Implementation of enhanced recovery after surgery (ERAS) protocol for anterior cervical discectomy and fusion: a propensity score-matched analysis.

PURPOSE: Enhanced recovery after surgery (ERAS), still emerging for the spine, proposes a multimodal approach of perioperative care involving the optimization of every procedural step, with the patient in a proactive position regarding his/her management. We aimed to demonstrate a reduction in the length of hospital stay for ACDF without increasing the risk for patients by comparing 2 groups before and after ERAS implementation using propensity score (PS)-matched analysis. METHODS: We selected 2 periods of 1 year, before (n = 268 patients) and after ERAS implementation (n = 271 patients). Data were collected on patient demographics, operative and perioperative details, 90-day readmissions and morbidity. ERAS-trained nurses were involved to support patients at each pre/per/postoperative step with the help of a mobile app. A satisfaction survey was included. PS analyses were used for dealing with confounding bias in this retrospective observational study. RESULTS: After PS matching, the outcomes of 202 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was reduced from 2.96 ± 1.35 to 1.40 ± 0.6 days (Student, p < 0.001). All 90-day surgical morbidity was similar between the 2 groups, including 30-day readmission (0.5% vs 0%; p = 1), 30- to 90-day readmission (0.5% vs 0.0%; p = 1), 90-day reoperation (0% vs 1%; p = 0.49), major complications (3.0% vs 3.5%; p = 1) and minor complications (2.0% vs 3.5%; p = 0.54). There was no significant difference concerning the satisfaction survey. CONCLUSIONS: The introduction of ERAS for ACDF in our institution has resulted in a significant decrease in LOS, without causing an increase in postoperative complications and has maintained patients' satisfaction.

Litigations following spinal neurosurgery in France: "out-of-court system," therapeutic hazard, and welfare state.

OBJECTIVE: Spinal surgeries carry risks of malpractice litigation due to the random nature of their functional results, which may not meet patient expectations, and the hazards associated with these complex procedures. Claims are frequent and costly. In France, since 2002, a new law, the Patients' Rights Law of March 4, 2002, has created an alternative, out-of-court scheme, which established a simplified, rapid, free-of-charge procedure (Commission for Conciliation and Compensation [CCI]). Moreover, this law has optimized the compensation provided to patients for therapeutic hazards by use of a national solidarity fund. The authors analyzed the consequences of this alternative route in the case of claims against private neurosurgeons in France. METHODS: From the data bank of the insurer Mutuelle d'Assurances du Corps de Santé Français (MACSF), the main insurance company for private neurosurgeons in France, the authors retrospectively analyzed 193 files covering the period 2015-2019. These computerized files comprised the anonymized medical records of the patients, the reports of the independent experts, and the final judgments of the CCI and the entities supporting the compensation, if any. RESULTS: During the 5-year study period (2015-2019), the insurance company recorded 494 complaints involving private neurosurgeons for spinal surgery procedures, of which 126 (25.5%) were in civil court, 123 (24.9%) were under amicable procedure, and 245 (49.6%) were in the out-of-court scheme administered by the CCI. Out of these 245 cases, only 193 were closed due to delays. The conclusions of the commission were rejection/incompetence decisions in 47.2% of the cases, therapeutic hazards in 21.2%, nosocomial infections in 17.6%, and practitioner fault in 13.5%. National solidarity compensated for 48 complaints (24.8%). The final decision of the CCI is not always consistent with the conclusions of the experts mandated by it, illustrating the difficulty in defining the concept of hazards. The authors found that the therapeutic hazards retained and compensated by the national solidarity included decompensated spondylotic myelopathies (15% of the 40 cases) and cauda equina syndromes (30%). As allowed by law, 11.5% of the patients who were not satisfied triggered a classical procedure in a court. CONCLUSIONS: In the French out-of-court system, trial decisions resulting in rulings of proven medical malpractice are rare, but patients can start a new procedure in the classical courts. The therapeutic hazard remains a subtle definition, which may be problematic and require further discussion between experts and magistrates. In spite of the imperfections, this out-of-court system proposes a major evolution to move patients and medical providers from legal battles to reconciliations.

Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practice-a qualitative study.

BACKGROUND: The judicialization of medicine can lead to professional disenchantment and defensive attitudes among surgeons. Some quantitative studies have investigated this topic in spine surgery, but none has provided direct thematic feedback from physicians. This qualitative study aimed to identify the impact of this phenomenon in the practice of spine neurosurgeons. METHODS: We proposed a qualitative study using grounded theory approach. Twenty-three purposively selected private neurosurgeons participated. Inclusion took place until data saturation was reached. Data were collected through individual interviews and analyzed thematically and independently by three researchers (an anthropologist, a psychiatrist, and a neurosurgeon). RESULTS: Data analysis identified five superordinate themes that were based on items that recurred in interviews: (1) private practice of spinal surgery (high-risk surgery based on frequent functional symptoms, in an unfavorable medicolegal context); (2) societal transformation of the doctor-patient relationship (new societal demands, impact of the internet and social network); (3) judicialization of spine surgery (surgeons' feelings about the frequency and motivation of the complaints they receive, and their own management of them); (4) coping strategies (identification and solutions for "at risk" situations and patients); and (5) professional disenchantment (impact of these events on surgeons' daily practice and career planning). Selected quotes of interviews were reported to support these findings. CONCLUSIONS: Our study highlights several elements that can alter the quality of care in a context of societal change and the judicialization of medicine. The alteration of the doctor-patient relationship and the permanent pressure of a possible complaint encourage surgeons to adopt defensive attitudes in order to minimize the risks of litigation and increased insurance premiums. These phenomena can affect the quality of care and the privacy of physicians to the extent that they may consider changing or interrupting their careers earlier.

Enhanced recovery after spine surgery: review of the literature

The concept of Enhanced Recovery After Surgery (ERAS) entails recovery facilitation of patients who undergo surgery through the implementation of a multidisciplinary and multimodal perioperative care approach. By its application, ERAS improves the overall functional outcome after surgery while maintaining high standards of care. A review of the essential aspects of ERAS in spine surgery was undertaken. Special consideration was given to the risks and benefits for patients and caregivers, as well as the medical and economical aspects of this concept. ABBREVIATIONS EBL = estimated blood loss; ERAS = Enhanced Recovery After Surgery; MISS = minimally invasive spine surgery; TLIF = transforaminal lumbar interbody fusion.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction.

OBJECTIVEEnhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.METHODSThe authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012-2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016-2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.RESULTSThe pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.CONCLUSIONSThe introduction of the ERAS approach at the authors' institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

The "Friday peak" in surgical referrals for spinal metastases: lessons not learned. A retrospective analysis of 201 consecutive cases at a tertiary center.

BACKGROUND: Spinal cord compression and fracture are potential complications of spine metastasis (SM). Rapid management by an expert team can reduce these adverse developments. Delays in seeking therapeutic advices, which lead to the need for sub-optimal emergency procedures, were already demonstrated nearly 20 years ago. We aimed to analyze the current weak points of referrals for vertebral metastasis so as to improve the care pathways. METHODS: We retrospectively reviewed the data of all patients admitted on an emergency or elective basis who underwent palliative surgery for the treatment of neoplastic spine lesions in our institution (tertiary referral neurosurgical unit) between January 2009 and December 2016. RESULTS: This retrospective study included 201 patients, 121 men and 80 women (mean age 65.1 years ± 10.9). Cancer was known for 59.7% of cases. Patients were neurologically asymptomatic in 52.7% of cases (Frankel E), and 123 (60.7%) were hospitalized for emergency reasons, including 51 (41.5% of emergencies) on a Friday (p < 0.0001). A significant increase in emergencies occurred over the studied period (p = 0.0027). The "emergency" group had significantly unfavorable results in terms of neurological status (p < 0.001), the occurrence of complications (p = 0.04), the duration of hospitalization (p = 0.02), and the clinical evolution (p = 0.04). Among 123 patients hospitalized for emergency reasons, 65 (52.8%) had known cancers, of which 33 had an identified SM, including 22 with neurological deficits (Frankel A-D), without prior surgical assessment (17.8% of emergencies). CONCLUSION: Too many patients with previously identified metastases are referred for emergency reasons, including with a neurological deficit. Optimizing upstream pathways and referrals is imperative for improving the management of these patients. Involving a spine surgeon at the slightest symptom or an abnormal image is critical for defining the best treatment upstream. The use of telemedicine and the development of dedicated tumor boards are ways of improving this involvement.

Postoperative monitoring with a mobile application after ambulatory lumbar discectomy: an effective tool for spine surgeons.

BACKGROUND: The rise of eHealth, with the increasing use of a Mobile application provides a new perspective for outpatient spine surgery follow-up. OBJECTIVE: Assess the feasibility of Mobile app for postoperative monitoring after outpatient lumbar discectomy. PATIENTS AND METHODS: Sixty consecutive patients, who underwent an ambulatory lumbar discectomy, were proposed the use of Mobile app to optimize their home monitoring for 15 days. Contact was maintained with the clinic based on the level of symptom severity: pain, temperature, deficit, bleeding, to provide a suitable solution. Use of Mobile app compared to the standard follow-up procedure was evaluated daily and a satisfaction survey was carried-out 3 months after surgery. RESULTS: Thirty-six patients (60.0 %) completed the initial checklist within 48 h, with no triggered severity. Five patients (8.3 %) triggered a non-response alarm; no action was required in the follow-up of 41 patients. However, 19 patients (31.7 %) triggered a total of 29 alarms, automatically resulting in a neurosurgeon contact for: postoperative pain management and optimization of analgesics, 21 cases (72.4 %), low-grade fever <38.5°, 4 cases (13.8 %), voiding delay, 2 cases (6.9 %) and a problem related to dressing, 2 cases (6.9 %). The scale ranged from 1 (poor) to 4 (excellent), with a 3.5/4 overall satisfaction mean score for the mobile handheld-device. Most patients (91.6 %) responded that they would agree to repeat the postoperative experience. CONCLUSION: Overall patient satisfaction was excellent. Mobile app provides an effective useful tool for outpatient spine surgery monitoring and minimizes the need for in-person visits for postoperative patients.

Spine surgeons facing second opinions: a qualitative study.

BACKGROUND CONTEXT: The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients. PURPOSE: The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view. STUDY DESIGN/SETTING: This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions. PATIENT SAMPLE: We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared). OUTCOME MEASURES: Themes and subthemes were analyzed using semistructured interviews until saturation was reached. METHODS: Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon). RESULTS: Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations). CONCLUSIONS: The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.

Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice.

STUDY DESIGN: Retrospective multicenter cohort study. OBJECTIVE: Recurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France. METHODS: This retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively. RESULTS: The study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups. CONCLUSIONS: The decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.

Enhancing the referral process for surgical management of spinal metastases: insights from a 12-year, bi-institutional study of 533 patients.

Introduction: Delayed surgical management of spinal metastases (SMs) can have detrimental effects on patient survival and quality of life, leading to pain and potential neurological impairment. This study aimed to assess the impact of delayed referral for SMs on clinical outcomes by analyzing patients managed in emergency situations. Methods: We retrospectively reviewed the data of all patients admitted on either emergency or elective basis who underwent surgery for the treatment of neoplastic spine lesions at our two institutions (tertiary referral neurosurgical units) between January 2008 and December 2019. Results: We analyzed 210 elective (EGp) and 323 emergency patients (UGp); emergencies increased significantly over the 12-year period, with a Friday peak (39.3%) and frequent neurological impairment (61.6% vs. 20%). Among the UGp patients, 186 (7.5%) had a previously monitored primitive cancer, including 102 (31.6%) with known SMs. On admission, 71 of the 102 (69.9%) patients presented with neurological deficits. UGp patients were more likely to undergo a single decompression without fixation. Outcomes at the 3-month follow-up were significantly worse for UGp patients ([very] poor, 29.2 vs. 13.8%), and the median overall survival for UGp patients was statistically lower. Risk factors for patients with SM undergoing emergency management included short delay between onset of symptoms and first contact with a spine surgeon, and an initial motor deficit. Conclusion: Many patients with previously identified metastases, including those with neurological deficits, are urgently referred. Optimization is needed in the oncology pathway, and all stakeholders must be made aware of the factors contributing to the improvement in the clinical and radiological identification of potential complications affecting patient survival and quality of life.

Becoming a neurosurgeon in France: A qualitative study from the trainees' perspective.

Introduction: The training of neurosurgeons is evolving in a world of socio-professional changes, including the technological revolution, administrative pressure on stakeholders, reduced working hours, geographical heterogeneity, generational changes, to name but a few. Research question: This qualitative study aimed to explore experiences and feedback of French neurosurgical trainees concerning their training. Material and methods: The grounded theory approach was used with 23 neurosurgical trainees' interviews. Inclusion was continued until data saturation. Six researchers (an anthropologist, a psychiatrist, and four neurosurgeons) thematically and independently analyzed data collected through anonymized interviews. Results: Data analysis identified three superordinate themes: (1) The Trainee-Senior Dyad, where the respondents describe a similar bipolarity between trainees and faculty (trainees oscillating between those who fit into the system and those who are more reluctant to accept hierarchy, faculty using an ideal pedagogy while others refuse to help or invest in training); (2) The difficulty to learn (describing pressure exercised on trainees that can alter their motivation and degrade their training, including the impact of administrative tasks); (3) A pedagogy of empowerment (trainee' feelings about the pertinent pedagogy in the OR, ideal sequence to progress, progressive empowerment especially during the shifts, and stress of envisioning themselves as a senior neurosurgeon). Discussion and conclusion: Respondents emphasize the heterogeneity of their training both intra- and inter-university-hospital. Their critical analysis, as well as the formalization of their stress to become autonomous seniors, can be an important link with the reforms and optimizations currently being carried out to improve and standardize the training of young French neurosurgeons.

Spine Surgery Infection, Litigation, and Financial Compensation: Analysis of 98 Claims Involving French Spine Surgeons Between 2015 and 2019.

OBJECTIVE: Since 2002, France has adopted the Patients' Rights Law, an alternative malpractice scheme creating a faster, less expensive out-of-court settlement ensuring compensation even in the absence of fault. We aimed to describe the implications of this system by analyzing 5 years of claims for infections related to spinal surgeries collected by the main insurer of French spine surgeons. METHODS: We retrospectively analyzed 98 anonymized malpractice claims from 2015 to 2019 (20% of overall claims), including anonymized medical records of the patients, reports of the independent experts, final judgments, and entities supporting the compensation if any. RESULTS: Claims included 8 deaths and 17 newly acquired neurological sequelae. The conclusions identified 22 faulty cases. The most frequent fault was a delay in diagnosis (10 cases), followed by inadequate surgical management (6 cases), inadequate antibiotic therapy (5 cases), and inadequate follow-up (1 case). Among the 67 cases (68.4%) proved not to be at fault, 10 were covered by the national solidarity fund because of their severity, and the remaining 57 were covered by hospitals. CONCLUSIONS: Since the 2002 Patients' Rights Law, patients with postoperative infections have always received compensation. The out-of-court settlement offers the patients incurring morbidities the assurance of faster compensation. Although certainly subject to selection criteria, this procedure is free and does not necessitate the presence of a lawyer. The analysis of expert reports and the resulting court decisions imply prevention, anticipation, and collaboration of all health care providers and open an opportunity to improve their practices to limit these crucial followings.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery. PURPOSE: This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program. STUDY DESIGN: This is a review article. METHODS: Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature. RESULTS: Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented. CONCLUSION: Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Microsubthalamotomy effect at day 3: screening for determinants.

A microsubthalamotomy (mSTN) effect has been frequently reported after implantation that improves Parkinson's motor disability. It is usually believed that mSTN effect reflects the post-traumatic tissue reaction within the STN. However, it has never, to our knowledge, been reported whether pre and intraoperative factors could predict this mSTN effect. Preoperative clinical characteristics, that is, age, disease duration, Mattis Dementia Rating Scale score, levodopa responsiveness, severity of motor fluctuations and dyskinesia, and intraoperative parameters, that is, the number of tracks, distance of typical STN neuronal activity recorded along all microelectrodes, and along the definitive electrodes, were assessed in 40 consecutive PD patients submitted for STN stimulation. Multiple stepwise regression analysis showed that only the number of tracks used for microelectrodes recordings was predictor of the contralateral mSTN effect (F (4,73) = 1.83, P = 0.02). This result suggests that the contralateral mSTN depends on the tissue changes along the entirety of surgical trajectories affecting both STN and its adjacent structures.

Dedicated Linear Accelerator Radiosurgery for Classic Trigeminal Neuralgia: A Single-Center Experience with Long-Term Follow-Up.

BACKGROUND: During the past decades, stereotactic radiosurgery, and Gamma Knife in particular, has proved its safety and efficacy for drug-resistant classic trigeminal neuralgia. However, few large series exist using linear accelerator (LINAC) reporting long-term follow-up. METHODS: Between 2006 and 2015, 301 patients were treated by LINAC at our institution. The prescribed radiation dose was 90 Gy at the far anterior target. Clinical response was defined using the Barrow Neurological Institute scale. We considered grades I and IIIa as a successful response. Mean duration of follow-up was 54.6 months (range, 12-132 months). RESULTS: Two hundred and seventy-three patients (90.7%) were initially pain free, and 28 patients (9.3%) were unchanged. The actuarial probabilities of maintaining pain relief with or without medication (Barrow Neurological Institute grade I and IIIa) at 0.5, 1, 2, 4, 5, and 10 years were 88.7%, 85.0%, 76.1%, 68.8%, 65.8%, and 48.1%, respectively. Hypesthesia was present in only 26.2% of patients (very bothersome, 0.3%). No anesthesia dolorosa was reported. The actuarial probabilities of maintaining pain relief without further surgery at 0.5, 1, 2, 4, and 5 years were 99.3%, 98.3%, 95.8%, 91.0%, and 89.7%, respectively. Among all treated patients, 86.5% were satisfied by the procedure and would undergo stereotactic radiosurgery again. CONCLUSIONS: Stereotactic radiosurgery with dedicated LINAC is associated with high rates of long-term pain relief, with minimal invasiveness and rare complications. LINAC is a possible therapeutic alternative for drug-resistant trigeminal neuralgia and could be proposed to selected patients as the first intention therapy, among other surgical solutions.

Discordance between measured postural instability and absence of clinical symptoms in Parkinson's disease patients in the early stages of the disease.

We compared postural performances in early stage Parkinson's disease (PD) patients and healthy subjects, and to determine if PD patients have infraclinical postural instability. Nine PD patients and 18 age- and sex-matched control subjects were recorded with open eyes (OE) and closed eyes (CE) using a force platform in static and dynamic conditions with a mobile platform allowing antero posterior and medio lateral oscillations. Oscillations of the mobile platform and balance strategy were quantified using both a force platform and the Vicon system. Under static conditions with both OE and CE, PD patients had a larger center foot pressure sway area than the control subjects (P = 0.007 and P = 0.04, respectively). Under dynamic conditions, the PD patients' sway area was greater than that of the control subjects in the CE antero posterior position (P = 0.04). Oscillations of the mobile platform were not different between the two groups. Lastly, all subjects used an ankle strategy, but PD patients had larger head oscillations than the control subjects. Early stage PD patients have an infraclinical postural instability which is compensated when it is more difficult to maintain good balance, suggesting that the neurological mechanisms of balance are partially still operating at this stage of the disease.

Microsubthalamotomy: an immediate predictor of long-term subthalamic stimulation efficacy in Parkinson disease.

A microsubthalamotomy (mSTN) effect is commonly described after implantation that improves Parkinson's motor disability and is considered to be an obvious sign of good placement of the definitive electrode within the subthalamic nucleus (STN). There has been no formal study, however, demonstrating whether this mSTN effect can predict the long-term efficacy of STN stimulation in Parkinson Disease. The mSTN effect was defined by the percentage improvement of unified parkinson's disease rating scale (UPDRS III) baseline score assessed the third day morning following STN implantation, after at least a 12 hour withdrawal of dopaminergic treatment and before the programmable pulse generator was switched on. It was assessed in 30 consecutive patients with PD submitted for STN stimulation. Multiple stepwise regression analysis showed that mSTN effect (P = 0.005) and global mean intensity of stimulation (P = 0.004) were accurate independent predictors of the 6-month postoperative UPDRS III motor score improvement in the off-drug/on-stimulation condition.

Deep brain stimulation of the subthalamic nucleus in Parkinson's disease: usefulness of intraoperative radiological guidance. The Stereoplan.

BACKGROUND: In our stereotactic procedure, intraoperative radiological documentation of electrode localization is performed using the Stereoplan. The aim of the study was to evaluate its accuracy. PATIENTS AND METHODS: Data of 20 consecutive patients, treated for Parkinson's disease by implantation of deep brain stimulators into the subthalamic nucleus, were collected prospectively. During surgery, Stereoplan coordinates of the tip of the central macroelectrodes were compared with intended coordinates along the central trajectory at 4 levels: (1) 10 mm above the anatomical target, (2) in the target, (3) in the substantia nigra pars reticulata, and (4) at the depth of contact 1. Before the frame's removal, Stereoplan coordinates of the contacts of the definitive electrode were compared with postoperative MRI coordinates. The mean of the differences was calculated in the x-, y-, and z-axis. Clinical results at 6 months were recorded. RESULTS: The mean of the differences between Stereoplan coordinates and intended coordinates for the macroelectrodes was lower than 1 mm. A submillimeter difference was also found for the definitive contacts. At 6 months, the Unified Parkinson's Disease Rating Scale III score improved by 70.6% compared with the baseline score. Dyskinesia and motor fluctuations decreased by 85.7 and 87%, respectively (p < 0.0001). CONCLUSION: Stereoplan could be considered an accurate intraoperative radiological system which assures the correct position of the electrode in the anatomical target.