Faculty Bibliography

This review was focused on understanding which substances inside the human body increase and decrease with increasing neuropathic pain. We reviewed various studies, and saw correlations between neuropathic pain and components of the immune system (this system defends the body against diseases and infections). Our findings will especially be useful for understanding ways to reduce or eliminate the discomfort, chronic neuropathic pain brings with it. Spinal cord stimulation (SCS) procedure is one of the few fairly efficient remedial treatments for pain. A follow-up study will apply our findings from this review to SCS, in order to understand the mechanism, and further optimize efficaciousness.

BACKGROUND:Bilateral anterior cingulotomy is well described for certain pain and psychiatric disorders. Typically, stereotactic frame-based radiofrequency ablation is used. We report the feasibility of a frameless approach using magnetic resonance imaging-guided laser induced thermal therapy (MRgLITT). OBJECTIVE:To report experience and outcomes for MRgLITT in bilateral anterior cingulotomy. METHODS:Three patients with chronic refractory cancer-related pain underwent bilateral anterior cingulotomy. The Brief Pain Inventory (Short Form) was used for pain evaluation. Frameless stereotaxy using the Medtronic S7 Navigation system was used for laser catheter placement. Patients were followed for evaluation of pain control outcomes. RESULTS:Four MRgLITT bilateral cingulotomy procedures were performed in 3 patients. Two patients had a single MRgLITT procedure while the third had repeat ablation after pain recurrence. First time ablation coordinates were (medians): x = 7.9 mm (range, 6.9-8.6); y = 20.5 mm (range, 20-22); z = 6.9 mm (range, 2.9-7.0) above the lateral ventricle roof. Median trajectory length was 85.5 mm (range, 80-90). Median ablation volume was 1.5 cm3 (range, 0.6-1.2). Median ablation time was 257 seconds (range, 136-338) per cingulum and power was 10.0 Watts (range, 10-11). Median preoperative pain severity (PSS) and interference scores (PIS) were 7.7 (range, 7.5-9.3) and 9.9 (range, 9.7-10.0), respectively. Median postoperative PSS and PIS scores were 1.6 (range, 1.0-2.8) and 2.0 (range, 0.3-2.6), respectively. CONCLUSION:MRgLITT cingulotomy is well tolerated for treatment of cancer pain and can be easily performed framelessly for appropriate candidates.

INTRODUCTION/BACKGROUND:Dynamic stabilization offers an adjunct to fusion with motion preservation. In comparison, standard instrumented fusion (if) consists of titanium screws and rods/plates, which do not allow for motion at the level of the fusion. The reported infection rate following a standard if ranges from 0.2% to 7%. METHODS:a retrospective chart review of 142 patients who underwent posterior lumbar stabilization procedures was conducted. Ten patients received dynamic stabilization and 132 patients had a standard if. Rates of infection, requiring hardware removal, were compared between the aforementioned groups. RESULTS:Of the 132 patients undergoing posterior if, three developed a deep wound infection requiring removal of hardware (2.3%). Of the 10 patients undergoing dynamic stabilization, three developed a deep wound infection (30%) with 2 requiring removal of hardware (20%), secondary to persistent deep wound infection or osteomyelitis at the pedicle screw sites. There was a significantly increased risk of deep wound infection (p < 0.0001) with the use of dynamic stabilization compared to standard if. CONCLUSIONS:Our series demonstrates that the infection rate in patients undergoing dynamic stabilization is higher than the infection rate for instrumented fusion without a significant difference in comorbidity scores. We postulate that the polycarbonate urethane spacer acts as a medium for bacteria, whereas the titanium screws and rods are smooth, solid, and inert, resulting in a lower risk of infection.

Occipital nerve stimulation (ONS) is a form of neuromodulation therapy aimed at treating intractable headache and craniofacial pain. The therapy utilizes neurostimulating electrodes placed subcutaneously in the occipital region and connected to a permanently implanted programmable pulse generator identical to those used for dorsal column/spinal cord stimulation. The presumed mechanisms of action involve modulation of the trigeminocervical complex, as well as closure of the physiologic pain gate. ONS is a reversible, nondestructive therapy, which can be tailored to a patient's individual needs. Typically, candidates for successful ONS include those patients with migraines, Chiari malformation, or occipital neuralgia. However, recent MRSA infections, unrealistic expectations, and psychiatric comorbidities are generally contraindications. As with any invasive procedure, complications may occur including lead migration, infection, wound erosion, device failure, muscle spasms, and pain. The success of this therapy is dependent on careful patient selection, a preimplantation trial, meticulous implantation technique, programming strategies, and complication avoidance.

ABSTRACT Introduction: Intracranial hypotension is a neurologic syndrome characterized by orthostatic headaches and, radiographically, by dural thickening and enhancement as well as subdural collections. Several of etiologies exist, including surgical dural violations, lumbar puncture, or spontaneous cerebrospinal fluid leak. Current management includes conservative management consisting of bed rest, caffeine, and hydration. When conservative management fails, open surgical or percutaneous options are considered. Currently, the gold standard in percutaneous management of intracranial hypotension involves the epidural injection of autologous blood. Recently, some therapies for intracranial hypotension have employed the use of epidural fibrin glue. Case Presentation: Two cases of patients with persistent postdural puncture headaches are presented. Epidural fibrin glue injection alleviated the orthostatic headaches of two patients with intracranial hypotension. Conclusion: Although consideration must be afforded for the potential risks of viral transmission and aseptic meningitis, the utilization of epidural fibrin glue injection as an alternative or adjunct to the epidural blood patch in the treatment of intracranial hypotension should be further investigated.

Both the history of headache and the practice of craniotomy can be traced to antiquity. From ancient times through the present day, numerous civilizations and scholars have performed craniotomy in attempts to treat headache. Today, surgical intervention for headache management is becoming increasingly more common due to improved technology and greater understanding of headache. By tracing the evolution of the understanding of headache alongside the practice of craniotomy, investigators can better evaluate the mechanisms of headache and the therapeutic treatments used today.

BACKGROUND CONTEXT/BACKGROUND:Cauda equina syndrome is caused by compression or injury to the nerve roots distal to the level of the spinal cord. This syndrome presents as low back pain, motor and sensory deficits in the lower extremities, and bladder as well as bowel dysfunction. Although various etiologies of cauda equina syndrome have been reported, a less common cause is infection. PURPOSE/OBJECTIVE:To report a case of cauda equina syndrome caused by infection of an intradural extramedullary abscess with Staphylococcus aureus. STUDY DESIGN/SETTING/METHODS:Case report and review of the literature. METHODS:The literature regarding the infectious causes of cauda equina syndrome was reviewed and a case of cauda equina syndrome caused by infection of an intradural extramedullary abscess with Staphylococcus aureus was reported. RESULTS:A 37-year-old woman, with history of intravenous drug abuse, hepatitis C, and hepatitis B, presented with low back pain lasting 2 months, lower extremity pain, left greater than right with increasing weakness and difficulty ambulating, and urinary and fecal incontinence. Her presentation was consistent with cauda equina syndrome. The patient underwent a T12-L2 laminectomy, and intradural exploration revealed an abscess. Methicillin-resistant Staphylococcus aureus was found on wound culture. CONCLUSIONS:Cauda equina syndrome, presenting as a result of spinal infection, such as the case reported here, is extremely rare but clinically important. Surgical intervention is generally the recommended therapeutic modality.

BACKGROUND AND STUDY AIMS/OBJECTIVE:Postoperative pneumocephalus is commonly observed after neurosurgical intracranial procedures and is usually of little consequence. Intraventricular tension pneumocephalus, however, is a rare complication and a neurosurgical emergency that requires immediate intervention. We describe the first case of intraventricular tension pneumocephalus that developed 1 week following an expanded endoscopic endonasal approach for resection of a suprasellar mass. PATIENT/METHODS:A patient who underwent an endoscopic transplanum transtuberculum approach for resection of a suprasellar epidermoid tumor developed a sudden change in mental status, with imaging consistent with intraventricular tension pneumocephalus. Immediate endotracheal intubation and placement of an external ventricular drain prevented further deterioration. Endoscopic exploration of the skull base reconstruction revealed a one-way ball valve mechanism as the source of pneumocephalus. The skull base reconstruction was revised with autologous fascia lata and repositioning of the pedicled nasoseptal flap. CONCLUSION/CONCLUSIONS:Intraventricular tension pneumocephalus is a rare neurosurgical emergency that may develop after endoscopic skull base surgery. Initial management includes endotracheal intubation and placement of an external ventricular drain to decompress the ventricles. Endoscopic exploration and revision of the skull base repair is imperative to obliterate the ball-valve fistula to prevent further entrapment of air.