeminus (SATNaPT) is an MRI biomarker that can identify a subset of patients with cTN whose trigeminal nerve anatomy is different from normal controls. The purpose of this case-control study was to determine whether an abnormally hyperacute SATNaPT is a negative prognostic biomarker in patients with cTN undergoing MVD. METHODS Preoperative MRIs from 300 patients with cTN who underwent MVD were analyzed to identify patients with a hyperacute SATNaPT (defined as less than 3 SDs below the mean). The rate of surgical success (pain-free after at least 12 months) was compared between patients with a hyperacute SATNaPT and all other patients. RESULTS Patients without a hyperacute SATNaPT had an 82% likelihood of surgical success, whereas patients with a hyperacute SATNaPT had a 58% likelihood of surgical success ( P < .05). Patients with a hyperacute SATNaPT who also had no evidence of vascular compression on preoperative MRI had an even lower likelihood of success (29%, P < .05). CONCLUSION In patients with cTN being considered for MVD, a hyperacute SATNaPT is a negative prognostic biomarker that predicts a higher likelihood of surgical failure. Patients with a hyperacute SATNaPT, particularly those without MRI evidence of vascular compression, may benefit from other surgical treatments or a modification of MVD to adequately address the underlying cause of cTN.
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Affiliation(s)
- Barton F Branstetter
- Departments of Radiology, Otolaryngology, and Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York , New York , USA
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3
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Tugend M, Dattero J, Shore T, Korobeynikov V, Sekula RF. Primary central nervous system post-transplant lymphoproliferative disorder after allogeneic stem cell transplantation: a case report. Front Oncol 2024; 14:1284577. [PMID: 38313803 PMCID: PMC10837847 DOI: 10.3389/fonc.2024.1284577] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
Purpose Primary central nervous system, diffuse large B-cell lymphoma, post-transplant lymphoproliferative disorder in the cerebellopontine angle after an allogeneic stem cell transplantation has never been reported in the literature. Typically, diffuse large B-cell lymphoma is non-polyploid. We report the first case of a patient with polyploid post-transplant lymphoproliferative disorder in the cerebellopontine angle who presented with back pain. Case presentation A 45-year-old man with a history of nodular sclerosing classic Hodgkin lymphoma stage IIB treated with systemic chemotherapy, external radiation and autologous stem cell transplant and double umbilical cord allogeneic transplant presented with several weeks of back pain. He was found to have a small right cerebellopontine angle mass thought to be consistent with a meningioma. Patient presented again two weeks later with acute onset of severe headache, right sided ptosis, right facial numbness, weakness and possible seizure event. Repeat MRI scans showed an interval and significant increase of the right cerebellopontine angle lesion. Biopsy of the cerebellopontine angle lesion was planned with suspicion of lymphoma. Intraoperative pathology consultation findings were not consistent with an acoustic neuroma, meningioma, or epidermoid cyst. Lymphoma could not be definitively identified by intra-operative frozen section. However, it was suspected, and a portion of fresh specimen was submitted for flow cytometry analysis. A near total resection of the tumor and decompression of the brainstem was achieved. Final pathologic analysis was positive for post-transplant lymphoproliferative disorder, monomorphic type, diffuse large B-cell lymphoma, non-germinal center B-cell type, EBV+, post-transplant (allogeneic stem cell) setting (post-transplant lymphoproliferative disorder (PTLD), monomorphic type, diffuse large B-cell lymphoma, non-germinal center B-cell type (non-GCB), EBV-positive under pre-2022 WHO terminology). The patient began a high-dose methotrexate-based regimen (the MATRIX regimen). Conclusions Our case illustrates an unusual presentation of post-transplant lymphoproliferative disorder in the cerebellopontine angle in a patient with a remote history of allogeneic stem cell transplantation. It demonstrates the importance of keeping primary central nervous system post-transplant lymphoproliferative disorder on the differential for patients who present with back pain or headache that have a history of allogeneic stem cell transplant.
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Affiliation(s)
- Margaret Tugend
- Department of Neurological Surgery, Columbia University, New York Presbyterian Hospital, New York, NY, United States
| | - Jordan Dattero
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Boston, MA, United States
| | - Tsiporah Shore
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, United States
| | - Vladislav Korobeynikov
- Department of Pathology, Columbia University, New York Presbyterian Hospital, New York, NY, United States
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University, New York Presbyterian Hospital, New York, NY, United States
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Tugend M, Sekula RF. Microvascular decompression for developmental venous anomaly causing hemifacial spasm: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23479. [PMID: 38163344 PMCID: PMC10763632 DOI: 10.3171/case23479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Developmental venous anomaly (DVA) is a rare cause of hemifacial spasm (HFS). The treatment of HFS caused by a DVA varies in the literature and includes medication management, botulinum toxin injections, and microvascular decompression (MVD). OBSERVATIONS A 64-year-old woman presented with right-sided HFS. Preoperative magnetic resonance imaging showed a DVA in the right inferior pons, with an enlarged segment compressing the facial nerve at its root detachment point prior to drainage into the superior petrosal sinus. MVD was performed, and the facial nerve was decompressed without sacrifice of the vein. Immediately following the procedure, the patient had significantly reduced spasms. The patient became spasm-free 3 months after MVD and maintained spasm freedom for 3 months. Six months after MVD, the patient had a partial return of spasms. At 8 months, the patient continued to have reduced and intermittent spasms in the right orbicularis oculi muscle. LESSONS MVD for HFS caused by a DVA is a safe procedure and can be effective at reducing spasm frequency and severity.
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Sudhakar V, Sekula RF. Retrosigmoid microvascular decompression as a treatment for trigeminal neuralgia in a patient with osteogenesis imperfecta. Br J Neurosurg 2023; 37:1667-1669. [PMID: 34057868 DOI: 10.1080/02688697.2021.1931811] [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: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
Individuals with osteogenesis imperfecta develop pathologic bone due to genetic defects in collagen synthesis. These patients are prone to skull base abnormalities with resultant lower cranial nerve deficits, most common of which is trigeminal neuralgia. Typically, such patients are managed medically, and surgical options are not well explored for those patients, who become refractory to medication management. While microvascular decompression is often recommended for patients with classical trigeminal neuralgia, neurovascular compression by MRI, and normal skull base anatomy, ablative procedures have been described for patients with trigeminal neuralgia and osteogenesis imperfecta. MVD via a retrosigmoid approach has not been described in a patient with trigeminal neuralgia and skull base abnormalities secondary to osteogenesis imperfecta. A 23-year-old man with osteogenesis imperfecta was referred with right-sided classical trigeminal neuralgia. His trigeminal pain had become refractory to a number of medications. High-resolution MRI demonstrated compression of the trigeminal nerve by the superior cerebellar artery. Microvascular decompression of the trigeminal nerve via a retrosigmoid craniectomy was performed, and he remains pain-free 6 months after surgery. Microvascular decompression of the trigeminal nerve through a retrosigmoid approach can be an effective surgical treatment for young patients with trigeminal neuralgia secondary to osteogenesis imperfecta.
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Affiliation(s)
- Vivek Sudhakar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bethamcharla R, Abou-Al-Shaar H, Maarbjerg S, Chang YF, Gacka CN, Sekula RF. Percutaneous glycerol rhizolysis of the trigeminal ganglion for the treatment of idiopathic and classic trigeminal neuralgia: Outcomes and complications. Eur J Neurol 2023; 30:3307-3313. [PMID: 37422922 DOI: 10.1111/ene.15977] [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: 01/20/2023] [Revised: 04/23/2023] [Accepted: 07/04/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND AND PURPOSE Patients with idiopathic trigeminal neuralgia (TN) with absent arterial contact or venous contact only and classic TN with morphological changes of the trigeminal nerve secondary to venous compression are not routinely recommended microvascular decompression at our institution. In patients with these anatomical subtypes of TN, limited data exists describing the outcomes of percutaneous glycerol rhizolysis (PGR) of the trigeminal ganglion (TG). METHODS We performed a retrospective single-center cohort study and analyzed outcomes and complications after PGR of the TG. Clinical outcome after PGR of the TG was assessed via the Barrow Neurological Institute (BNI) Pain Scale. RESULTS Forty-five patients underwent a total of 66 PGRs of the TG. At short-term follow-up, 58 procedures (87.9%) resulted in a BNI score of I (i.e., freedom from pain without medication). At a median follow-up of 3.07 years, 18 procedures (27.3%) resulted in a BNI score of I, 12 procedures (18.1%) resulted in BNI score of IIIa, and 36 procedures (54.5%) resulted in a BNI score of IIIb-V. The median length of freedom from pain without medication was 1.5 years. Eighteen procedures (27.3%) caused hypesthesia and two (3.0%) caused paresthesias. There were no serious complications. CONCLUSION In patients with these anatomical subtypes of TN there was a high rate of short-term pain relief for the first 1-2 years and thereafter a large proportion of patients experienced pain relapse. In this patient group, PGR of the TG represents a safe procedure that is efficacious in the short term.
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Affiliation(s)
- Raviteja Bethamcharla
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stine Maarbjerg
- Danish Headache Centre, Department of Neurology, Glostrup Hospital, University of Copenhagen, Glostrup, Denmark
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Caroline N Gacka
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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CreveCoeur TS, Bethamcharla R, Gold MS, Liedtke WB, Sekula RF. Letter to the Editor. Potential confounding variables when assessing racial disparities in outcomes after MVD for TN. J Neurosurg 2023; 140:315-317. [PMID: 37724807 DOI: 10.3171/2023.6.jns231346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Affiliation(s)
| | | | - Michael S Gold
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Wolfgang B Liedtke
- Duke University, Durham, NC
- College of Dentistry and NYU Pain Research Center, New York University, New York, NY
| | - Raymond F Sekula
- Columbia University Medical Center, New York, NY
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Yoh N, Abou-Al-Shaar H, Bethamcharla R, Beiriger J, Mallela AN, Connolly ES, Sekula RF. Minimally invasive surgical evacuation for spontaneous cerebellar hemorrhage: a case series and systematic review. Neurosurg Rev 2023; 46:208. [PMID: 37612544 DOI: 10.1007/s10143-023-02118-w] [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: 06/24/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
Spontaneous cerebellar hemorrhage (scICH) is a subset of intracerebral hemorrhage accounting for 5-10% of all cases. Despite potential advantages, minimally invasive surgical evacuation of scICH may be an underutilized strategy when compared to unilateral or bilateral large suboccipital craniectomy or craniotomy, with or without duraplasty. We performed a retrospective single-center cohort study and a systematic literature review. Radiographic and clinical data were recorded and analyzed. Five consecutive patients with minimally invasive surgical evacuation of scICH were identified. Average hematoma size was 16.4 ± 3.0 cm3. Mean Glasgow coma score (GCS) prior to surgery was 11.6 ± 3.0 with improvement to 14.6 ± 0.4 postoperatively. Mean hematoma evacuation was 92.6 ± 0.6% as confirmed by postoperative computed tomography (CT) imaging. All patients achieved a modified Rankin Scale (mRS) score of 0 or 1 with an average follow-up time of 31 ± 22 months. Mean length of hospital stay was 8.8 ± 3.0 days. No patients experienced significant complications or required reoperation. Systematic review revealed similar results for minimally invasive evacuation of scICH when reporting disaggregated outcomes. A review of recent studies utilizing large unilateral or bilateral suboccipital craniectomy or craniotomy, with or without duraplasty, revealed higher morbidity and mortality rates than minimally invasive surgical evacuation of scICH. Minimally invasive evacuation of scICH is safe and effective. Near complete evacuation of hematoma can be achieved with lower morbidity and mortality than large suboccipital craniectomy or craniotomy. A multi-center, prospective, and rigorous trial comparing the two strategies for evacuation of scICH is warranted.
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Affiliation(s)
- Nina Yoh
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Raviteja Bethamcharla
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
| | - Justin Beiriger
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
- Columbia University Vagelos College of Physicians and Surgeons, 710 West 168th Street, 4th Floor, New York, NY, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA.
- Columbia University Vagelos College of Physicians and Surgeons, 710 West 168th Street, 4th Floor, New York, NY, USA.
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Bethamcharla R, Mitrasinovic S, Sekula RF. In Reply: Facial Nerve Massage for the Treatment of Hemifacial Spasm Refractory to Microvascular Decompression: Outcomes and Complications. Neurosurgery 2023; 92:e95. [PMID: 36786583 DOI: 10.1227/neu.0000000000002398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 02/15/2023] Open
Affiliation(s)
| | - Stefan Mitrasinovic
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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10
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Bethamcharla R, Reddy H, Teich AF, Sekula RF. Histopathology of the trigeminal ganglion and nerve: A historical review. J Neurosci Res 2023. [PMID: 36977654 DOI: 10.1002/jnr.25192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Raviteja Bethamcharla
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Hasini Reddy
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, New York, New York, USA
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Andrew F Teich
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, New York, New York, USA
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Parikh P, Abdallah HM, Patel A, Shariff RK, Nowicki KW, Mallela AN, Tonetti DA, Sekula RF, Lunsford LD, Abou-Al-Shaar H. Bibliometric Analysis of the Top 100 Cited Articles on Stereotactic Radiosurgery for Trigeminal Neuralgia. Asian J Neurosurg 2023; 18:101-107. [PMID: 37056872 PMCID: PMC10089752 DOI: 10.1055/s-0043-1761240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background Stereotactic radiosurgical rhizolysis of the trigeminal nerve is an established modality increasingly employed to alleviate the symptoms of refractory trigeminal neuralgia. This study analyzes the academic impact of the top 100 cited articles on the radiosurgical management of trigeminal neuralgia.
Methods The Scopus database was searched for articles containing “radiosurgery” and one or more of “trigeminal neuralgia,” “trigeminus neuralgia,” and “tic douloureux.” The top 100 articles written in English were arranged in descending order by citation count. Documents were evaluated for authors, publication year, journal and impact factor, total citations, nationality, study type, radiosurgical modality, and the affiliated institution. Quantitative and qualitative analyses were performed on the data.
Results The most cited articles were published between 1971 and 2019. The average citation per year was 4.3. The most targeted anatomic area was the “root entry zone” or proximal portion of the cisternal segment of the trigeminal nerve. The most utilized modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Thirty-six percent of the articles were published in the Journal of Neurosurgery. Lunsford, Kondziolka, Flickinger, and Régis, respectively, were the most frequently listed co-authors. The most prolific institute was the University of Pittsburgh Medical Center.
Conclusion Stereotactic radiosurgery is an important modality in the management of medically or surgically refractory trigeminal neuralgia. This analysis assesses its contributions over the past five decades to identify trends in treatment practices for neurosurgeons and to highlight areas where further study is needed.
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Branstetter BF, Sekula RF. Reply. AJNR Am J Neuroradiol 2023; 44:E20. [PMID: 36822822 PMCID: PMC10187802 DOI: 10.3174/ajnr.a7802] [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: 02/25/2023]
Affiliation(s)
- B F Branstetter
- Departments of Radiology, Otolaryngology, and Biomedical InformaticsUniversity of PittsburghPittsburgh, Pennsylvania
| | - R F Sekula
- Department of NeurosurgeryColumbia UniversityNew York, New York
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13
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Bethamcharla R, McKhann Ii GM, Sekula RF. Letter to the Editor Regarding "Unilateral Supraorbital Keyhole Craniotomy Avoiding the Frontal Sinus for Large and Giant Olfactory Groove Meningiomas: A Case". World Neurosurg 2023; 170:262. [PMID: 36782420 DOI: 10.1016/j.wneu.2022.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 02/11/2023]
Affiliation(s)
- Raviteja Bethamcharla
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Guy M McKhann Ii
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Raymond F Sekula
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Abou-Al-Shaar H, Patel KP, Mallela AN, Sekula RF. Lateral supraorbital approach for resection of large and giant olfactory groove meningiomas: a single center experience. Br J Neurosurg 2023; 37:90-96. [PMID: 36053047 DOI: 10.1080/02688697.2022.2117273] [Citation(s) in RCA: 2] [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] [Indexed: 11/02/2022]
Abstract
BACKGROUND The lateral supraorbital approach (LSO) provides an optimal access corridor for various skull bases lesions, including olfactory groove meningiomas (OGMs). The aim of this study is to describe the authors' experience with the management of large and giant OGMs utilizing the LSO approach and describe the technical nuances of the procedure. METHODS A retrospective review of seven patients with large and giant OGMs managed with the LSO approach between 2013 and 2019 was performed. Radiographic and clinical data were recorded and analyzed. RESULTS Seven patients with large and giant OGMs underwent surgical resection via the LSO approach. Six patients were female, with a median age of 56 years. Patients commonly presented with altered mentation, anosmia, and headaches. The average tumor volume was 120.6 ± 64.7 cm3 with five cases of vascular encasement. Simpson grade II resection was achieved in four patients while Simpson grade IV resection was achieved in three patients. The median length of stay was 2.0 days. The median preoperative Karnofsky Performance Scale (KPS) score was 70, improving to 100 at last postoperative follow-up visit. Two complications were encountered in the form of postoperative cerebrospinal fluid leak in one patient and a transient diplopia in another patient. Tumor recurrence/progression was identified in two patients during a median follow-up time of 65.5 months. Both cases have been managed with adjuvant radiosurgery. CONCLUSION The LSO approach is a safe and effective minimally invasive transcranial corridor for the management of OGMs that should be part of the armamentarium of skull base neurosurgeons.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin P Patel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA.,Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Vieira AR, Sekula RF, Deeley K. Classical trigeminal neuralgia is associated with gephyrin and sodium voltage-gated channel alpha subunit 8. Front Dent Med 2023. [DOI: 10.3389/fdmed.2022.988094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Trigeminal neuralgia is highly debilitating, and its etiology is still undefined. The goal of this work was to define associations between well-characterized trigeminal neuralgia cases and common genetic variants in the population. two hundred and fifty-seven individuals diagnosed with classical trigeminal neuralgia were compared to 865 individuals without classical trigeminal neuralgia and with an assessment for lower or higher pain threshold based on the amount of anesthetic required for routine dental treatment. Genotypes of 24 variants marking genes in the VGSC (voltage-gated sodium channels) or GABA (gamma-aminobutyric acid) pathways were obtained using TaqMan chemistry end end-point analysis. Chi-square was used for all comparisons with an alpha of 0.002. An association between classical trigeminal neuralgia and individuals requiring less or more anesthetic for routine dental treatments showed associations with SCN8A rs1601012 and GPHN rs723432 (p = 0.0009 and p = 0.0002, respectively). In conclusion, classical trigeminal neuralgia is associated with SCN8A and GPHN and markers rs1601012 rs723432 may be useful to determine individual risks for the condition.
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16
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Lisboa RO, Sekula RF, Bezamat M, Deeley K, Santana-da-Silva LC, Vieira AR. Pain perception genes, asthma, and oral health: A reverse genetics study. PLoS One 2022; 17:e0277036. [PMID: 36395102 PMCID: PMC9671307 DOI: 10.1371/journal.pone.0277036] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022] Open
Abstract
Pain is an experience of a subjective nature, interpreted in a personal way and according to an extensive palette of factors unique to each individual. Orofacial pain can be acute or chronic and it is usually the main reason for the patient to seek dental care. Pain perception varies widely among individuals. This variability is considered a mosaic of factors, which include biopsychosocial factors and genetic factors. Understanding these differences can be extremely beneficial for pain management in a personalized and more efficient way. We performed association studies to investigate phenotypes associated with genetic markers in pain-related genes in two groups of patients who received more or less anesthesia during dental treatment. The study group was comprised of 1289 individuals participating in the Dental Registry and DNA Repository Project (DRDR) of the University of Pittsburgh, with 900 participants in the group that received the most anesthesia and 389 constituting the comparison group that received less anesthesia. We tested 58 phenotypes and genotypic data of seven SNPs in genes that are associated with pain perception, pain modulation and response to drugs used in pain treatment: COMT (rs4818 and rs6269), GCH1 (rs3783641), DRD2 (rs6276), OPRM1 (rs1799971), SCN9A (rs6746030) and SCN10A (rs6795970). The analysis revealed a protective effect of rs1799971 on asthma in the total sample. rs3783641 was associated with salivary secretion disorders in females who received more anesthesia. rs1799971 was also associated with periodontitis in Whites who received less anesthesia. rs4818 was associated with disease and other tongue conditions in the group composed of Blacks who received less anesthesia. In conclusion, our study implicated variants in pain-related genes in asthma and oral phenotypes.
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Affiliation(s)
- Rosany O. Lisboa
- Laboratory of Inborn Errors of Metabolism, Institute of Biological Sciences, Federal University of Pará, Pará, Brazil
- Departments of Oral and Craniofacial Sciences, Pediatric Dentistry and Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Graduate Program in Oncology and Medical Sciences, Federal University of Pará, Pará, Brazil
| | - Raymond F. Sekula
- Department of Neurological Surgery, Columbia University Vagelos School of Medicine, New York, New York, United States of America
| | - Mariana Bezamat
- Departments of Oral and Craniofacial Sciences, Pediatric Dentistry and Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Kathleen Deeley
- Departments of Oral and Craniofacial Sciences, Pediatric Dentistry and Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Luiz Carlos Santana-da-Silva
- Laboratory of Inborn Errors of Metabolism, Institute of Biological Sciences, Federal University of Pará, Pará, Brazil
- Graduate Program in Oncology and Medical Sciences, Federal University of Pará, Pará, Brazil
| | - Alexandre R. Vieira
- Departments of Oral and Craniofacial Sciences, Pediatric Dentistry and Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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17
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Patel KP, Eubanks K, Wecht DA, Sekula RF. Facial Nerve Massage for the Treatment of Hemifacial Spasm Refractory to Microvascular Decompression: Outcomes and Complications. Neurosurgery 2022; 91:570-574. [PMID: 35876666 DOI: 10.1227/neu.0000000000002075] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/10/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND After microvascular decompression (MVD) for hemifacial spasm (HFS), a minority of patients realize little to no relief of spasms. In some patients, the absence of relief of spasms results from incomplete or inadequate decompression of vascular compression of the facial nerve, and these patients represent excellent candidates for repeat MVD. However, in other patients, repeat MVD is not appropriate because adequate decompression and resolution of neurovascular compression, as determined by postoperative high-resolution MRI, was achieved with the initial operation. OBJECTIVE To present a cohort of patients with a history of HFS refractory to MVD, with no evidence of neurovascular compression on postoperative MRI, who underwent facial nerve massage (FNM) in the posterior fossa in an attempt to relieve spasms. METHODS Thirteen patients with a history of incomplete relief of spasms after technically adequate MVD surgery for hemifacial spasm underwent FNM. Immediate and long-term degree of spasm relief and complications after FNM were documented through in-person or telemedicine interview. RESULTS At follow-up after FNM, 7 of 12 patients (58.3%) reported complete spasm relief (grade I), 2 of 12 patients (16.7%) reported >75% spasm relief (grade II), 0 patient (0%) reported >50% spasm relief (grade III), 3 of 12 (25.0%) patients reported <50% spasm relief (grade IV), and 1 patient was lost to follow-up. One patient experienced a delayed facial paresis, and another patient experienced high-frequency hearing loss. CONCLUSION After FNM, durable and, at least, partial relief of spasms with a relatively low complication rate was observed in most patients with HFS with incomplete relief of spasms after technically adequate prior MVD.
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Affiliation(s)
- Kevin P Patel
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Komal Eubanks
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel A Wecht
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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18
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Muthiah N, Ozpinar A, Eubanks J, Peretti M, Yolcu YU, Anthony A, Sekula RF. Direct Pars Repair with Cannulated Screws in Adults: A Case Series and Systematic Literature Review. World Neurosurg 2022; 163:e263-e274. [PMID: 35367391 DOI: 10.1016/j.wneu.2022.03.107] [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: 12/07/2021] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Lumbar spondylolysis occurs in 5%-8% of adults. This study aimed to report clinical and radiographic outcomes of direct pars repair in adults with lumbar spondylolysis. METHODS We conducted a retrospective review of all patients treated for lumbar spondylolysis via open fracture reduction and direct pars repair with cannulated screws using a lag technique. Demographics, clinical presentation, perioperative and intraoperative imaging, and postoperative data were collected. We subsequently performed a systematic review to describe radiographic and clinical outcomes following direct pars repair. RESULTS Three patients were identified (mean age 40.3 years; range, 21-72 years; 2 male). All patients had bilateral L5 pars fractures treated via open, direct repair with cannulated screws. There were no intraoperative complications. Length of stay was <24 hours for each patient. All patients reported back/radicular symptom relief and returned to full-time manual labor by latest follow-up. Noncontrast lumbar computed tomography performed 14-20 months postoperatively confirmed that all patients had good bilateral screw placement without fracture. Two patients (21 and 28 years old at surgery) had evidence of fusion across fracture sites, while 1 patient exhibited radiolucency around the screws and no progression of spondylolisthesis. Additionally, we reviewed 8210 articles and included 15 in a systematic review of direct pars repair. Fusion rates were 67%-100%, with improved average Oswestry Disability Index and visual analog scale back pain scores by latest follow-up. CONCLUSIONS Lumbar spondylolysis treatment with open fracture reduction and direct pars repair with cannulated screws in adults is safe and may result in mechanical back/radicular pain relief, even in the absence of radiographic fusion.
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Affiliation(s)
- Nallammai Muthiah
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alp Ozpinar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James Eubanks
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marc Peretti
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yagiz Ugur Yolcu
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Austin Anthony
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
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19
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Thirumala PD, Altibi AM, Chang R, Saca EE, Iyengar P, Reddy R, Anetakis K, Crammond DJ, Balzer JR, Sekula RF. The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa069_s023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Traylor KS, Sekula RF, Eubanks K, Muthiah N, Chang YF, Hughes MA. Reply: Neurovascular compression in hemifacial spasm. Brain 2021; 144:awab339. [PMID: 34554199 DOI: 10.1093/brain/awab339] [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: 08/23/2021] [Accepted: 09/05/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Katie S Traylor
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 152103, USA
| | - Raymond F Sekula
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh 15313 PA, USA
| | - Komal Eubanks
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh 15313 PA, USA
| | - Nallammai Muthiah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh 15313 PA, USA
| | - Yue-Fang Chang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh 15313 PA, USA
| | - Marion A Hughes
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 152103, USA
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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21
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Hughes MA, Traylor KS, Branstetter Iv BF, Eubanks KP, Chang YF, Sekula RF. Imaging predictors of successful surgical treatment of hemifacial spasm. Brain Commun 2021; 3:fcab146. [PMID: 34396106 PMCID: PMC8361424 DOI: 10.1093/braincomms/fcab146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/17/2021] [Accepted: 05/17/2021] [Indexed: 11/14/2022] Open
Abstract
Identify preoperative imaging findings in hemifacial spasm patients that predict the post-surgical success following microvascular decompression. This is a retrospective study of patients who were diagnosed with hemifacial spasm, had a dedicated cranial nerve MRI, and underwent microvascular decompression for hemifacial spasm. Bilateral facial nerves were interrogated for neurovascular compression. If neurovascular compression was identified, we recorded whether the offending vessel was an artery, a vein or both. The location of the neurovascular compression (proximal nerve versus distal nerve) was noted. The severity of the neurovascular compression was categorized as contact versus deformity of the nerve. Patients were contacted to determine their post-operative spasm status. The relationships between imaging findings and post-surgical outcome were assessed by Chi-square tests, and odds ratios were calculated to quantify the degree of association. The study included 212 patients. Upon follow up, 192 patients were spasm free (90.57%). Imaging findings on the symptomatic side were as follows: arterial neurovascular compression was seen in 207 patients (97.64%), venous only neurovascular compression in two patients (0.94%), and no neurovascular compression in three patients (1.42%). Arterial neurovascular compression along the proximal, susceptible segment of the nerve was observed in 202 patients (95.28%); deformity was observed more commonly than contact alone. Arterial neurovascular compression along the distal segment only of the nerve was observed in five patients (2.36%). In patients with arterial neurovascular compression of the proximal and distal portions of the nerve, 93.07% and 60.0% of patients were spasm-free respectively. If venous neurovascular compression only was observed on imaging, 0% of patients were spasm-free. Patients with arterial neurovascular compression of the susceptible segment are much more likely to be spasm free than patients without this imaging finding, [odds ratio 20.14 (CI 5.08, 79.81), P-value <0.0001]. When comparing the two groups of arterial neurovascular compression (deformity versus contact), no statistically significant difference in outcomes was observed. In patients with hemifacial spasm undergoing microvascular decompression, imaging findings do predict surgical outcome. Patients with arterial neurovascular compression of the proximal, susceptible portion of the nerve are much more likely to be spasm free after surgery than those without this imaging finding. The imaging findings inform the risk benefit analysis and discussion with patients before they undergo microvascular decompression for hemifacial spasm.
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Affiliation(s)
- Marion A Hughes
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Katie S Traylor
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Barton F Branstetter Iv
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Komal P Eubanks
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Yue-Fang Chang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Raymond F Sekula
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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22
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Traylor KS, Sekula RF, Eubanks K, Muthiah N, Chang YF, Hughes MA. Prevalence and severity of neurovascular compression in hemifacial spasm patients. Brain 2021; 144:1482-1487. [PMID: 33842948 PMCID: PMC8262979 DOI: 10.1093/brain/awab030] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/03/2020] [Accepted: 11/19/2020] [Indexed: 11/18/2022] Open
Abstract
Hemifacial spasm is typically caused by vascular compression of the proximal intracranial facial nerve. Although the prevalence of neurovascular compression has been investigated in a cohort of patients with classical trigeminal neuralgia, the prevalence and severity of neurovascular compression has not been well characterized in patients with hemifacial spasm. We aimed to investigate whether presence and severity of neurovascular compression are correlated to the symptomatic side in patients with hemifacial spasm. All patients in our study were evaluated by a physician who specializes in the management of cranial nerve disorders. Once hemifacial spasm was diagnosed on physical exam, the patient underwent a dedicated cranial nerve protocol magnetic resonance imaging study on a 3 T scanner. Exams were retrospectively reviewed by a neuroradiologist blinded to the symptomatic side. The presence, severity, vessel type, and location of neurovascular compression along the facial nerve was recorded. Neurovascular compression was graded as contact alone (vessel touching the facial nerve) versus deformity (indentation or deviation of the nerve by the culprit vessel). A total of 330 patients with hemifacial spasm were included. The majority (232) were female while the minority (98) were male. The average age was 55.7 years. Neurovascular compression (arterial) was identified on both the symptomatic (97.88%) and asymptomatic sides (38.79%) frequently. Neurovascular compression from an artery along the susceptible/proximal portion of the nerve was much more common on the symptomatic side (96.36%) than on the asymptomatic side (12.73%), odds ratio = 93.00, P < 0.0001. When we assessed severity of arterial compression, the more severe form of neurovascular compression, deformity, was noted on the symptomatic side (70.3%) much more frequently than on the asymptomatic side (1.82%) (odds ratio = 114.00 P < 0.0001). We conclude that neurovascular compression that results in deformity of the susceptible portion of the facial nerve is highly associated with the symptomatic side in hemifacial spasm.
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Affiliation(s)
- Katie S Traylor
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raymond F Sekula
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Komal Eubanks
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nallammai Muthiah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yue-Fang Chang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marion A Hughes
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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23
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Sekula RF, Deeley K, Denwood H, Vieira AR. Gain-of-function mutation Met136Val in SCN8A may not be a common cause of trigeminal neuralgia. Mol Genet Genomic Med 2021; 9:e1587. [PMID: 33428824 PMCID: PMC8077135 DOI: 10.1002/mgg3.1587] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/24/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022] Open
Abstract
Background The Met136Val mutation in SCN8A was described in a case of trigeminal neuralgia but no frequency among affected individuals was provided. Methods Direct sequencing of 123 individuals diagnosed with classic trigeminal neuralgia was performed aimed to detect the Met136Val change. Results No cases of classical trigeminal neuralgia studied had the Met136Val mutation in SCN8A. Conclusion Met136Val mutation in SCN8A is not a frequent cause of classical trigeminal neuralgia.
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Affiliation(s)
- Raymond F Sekula
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen Deeley
- Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hayley Denwood
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandre R Vieira
- Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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24
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Sekula RF. Commentary: Neurosurgical Choice for Glossopharyngeal Neuralgia: A Benefit-Harm Assessment of Long-Term Quality of Life. Neurosurgery 2020; 88:E35. [PMID: 32735646 DOI: 10.1093/neuros/nyaa327] [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: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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25
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Alan N, Kim S, Agarwal N, Cohen-Gadol AA, Sekula RF. Inter-facility Transfer of Patients with Traumatic Intracranial Hemorrhage and GCS 14–15. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Alan N, Kim S, Agarwal N, Clarke J, Yealy DM, Cohen-Gadol AA, Sekula RF. Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14-15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers. J Clin Neurosci 2020; 81:246-251. [PMID: 33222924 PMCID: PMC7560640 DOI: 10.1016/j.jocn.2020.09.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/28/2020] [Indexed: 12/01/2022]
Abstract
We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38). In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.
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Affiliation(s)
- Nima Alan
- University of Pittsburgh Medical Center, Department of Neurological Surgery, Pittsburgh, PA, United States.
| | - Song Kim
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Nitin Agarwal
- University of Pittsburgh Medical Center, Department of Neurological Surgery, Pittsburgh, PA, United States
| | - Jamie Clarke
- University of Pittsburgh Medical Center, Department of Neurological Surgery, Pittsburgh, PA, United States
| | - Donald M Yealy
- University of Pittsburgh Medical Center, Department of Emergency Medicine, Pittsburgh, PA, United States
| | - Aaron A Cohen-Gadol
- Indiana University, Department of Neurological Surgery, Indianapolis, IN, United States
| | - Raymond F Sekula
- University of Pittsburgh Medical Center, Department of Neurological Surgery, Pittsburgh, PA, United States
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27
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Dong W, Jin SC, Allocco A, Zeng X, Sheth AH, Panchagnula S, Castonguay A, Lorenzo LÉ, Islam B, Brindle G, Bachand K, Hu J, Sularz A, Gaillard J, Choi J, Dunbar A, Nelson-Williams C, Kiziltug E, Furey CG, Conine S, Duy PQ, Kundishora AJ, Loring E, Li B, Lu Q, Zhou G, Liu W, Li X, Sierant MC, Mane S, Castaldi C, López-Giráldez F, Knight JR, Sekula RF, Simard JM, Eskandar EN, Gottschalk C, Moliterno J, Günel M, Gerrard JL, Dib-Hajj S, Waxman SG, Barker FG, Alper SL, Chahine M, Haider S, De Koninck Y, Lifton RP, Kahle KT. Exome Sequencing Implicates Impaired GABA Signaling and Neuronal Ion Transport in Trigeminal Neuralgia. iScience 2020; 23:101552. [PMID: 33083721 PMCID: PMC7554653 DOI: 10.1016/j.isci.2020.101552] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 02/07/2023] Open
Abstract
Trigeminal neuralgia (TN) is a common, debilitating neuropathic face pain syndrome often resistant to therapy. The familial clustering of TN cases suggests that genetic factors play a role in disease pathogenesis. However, no unbiased, large-scale genomic study of TN has been performed to date. Analysis of 290 whole exome-sequenced TN probands, including 20 multiplex kindreds and 70 parent-offspring trios, revealed enrichment of rare, damaging variants in GABA receptor-binding genes in cases. Mice engineered with a TN-associated de novo mutation (p.Cys188Trp) in the GABAA receptor Cl− channel γ-1 subunit (GABRG1) exhibited trigeminal mechanical allodynia and face pain behavior. Other TN probands harbored rare damaging variants in Na+ and Ca+ channels, including a significant variant burden in the α-1H subunit of the voltage-gated Ca2+ channel Cav3.2 (CACNA1H). These results provide exome-level insight into TN and implicate genetically encoded impairment of GABA signaling and neuronal ion transport in TN pathogenesis. Genomic analysis of trigeminal neuralgia (TN) using exome sequencing Rare mutations in GABA signaling and ion transport genes are enriched in TN cases Generation of a genetic TN mouse model engineered with a patient-specific mutation
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Affiliation(s)
- Weilai Dong
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Sheng Chih Jin
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - August Allocco
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Xue Zeng
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Amar H Sheth
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Annie Castonguay
- CERVO Brain Research Centre, Université Laval, Québec, QC, Canada
| | | | - Barira Islam
- University College London, School of Pharmacy, London, England
| | | | - Karine Bachand
- CERVO Brain Research Centre, Université Laval, Québec, QC, Canada
| | - Jamie Hu
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Agata Sularz
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan Gaillard
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Jungmin Choi
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA.,Department of Biomedical Sciences, Korea University College of Medicine, 02841 Seoul, Korea
| | - Ashley Dunbar
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Emre Kiziltug
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Sierra Conine
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q Duy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Erin Loring
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Boyang Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Qiongshi Lu
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Geyu Zhou
- Program of Computational Biology and Bioinformatics, Yale University, New Haven, CT, USA
| | - Wei Liu
- Program of Computational Biology and Bioinformatics, Yale University, New Haven, CT, USA
| | - Xinyue Li
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Michael C Sierant
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Shrikant Mane
- Yale Center for Genome Analysis, West Haven, CT, USA
| | | | | | | | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emad N Eskandar
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, New York
| | | | | | - Murat Günel
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Jason L Gerrard
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Sulayman Dib-Hajj
- Center for Neuroscience & Regeneration Research, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Neurology; Yale University, New Haven, CT, USA
| | - Stephen G Waxman
- Center for Neuroscience & Regeneration Research, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Neurology; Yale University, New Haven, CT, USA
| | - Fred G Barker
- Harvard Medical School, Boston, MA, USA.,Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mohamed Chahine
- CERVO Brain Research Centre, Université Laval, Québec, QC, Canada.,Department of Medicine, Université Laval, Québec, QC, Canada
| | - Shozeb Haider
- University College London, School of Pharmacy, London, England
| | - Yves De Koninck
- CERVO Brain Research Centre, Université Laval, Québec, QC, Canada.,Department of Psychiatry and Neuroscience, Université Laval, Québec, QC, Canada
| | - Richard P Lifton
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.,Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.,Department of Cellular & Molecular Physiology, Yale School of Medicine, New Haven, CT, USA
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Affiliation(s)
- Raymond F Sekula
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
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Thirumala PD, Altibi AM, Chang R, Saca EE, Iyengar P, Reddy R, Anetakis K, Crammond DJ, Balzer JR, Sekula RF. The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis. Neurosurgery 2020; 87:E473-E484. [DOI: 10.1093/neuros/nyaa069] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/30/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Microvascular decompression (MVD) is the surgical treatment of choice for hemifacial spasm (HFS). During MVD, monitoring of the abnormal lateral spread response (LSR), an evoked response to facial nerve stimulation, has been traditionally used to monitor adequacy of cranial nerve (CN) VII decompression.
OBJECTIVE
To assess the utility of LSR monitoring in predicting spasm-free status after MVD postoperatively.
METHODS
We searched PubMed, Web of Science, and Embase for relevant publications. We included studies reporting on intraoperative LSR monitoring during MVD for HFS and spasm-free status following the procedure. Sensitivity of LSR, specificity, diagnostic odds ratio, and positive predictive value were calculated.
RESULTS
From 148 studies, 26 studies with 7479 patients were ultimately included in this meta-analysis. The final intraoperative LSR status predicted the clinical outcome of MVD with the following specificities and sensitivities: 89% (0.83- 0.93) and 40% (0.30- 0.51) at discharge, 90% (0.84-0.94) and 41% (0.29-0.53) at 3 mo, 89% (0.83-0.93) and 40% (0.30-0.51) at 1 yr. When LSR persisted after MVD, the probability (95% CI) for HFS persistence was 47.8% (0.33-0.63) at discharge, 40.8% (0.23-0.61) at 3 mo, and 24.4% (0.13-0.41) at 1 yr. However, when LSR resolved, the probability for HFS persistence was 7.3% at discharge, 4.2% at 3 mo, and 4.0% at 1 yr.
CONCLUSION
Intraoperative LSR monitoring has high specificity but modest sensitivity in predicting the spasm-free status following MVD. Persistence of LSR carries high risk for immediate and long-term facial spasm persistence. Therefore, adequacy of decompression should be thoroughly investigated before closing in cases where intraoperative LSR persists.
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Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ahmed M Altibi
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert Chang
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eyad E Saca
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pragnya Iyengar
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajiv Reddy
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine Anetakis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jani RH, Hughes MA, Gold MS, Branstetter BF, Ligus ZE, Sekula RF. Trigeminal Nerve Compression Without Trigeminal Neuralgia: Intraoperative vs Imaging Evidence. Neurosurgery 2020; 84:60-65. [PMID: 29425330 DOI: 10.1093/neuros/nyx636] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/26/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND While high-resolution imaging is increasingly used in guiding decisions about surgical interventions for the treatment of trigeminal neuralgia, direct assessment of the extent of vascular contact of the trigeminal nerve is still considered the gold standard for the determination of whether nerve decompression is warranted. OBJECTIVE To compare intraoperative and magnetic resonance imaging (MRI) findings of the prevalence and severity of vascular compression of the trigeminal nerve in patients without classical trigeminal neuralgia. METHODS We prospectively recruited 27 patients without facial pain who were undergoing microvascular decompression for hemifacial spasm and had undergone high-resolution preoperative MRI. Neurovascular contact/compression (NVC/C) by artery or vein was assessed both intraoperatively and by MRI, and was stratified into 3 types: simple contact, compression (indentation of the surface of the nerve), and deformity (deviation or distortion of the nerve). RESULTS Intraoperative evidence of NVC/C was detected in 23 patients. MRI evidence of NVC/C was detected in 18 patients, all of whom had intraoperative evidence of NVC/C. Thus, there were 5, or 28% more patients in whom NVC/C was detected intraoperatively than with MRI (Kappa = 0.52); contact was observed in 4 of these patients and compression in 1 patient. In patients where NVC/C was observed by both methods, there was agreement regarding the severity of contact/compression in 83% (15/18) of patients (Kappa = 0.47). No patients exhibited deformity of the nerve by imaging or intraoperatively. CONCLUSION There was moderate agreement between imaging and operative findings with respect to both the presence and severity of NVC/C.
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Affiliation(s)
- Ronak H Jani
- Department of Neurological Surgery, University of Pittsburgh School of Med-icine, Pittsburgh, Pennsylvania
| | - Marion A Hughes
- Department of Neurological Surgery, University of Pittsburgh School of Med-icine, Pittsburgh, Pennsylvania.,Dep-artment of Radiology, University of Pit-tsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael S Gold
- Department of Neurological Surgery, University of Pittsburgh School of Med-icine, Pittsburgh, Pennsylvania.,Department of Neurobi-ology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Barton F Branstetter
- Department of Neurological Surgery, University of Pittsburgh School of Med-icine, Pittsburgh, Pennsylvania.,Dep-artment of Radiology, University of Pit-tsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zachary E Ligus
- Department of Neurological Surgery, University of Pittsburgh School of Med-icine, Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh School of Med-icine, Pittsburgh, Pennsylvania.,Department of Neuro-logical Surgery, University of Pitt-sburgh School of Medicine, Pittsburgh, Pennsylvania
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31
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Sansosti AA, Jacobs RC, Safonova A, Jani RH, Schumann J, Friedlander RM, Lunsford LD, McDowell MM, Sekula RF. Impact of a Hands-on Pre-Clinical Neurosurgery Elective Course on Second-Year Medical Student Interest and Attitudes. J Med Educ Curric Dev 2020; 7:2382120520964852. [PMID: 33150209 PMCID: PMC7580150 DOI: 10.1177/2382120520964852] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/11/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Medical student involvement opportunities and educational experiences with surgical residents during medical school have been shown to increase the chance of students deciding to specialize in surgical specialties. This study aims to determine the effect of a neurosurgery elective during the second preclinical year on student interest and opinion of neurosurgery. METHODS Thirty-nine students completed opinion-based surveys and factual knowledge quizzes during a neurosurgical elective course over 3 iterations, which included lecture and skills lab instruction. Pre- and post-course surveys used the Likert scale, with a score of 1 corresponding to the most negative opinion and a score of 10 corresponding to the most positive opinion, in order to measure various aspects including interest in neurological surgery, understanding of the field, and perception of female inclusion in the field. Weekly pre- and post-lecture quizzes assessed practical knowledge of neurosurgical topics. RESULTS A higher percentage of students rated neurosurgery highly as a career possibility (⩾8/10 interest level) post-course (58.6%) compared to pre-course (45.7%). Post-course, students reported a significantly increased mean understanding of neurosurgery on the Likert scale compared to pre-course (6.1 ± 1.7 vs 4.4 ± 2.0; P = .001). Knowledge based-content assessment revealed a significant increase in overall correct answers after lectures (meanpre = 3.85, meanpost = 5.05, P = .001). Inclusion of female instructors in the second and third iteration of the course resulted in a significant increase in students' perception of female inclusion in the field of neurosurgery (7.6 compared to 5.6, P = .01). CONCLUSIONS Early exposure to subspecialties may assist in making important career decisions. The implementation of this neurosurgical elective improved medical students' perception of the field and enhanced knowledge of the lectures and procedures. This study can be used as a framework for implementation of this curriculum at other institutions.
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Affiliation(s)
| | | | | | | | | | - Robert M Friedlander
- University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raymond F Sekula
- University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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32
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Feroze RA, McDowell MM, Balzer J, Crammond DJ, Thirumala P, Sekula RF. Estimation of Intraoperative Stimulation Threshold of the Facial Nerve in Patients Undergoing Microvascular Decompression. J Neurol Surg B Skull Base 2019; 80:599-603. [PMID: 31750045 DOI: 10.1055/s-0038-1677538] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/09/2018] [Indexed: 10/27/2022] Open
Abstract
Introduction Facial weakness can result from surgical manipulation of the facial nerve. Intraoperative neuromonitoring reduces functional impairment but no clear guidelines exist regarding interpretation of intraoperative electrophysiological results. Most studies describe subjects with facial nerves encumbered by tumors or those with various grades of facial nerve weakness. We sought to obtain the neurophysiological parameters and stimulation threshold following intraoperative facial nerve triggered electromyography (t-EMG) stimulation during microvascular decompression for trigeminal neuralgia to characterize the response of normal facial nerves via t-EMG. Methods Facial nerve t-EMG stimulation was performed in seven patients undergoing microvascular decompression for trigeminal neuralgia. Using constant current stimulation, single stimulation pulses of 0.025 to 0.2 mA intensity were applied to the proximal facial nerve. Compound muscle action potentials, duration to onset, and termination of t-EMG responses were recorded for the orbicularis oculi and mentalis muscles. Patients were evaluated for facial weakness following the surgical procedure. Results Quantifiable t-EMG responses were generated in response to all tested stimulation currents of 0.025, 0.05, 0.1, and 0.2 mA in both muscles, indicating effective nerve conduction. No patients developed facial weakness postoperatively. Conclusions The presence of t-EMG amplitudes in response to 0.025 mA suggests that facial nerve conduction can take place at lower stimulation intensities than previously reported in patients with tumor burden. Proximal facial nerve stimulation that yields responses with thresholds less than 0.05 mA may be a preferred reference baseline for surgical procedures within the cerebellopontine angle to prevent iatrogenic injury.
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Affiliation(s)
- Rafey A Feroze
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Partha Thirumala
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Panczykowski DM, Jani RH, Hughes MA, Sekula RF. Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression. Neurosurgery 2019; 87:71-79. [DOI: 10.1093/neuros/nyz376] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 07/05/2019] [Indexed: 01/03/2023] Open
Abstract
AbstractBACKGROUNDMicrovascular decompression (MVD) can be an effective intervention for trigeminal neuralgia (TN); however, an optimal system for patient selection and surgical outcome prediction has not been defined.OBJECTIVETo develop and validate a preoperative TN grading system for the prediction of long-term pain relief after MVD.METHODSThis retrospective cohort study included consecutive patients suffering unilateral TN who underwent MVD with >18-mo follow-up. A grading system was formulated using 3 previously validated preoperative characteristics. The primary end-point was long-term, pain-free status without use of medication. Ability to predict pain-free status was analyzed by multiple regression and assessed by area under the receiver operating characteristic curve (AUC). Clinical utility to predict MVD success and reduce unnecessary surgeries was assessed by decision-curve analysis.RESULTSOf 208 patients analyzed, 73% were pain-free without medication at >18-mo follow-up. Pain-free status was predicted by classical TN type, positive response to carbamazepine and/or oxcarbazepine, and presence and nature of neurovascular compression demonstrated on MRI (all P < .01). The TN grading system demonstrated good discriminatory ability for prediction of pain-free status (AUC 0.85, 95% CI 0.80-0.91). Decision-curve analysis demonstrated a net reduction of 20 cases likely to be unsuccessful per 100 patients evaluated with this grading system above a decision threshold of 80%.CONCLUSIONThis TN grading system reliably predicts long-term pain-free status without medications following MVD. The use of the TN grading system as part of a comprehensive work-up may reduce the number of unsuccessful operations.
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Affiliation(s)
- David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ronak H Jani
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marion A Hughes
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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White MD, Nowicki KW, Sekula RF. Spatiotemporal Stimulation Re-establishes Voluntary Control of Previously Paralyzed Muscles During Locomotion After Spinal Cord Injury. Neurosurgery 2019; 85:E200-E202. [DOI: 10.1093/neuros/nyz168] [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] [Received: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/12/2022] Open
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Hughes MA, Jani RH, Fakhran S, Chang YF, Branstetter BF, Thirumala PD, Sekula RF. Significance of degree of neurovascular compression in surgery for trigeminal neuralgia. J Neurosurg 2019; 133:411-416. [PMID: 31200377 DOI: 10.3171/2019.3.jns183174] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/19/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The aim of this study was to identify preoperative imaging predictors of surgical success in patients with classic trigeminal neuralgia (cTN) undergoing microvascular decompression (MVD) via retrospective multivariate regression analysis. METHODS All included patients met criteria for cTN and underwent preoperative MRI prior to MVD. MR images were blindly graded regarding the presence and severity (i.e., mild or severe) of neurovascular compression (NVC). All patients were contacted by telephone to determine their postoperative pain status. RESULTS A total of 79 patients were included in this study. Sixty-two patients (78.5%) were pain-free without medication following MVD. The following findings were more commonly observed with the symptomatic nerve when compared to the contralateral asymptomatic nerve: NVC (any form), arterial compression alone, NVC along the proximal trigeminal nerve, and severe NVC (p values < 0.0001). The only imaging variable that was a statistically significant predictor of being pain-free without medication following MVD was severe NVC. Patients with severe NVC were 6.36 times more likely to be pain-free following MVD compared to those without severe NVC (p = 0.007). CONCLUSIONS In patients with cTN undergoing MVD, severe NVC on preoperative MRI is a strong predictor of an excellent surgical outcome.
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Affiliation(s)
| | | | | | | | | | - Parthasarathy D Thirumala
- 3Neurology, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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36
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Staub BP, Casini GP, Monaco EA, Sekula RF, Emerick TD. Near-resolution of persistent idiopathic facial pain with low-dose lumbar intrathecal ziconotide: a case report. J Pain Res 2019; 12:945-949. [PMID: 30881103 PMCID: PMC6413753 DOI: 10.2147/jpr.s193746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Purpose Persistent idiopathic facial pain (PIFP) is a poorly defined and debilitating chronic pain state with a challenging and often inadequate treatment course. This is the first case report identifying the novel use of low-dose lumbar intrathecal ziconotide to successfully treat PIFP with nearly complete resolution of pain and minimal to no side effects. Methods The patient was a 37 year-old female whose PIFP was refractory to multimodal medication management and multiple neurovascular surgical interventions. A single-shot lumbar intrathecal trial of ziconotide (2.5 mL, equivalent 2.5 μg) was injected when she was at her baseline pain level — VAS 7/10. She received complete resolution of her pain for about 9 hours, concordant with ziconotide’s half-life. She was subsequently implanted with a lumbar intrathecal delivery system. Results The patient experienced complete resolution of her facial pain with a single-shot intrathecal trial of ziconotide. The intrathecal pump system has provided nearly complete (VAS 1/10) pain relief. Two flares of pain occurred 10 and 18 months after pump placement, which subsequently resolved after increasing the ziconotide dose by 0.5 μg/day on each occasion. The patient is currently maintained on a dose of 2.0 μg/day and is pain-free. Conclusion This is the first case report describing the use of a single-shot lumbar intrathecal trial of ziconotide and subsequent placement of lumbar (as opposed to thoracic) intrathecal ziconotide pump for PIFP. A single-injection intrathecal trial is a low-risk, viable option for patients with this debilitating and frustrating pain condition. Successful trials and subsequent intrathecal pump placement with ziconotide may supplant multimodal medication management and/or invasive orofacial surgical intervention for PIFP.
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Affiliation(s)
- Brandon P Staub
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Edward A Monaco
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Physicians, Pittsburgh, PA, USA,
| | - Raymond F Sekula
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Physicians, Pittsburgh, PA, USA,
| | - Trent D Emerick
- University of Pittsburgh Physicians, Pittsburgh, PA, USA, .,Division of Chronic Pain, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
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Nowicki KW, D'Angelo MP, Sekula RF. Engineering Chimeric Antigen Receptors Into Homing Missiles. Neurosurgery 2019; 84:E148-E149. [PMID: 30590676 DOI: 10.1093/neuros/nyy629] [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: 11/08/2018] [Accepted: 12/10/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kamil W Nowicki
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Michael P D'Angelo
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
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38
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Gandhoke GS, Smith KJ, Niranjan A, Sekula RF, Lunsford LD. Comparing Microvascular Decompression with Gamma Knife Radiosurgery for Trigeminal Neuralgia. A Cost-Effectiveness Analysis. World Neurosurg 2019; 125:207-216. [PMID: 30660885 DOI: 10.1016/j.wneu.2018.12.204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Both microvascular decompression (MVD) and Gamma Knife radiosurgery (GKRS) are time-tested treatment modalities for trigeminal neuralgia (TN). There is little evidence in the literature studying these modalities head to head in a cost-effectiveness comparison. OBJECTIVE To evaluate the cost-effectiveness of MVD compared with GKRS for treating patients with TN. METHODS We developed a Markov cost-effectiveness model for the U.S. health care system to account for all costs related to MVD and GKRS as treatment modalities for TN, from the health care system perspective, over a patient lifetime horizon. A base case was estimated using data from previous studies, from our own GKRS experience, and from a current data analysis of patients undergoing MVD. We derived model inputs, including health care costs, survival, and utility estimates, from the literature. We used age-specific, sex-specific, and race-specific mortality from national registries. Costs studied included those for MVD, for GKRS, for treating complications from either procedure, and for medications throughout patient lifetimes. We performed multiple 1-way, 2-way, and probabilistic sensitivity analyses to confirm the robustness of model assumptions and results. The incremental cost-effectiveness ratio (ICER), with a threshold of $50,000 per quality-adjusted life-year (QALY) gained, defined cost-effectiveness. RESULTS The base case had an ICER of $12,154 per QALY for MVD compared with GKRS. Probabilistic sensitivity (Monte Carlo) analysis showed that MVD was cost-effective in 70% of model iterations. GKRS was favored when the willingness to pay threshold was <$12,000 per QALY gained. CONCLUSIONS In patients medically eligible for either procedure, we found MVD to be the most cost-effective modality to treat TN, primarily because of its reported greater durability. MVD remained the most cost-effective strategy across a broad range of model input values in sensitivity analyses.
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Affiliation(s)
- Gurpreet S Gandhoke
- Marion Bloch Neuroscience Institute, Saint Luke's Hospital, Kansas City, Missouri, USA.
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raymond F Sekula
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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39
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D'Angelo MP, Nowicki KW, Beresteanu G, Sekula RF. Neutrophilic Ribonucleic Acid Expression as a Clinical Tool in Detecting Cerebral Aneurysms. Neurosurgery 2019; 84:E17-E19. [PMID: 30395290 DOI: 10.1093/neuros/nyy510] [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: 11/12/2022] Open
Affiliation(s)
- Michael P D'Angelo
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Kamil W Nowicki
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Guy Beresteanu
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
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40
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Moccia S, Foti S, Routray A, Prudente F, Perin A, Sekula RF, Mattos LS, Balzer JR, Fellows-Mayle W, De Momi E, Riviere CN. Toward Improving Safety in Neurosurgery with an Active Handheld Instrument. Ann Biomed Eng 2018; 46:1450-1464. [PMID: 30014286 PMCID: PMC6150797 DOI: 10.1007/s10439-018-2091-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 01/18/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
Microsurgical procedures, such as petroclival meningioma resection, require careful surgical actions in order to remove tumor tissue, while avoiding brain and vessel damaging. Such procedures are currently performed under microscope magnification. Robotic tools are emerging in order to filter surgeons' unintended movements and prevent tools from entering forbidden regions such as vascular structures. The present work investigates the use of a handheld robotic tool (Micron) to automate vessel avoidance in microsurgery. In particular, we focused on vessel segmentation, implementing a deep-learning-based segmentation strategy in microscopy images, and its integration with a feature-based passive 3D reconstruction algorithm to obtain accurate and robust vessel position. We then implemented a virtual-fixture-based strategy to control the handheld robotic tool and perform vessel avoidance. Clay vascular phantoms, lying on a background obtained from microscopy images recorded during petroclival meningioma surgery, were used for testing the segmentation and control algorithms. When testing the segmentation algorithm on 100 different phantom images, a median Dice similarity coefficient equal to 0.96 was achieved. A set of 25 Micron trials of 80 s in duration, each involving the interaction of Micron with a different vascular phantom, were recorded, with a safety distance equal to 2 mm, which was comparable to the median vessel diameter. Micron's tip entered the forbidden region 24% of the time when the control algorithm was active. However, the median penetration depth was 16.9 μm, which was two orders of magnitude lower than median vessel diameter. Results suggest the system can assist surgeons in performing safe vessel avoidance during neurosurgical procedures.
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Affiliation(s)
- Sara Moccia
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Simone Foti
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Arpita Routray
- Robotics Institute, Carnegie Mellon University, Pittsburgh, USA
| | - Francesca Prudente
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Alessandro Perin
- Besta NeuroSim Center, IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Leonardo S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Wendy Fellows-Mayle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
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Nowicki KW, Sekula RF. Pericytes Protect White-Matter Structure and Function. Neurosurgery 2018; 83:E103-E104. [DOI: 10.1093/neuros/nyy300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Jani RH, Hughes MA, Ligus ZE, Nikas A, Sekula RF. MRI Findings and Outcomes in Patients Undergoing Microvascular Decompression for Glossopharyngeal Neuralgia. J Neuroimaging 2018; 28:477-482. [PMID: 30102011 DOI: 10.1111/jon.12554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/23/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Glossopharyngeal neuralgia causes extreme paroxysmal pain in the posterior pharynx, tonsillar region, base of tongue, or deep ear, that is, the distribution of the glossopharyngeal nerve. Some cases of glossopharyngeal neuralgia are associated with neurovascular conflict, usually by the posterior inferior cerebellar artery. Such symptomatic compression occurs only in proximal, centrally myelinated portions of the glossopharyngeal nerve near the brainstem. Microvascular decompression provides effective and durable pain relief for properly selected patients with medically refractory glossopharyngeal neuralgia. The purpose of this study is to describe a tailored MRI evaluation of neurovascular conflict in glossopharyngeal neuralgia to improve candidate selection for microvascular decompression. METHODS Our team developed a glossopharyngeal neuralgia imaging and evaluation protocol including a grading system for neurovascular conflict of the glossopharyngeal nerve and applied it to evaluate candidates for microvascular decompression. RESULTS Our team grades neurovascular conflict as "contact" (vessel touching nerve without intervening cerebrospinal fluid) versus "deformation" (deviation or distortion of nerve from its normal course by the offending vessel). MRIs of patients with glossopharyngeal neuralgia demonstrate proximal neurovascular conflict. Postoperative MRI demonstrates separation of the glossopharyngeal nerve from the offending vessel. CONCLUSION A tailored glossopharyngeal neuralgia imaging evaluation protocol is presented. We believe this approach has helped improve microvascular decompression outcomes and reduce unnecessary procedures at our institution. Further research may elucidate whether clinical and imaging features, including neurovascular conflict severity, predict surgical outcome for glossopharyngeal neuralgia.
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Affiliation(s)
- Ronak H Jani
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marion A Hughes
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Radiology, Pittsburgh, Pennsylvania, USA
| | - Zachary E Ligus
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alexandra Nikas
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raymond F Sekula
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Neurological Surgery, Pittsburgh, Pennsylvania, USA
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Abstract
OBJECTIVE We have previously documented the utility of calcium phosphate cement cranioplasty following retromastoid craniectomy. In this study, we aimed to demonstrate its efficacy following a supraorbital approach for tumor resection. METHODS A retrospective analysis of a prospectively maintained database was conducted of eight patients (7 female, 1 male) with anterior cranial fossa meningiomas resected via a supraorbital approach followed by cranioplasty involving adjunctive or sole use of calcium phosphate cement. RESULTS Cranioplasty was achieved in all patients. No patient developed an incisional leak. The cohort had a mean follow-up of approximately 3.1 months (range: 0.5-7 months) in which time no further complications were noted. No patients developed post-surgical infections. CONCLUSION In our experience, a low incidence of infection or CSF leaks has been noted after the use of calcium phosphate cement retromastoid cranioplasty. Extending this technique to supraorbital craniotomies may minimize incisional CSF leak.
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Affiliation(s)
- Rafey A Feroze
- a Department of Neurological Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania, USA
| | - Nitin Agarwal
- a Department of Neurological Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania, USA
| | - Raymond F Sekula
- a Department of Neurological Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania, USA
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Affiliation(s)
- Ronak H Jani
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurosurgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
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45
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Nowicki KW, Jennings R, Sekula RF. Brainstem Hypoperfusion as the Inciting Factor in the Development of Essential Hypertension. Neurosurgery 2018; 82:N20-N21. [DOI: 10.1093/neuros/nyx601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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46
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Sekula RF. In Reply to the Letter to the Editor "Apples and Oranges: Proper Comparison of Costs - Endonasal vs. Transnasal". World Neurosurg 2017; 106:986-987. [PMID: 28985665 DOI: 10.1016/j.wneu.2017.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Raymond F Sekula
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA.
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47
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Agarwal N, Kashkoush AI, Prabhu AV, Sekula RF. Ventral Spontaneous Durotomy Following Vaginal Delivery. World Neurosurg 2017; 102:697.e5-697.e7. [DOI: 10.1016/j.wneu.2017.01.133] [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] [Received: 12/04/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
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Gandhoke GS, Pease M, Smith KJ, Sekula RF. Supraorbital Versus Endoscopic Endonasal Approaches for Olfactory Groove Meningiomas: A Cost-Minimization Study. World Neurosurg 2017; 105:126-136. [PMID: 28408255 DOI: 10.1016/j.wneu.2017.03.148] [Citation(s) in RCA: 16] [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: 01/29/2017] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To perform a cost-minimization study comparing the supraorbital and endoscopic endonasal (EEA) approach with or without craniotomy for the resection of olfactory groove meningiomas (OGMs). METHODS We built a decision tree using probabilities of gross total resection (GTR) and cerebrospinal fluid (CSF) leak rates with the supraorbital approach versus EEA with and without additional craniotomy. The cost (not charge or reimbursement) at each "stem" of this decision tree for both surgical options was obtained from our hospital's finance department. After a base case calculation, we applied plausible ranges to all parameters and carried out multiple 1-way sensitivity analyses. Probabilistic sensitivity analyses confirmed our results. RESULTS The probabilities of GTR (0.8) and CSF leak (0.2) for the supraorbital craniotomy were obtained from our series of 5 patients who underwent a supraorbital approach for the resection of an OGM. The mean tumor volume was 54.6 cm3 (range, 17-94.2 cm3). Literature-reported rates of GTR (0.6) and CSF leak (0.3) with EEA were applied to our economic analysis. Supraorbital craniotomy was the preferred strategy, with an expected value of $29,423, compared with an EEA cost of $83,838. On multiple 1-way sensitivity analyses, supraorbital craniotomy remained the preferred strategy, with a minimum cost savings of $46,000 and a maximum savings of $64,000. Probabilistic sensitivity analysis found the lowest cost difference between the 2 surgical options to be $37,431. CONCLUSION Compared with EEA, supraorbital craniotomy provides substantial cost savings in the treatment of OGMs. Given the potential differences in effectiveness between approaches, a cost-effectiveness analysis should be undertaken.
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Affiliation(s)
- Gurpreet S Gandhoke
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew Pease
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Section of Decision Sciences, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Lawrence JD, Frederickson AM, Chang YF, Weiss PM, Gerszten PC, Sekula RF. An investigation into quality of life improvement in patients undergoing microvascular decompression for hemifacial spasm. J Neurosurg 2017; 128:193-201. [PMID: 28186450 DOI: 10.3171/2016.9.jns161022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hemifacial spasm (HFS) is a movement disorder characterized by involuntary spasms of the facial muscles, and it can negatively impact quality of life (QOL). This retrospective study and systematic review with meta-analysis was conducted to investigate the QOL in patients with HFS following intervention with microvascular decompression (MVD) and botulinum toxin (BT). METHODS In the retrospective analysis, a QOL questionnaire was administered to all patients undergoing MVD performed by a single surgeon. The QOL questionnaire included unique questions developed based on the authors' experience with HFS patients in addition to the health-related QOL HFS-8 questionnaire. The authors also report on a systematic review of the English literature providing outcomes and complications in patients with HFS undergoing treatment with either MVD or BT. RESULTS Regarding the retrospective analysis, 242 of 331 patients completed the questionnaire. The mean score of the 10 QOL questions improved from 22.78 (SD 9.83) to 2.17 (SD 5.75) following MVD (p < 0.001). There was significant improvement across all subscales of the questionnaire between pre- and postoperative responses (p < 0.001). Regarding the systematic review, it is reported that approximately 90% of patients undergoing MVD for HFS experience a complete recovery from symptoms, whereas the mean peak improvement of symptoms following treatment with BT is 77%. Furthermore, patients undergoing MVD reported a greater improvement in the mean supplemental index of QOL as compared with patients receiving BT therapy. CONCLUSIONS Microvascular decompression offers a significant improvement in QOL in well-selected patients suffering from HFS, and may offer an increased benefit for QOL over BT injections.
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Affiliation(s)
| | | | - Yue-Fang Chang
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Patricia M Weiss
- 3Health Sciences Library System, University of Pittsburgh, Pennsylvania
| | - Peter C Gerszten
- 1University of Pittsburgh School of Medicine.,2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Raymond F Sekula
- 1University of Pittsburgh School of Medicine.,2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
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50
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Agarwal N, Choi PA, Sekula RF. Minimally Invasive Spine Surgery for Unstable Thoracolumbar Burst Fractures: A Case Series. Surg J (N Y) 2016; 2:e131-e138. [PMID: 28825006 PMCID: PMC5553496 DOI: 10.1055/s-0036-1594248] [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: 07/04/2016] [Accepted: 10/19/2016] [Indexed: 11/03/2022] Open
Abstract
Introduction Traumatic thoracolumbar burst fracture is a common pathology without a clear consensus on best treatment approach. Minimally invasive approaches are being investigated due to potential benefits in recovery time and morbidity. We examine long-term resolution of symptoms of traumatic thoracolumbar burst fractures treated with percutaneous posterior pedicle screw fixation. Methods Retrospective clinical review of seven patients with spinal trauma who presented with thoracolumbar burst fracture from July 2012 to April 2013 and were treated with percutaneous pedicle screw fixation. Electronic patient charts and radiographic imaging were reviewed for initial presentation, fracture characteristics, operative treatment, and postoperative course. Results The patients had a median age of 29 years (range 18 to 57), and 57% were men. The median Thoracolumbar Injury Classification and Severity Scale score was 4 (range 2 to 9). All patients had proper screw placement and uneventful postoperative courses given the severity of their individual traumas. Five of seven patients were reached for long-term follow-up of greater than 28 months. Six of seven patients had excellent pain control and stability at their last follow-up. One patient required revision surgery for noncatastrophic hardware failure. Conclusion Percutaneous pedicle screw fixation for the treatment of unstable thoracolumbar burst fracture may provide patients with durable benefits and warrants further investigation.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Phillip A Choi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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