The "state of the art" of intraoperative neurophysiological monitoring: An Italian neurosurgical survey.

Introduction: Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question: The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods: A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results: A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions: The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.

A Benefit/Risk Assessment of Intrathecal Ziconotide in Chronic Pain: A Narrative Review.

BACKGROUND: Ziconotide is an intrathecal drug administered for the treatment of chronic pain. The current literature lacks an exhaustive benefit/risk assessment on this drug. We herein focus on Ziconotide's pharmacology and clinical applications. METHODS: Literature research was conducted to identify studies on Ziconotide administration for the treatment of chronic pain, published between January 1990 and March 2023 and located via PubMed, Embase, Medline, Cinahl, and Web of Science, using the following keywords: Ziconotide, Omega conotoxin, Prialt, SNX-111, intrathecal therapy, and neuropathic pain. Only publications written in English were selected. RESULTS: Among the 86 selected studies, we found 4 Randomized Controlled Trials (RCTs) and 3 prospective long-term studies concerning the intrathecal use of Ziconotide as a monotherapy in chronic pain. Other studies described the intrathecal infusion of Ziconotide combined with other drugs. Overall, Ziconotide has been proved to have strong efficacy for relieving chronic pain, although patients with co-morbid psychiatric disorders require a careful monitoring when treated with Ziconotide. CONCLUSIONS: Overall, the use of Ziconotide, as a monotherapy or in conjunction with other therapies for the treatment of chronic pain, was reported to be efficacious. Overall, its use in patients with chronic pain refractory to other pharmacologic agents outweighs the possible adverse consequences, thus resulting in a favorable benefit/risk assessment.

The treatment of persistent spinal pain syndrome with epidural pulsed radiofrequency: improvement of the technique.

Background: In Persistent Spinal Pain Syndrome (PSPS), Pulsed Radiofrequency (PRF) is a used procedure. The results of PRF in PSPS performed with an electrode placed through the sacral hiatus were reported to be successful on pain in only 32% of patients. We have tried to improve the results by applying a new system to PRF. Methods: Ten patients were treated with PRF application through a steerable epidural catheter with a reference electrode outside the foramen. This method was named "Optimization Current Flow" (OCF). The duty cycle of PRF was 2 × 10 msec and total exposure time was 150 s. Follow up was planned for 1, 3, and 6 months. The NRS score was considered to be the primary outcome. Results: In the first 10 patients treatment was successful (69% of the patients) at 6 months follow-up. Conclusion: This new modality of PRF in patients with PSPS seems to be superior to procedures done with a needle. Further prospective double-blind randomized long-term studies with a significant number of patients are required to validate this technique as there is a need to improve PRF results in PSPS.

Peripheral Nerve Stimulation on the Brachial Plexus With Ultrasound-guided Percutaneous Technique: A Case Series.

INTRODUCTION: The aim of this case series was to assess the safety and effectiveness of peripheral nerve stimulation (PNS) of the brachial plexus performed using a low invasive percutaneous approach with ultrasound guide. MATERIALS AND METHODS: Patients affected by neuropathic pain with a documented brachial plexus partial avulsion were included in this observational study. A totally implantable PNS system specifically designed for peripheral placement (Neurimpulse, Padua, Italy) was implanted and followed for 18 months, recording the level of pain (Numeric Rating Scale [NRS]), therapy satisfaction (Patient Global Impression of Improvement), quality of life (Short Form Health Survey questionnaire), and change in drug consumption and work status. Descriptive statistic (mean and SD) was used to compare pre- and postimplantation differences. RESULTS: A total of 18 patients were included in the observational study; 16 of them proceeded with the permanent implantation. System infection (N = 1) and lead migrations (N = 2) were recorded during a follow-up mean of 14.8 ± 5.4 months. The average NRS reduction at 18 months was 41%. Average quality-of-life physical and mental indexes increased by 14% and 32%, respectively. Drug intake was stopped in 22% and reduced in 56% of the patients. CONCLUSIONS: PNS systems of the brachial plexus implanted with percutaneous approach appear to be safe and effective in a follow-up period of 18 months. Longer and larger studies are needed to confirm and extend these outcomes.

Frameless neuronavigation-assisted brain biopsy with electromagnetic tracking: how I do it?

BACKGROUND: In recent years, thanks to several technological innovations, stereotactic cerebral biopsies have evolved from frame-based to frameless neuronavigation-assisted techniques. METHODS: The authors provide herein a detailed step-by-step description of the technique, shedding light on surgical tips and how to avoid complications. The practical application of the technique is demonstrated with a high-quality video. CONCLUSION: The neuronavigation-assisted brain biopsy with electromagnetic tracking is a "true frameless" procedure. It represents a simple, safe, and effective innovation for frameless biopsy of cerebral lesions. This technique is time efficient, offering a high degree of accuracy required for the establishment of a definitive diagnosis, enabling optimal further treatment, and thus improving patient outcome.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation.

INTRODUCTION: The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice. MATERIALS AND METHODS: Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant. RESULTS: This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion. CONCLUSIONS: The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Best Practices for Cervical Neurostimulation.

INTRODUCTION: The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on the use of neurostimulation in the cervical region to improve outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for an often-overlooked area of neurostimulation practice. MATERIALS AND METHODS: Authors were chosen based upon their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to the present. Identified studies were graded using the US Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant. RESULTS: The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS: The NACC recommends best practices regarding the use of cervical neuromodulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be utilized as a guide to assist decision making when clinically appropriate.