Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement.

OBJECTIVES: Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS: Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS: A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS: This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.

Novel Technologies in Interventional Pain Management.

This article comprehensively covers 3 major novel technologies and techniques in the management of chronic lower back pain. The first 2 procedures, percutaneous interspinous spacer implantation, and minimally invasive lumbar decompression have shown significant impact in the management of lumbar spinal stenosis (LSS), especially in patients who are not great surgical candidates or are otherwise not amenable to open spinal surgery. The wealth of data for these procedures continues to increase, with up to 4 to 6-year follow-up data recently being made available. A novel solution for vertebrogenic back pain is also discussed as follow-up data emphasizes the safety and sustainability of the procedure. This article also establishes a framework for evaluating novel technologies in interventional pain management.

Outcome of Percutaneous Lumbar Synovial Cyst Rupture in Patients with Lumbar Radiculopathy.

BACKGROUND: Lumbar synovial cysts can result from spondylosis of facet joints. These cysts can encroach on adjacent nerve roots, causing symptoms of radiculopathy. Currently the only definitive treatment for these symptoms is surgery, which may involve laminectomy or laminotomy, with or without spinal fusion. Surgery has been reported to successfully relieve radicular pain in 83.5% of patients by Zhenbo et al. Little information is available concerning the efficacy and outcome of percutaneous fluoroscopic synovial cyst rupture for treatment of facet joint synovial cysts. OBJECTIVE: The goal of this investigation was to assess the efficacy of fluoroscopically guided lumbar synovial cyst rupture, in particular for its relief of radicular symptoms and its potential to reduce the need for surgical intervention. STUDY DESIGN: Retrospective evaluation of a case series. SETTING: University hospital and urban public health care system. METHODS: With approval from the Institutional Review Board of Case Western Reserve University/ MetroHealth Medical Center, we reviewed the medical charts of patients with lumbar radiculopathy who underwent percutaneous lumbar synovial cyst rupture. The 30 patients in the cohort were treated by one pain specialist between 2006 and 2013. These patients were diagnosed with moderate to severe lower back pain, radiculopathy, and ranged in age from 42 to 80 years. Patients were followed up for a minimum of 6 months and up to 24 months. Pre- and post-procedure pain assessments were reviewed by clinical chart review. In addition post-procedure pain assessments and duration of pain relief were obtained with telephone interviews. Pain had been reported by the patients using a numeric rating scale of 0 - 10 (0 = no pain; 10 = worst possible pain). Charts were reviewed to determine if surgery was eventually performed to correct radicular symptoms. RESULTS: More than 6 months of pain relief was achieved in 14/30 patients (46%) and between one and 6 months of pain relief was achieved in 7/30 patients (23.3%). Nine patients (30.0%) had recurrence of the synovial cyst requiring repeat rupture and 6 patients (20.0%) required surgical intervention for cyst removal. A Wilcoxon signed-rank test demonstrated that the difference in numeric pain rating scale scores before and after the procedure was statistically significant (P < 0.0001). The average pain reduction was 71.2%. No complications were reported. LIMITATIONS: The results are limited by the retrospective nature of the data collection and the lack of detailed information regarding patients' functional improvement. CONCLUSIONS: Rupture of percutaneous lumbar synovial cysts in patients with lumbar radiculopathy was associated with immediate relief of radicular symptoms. In 80% of the patients, synovial cyst rupture eliminated the need for surgical interventions over the measured term. This minimally invasive procedure helps relieve pain in a subset of a patient population associated with these characteristics and is useful for management of this condition. Cyst expansion and failure to rupture with possible neuronal compression are the potential complications of this procedure. This complication did not occur in the study population. KEY WORDS: Fluoroscopically guided lumbar synovial cyst rupture, lumbar synovial cyst, lumbar zygapophyseal joint cyst, nonsurgical intervention, radiculopathy, spondylosis.

Cervical Transforaminal Epidural Steroid Injections: Diagnostic and Therapeutic Value.

BACKGROUND: Cervical transforaminal epidural steroid injections (CTFESIs) may help decrease pain and restore function in patients with cervical radiculopathy. Evidence of the injections' effectiveness, however, remains controversial, and multiple case reports have identified potential complications. Such reports have led to diminished interest in including the procedure in patient care algorithms. OBJECTIVES: Our retrospective analysis aims to evaluate the CTFESI-associated pain relief and possible decreased need for spine surgery, along with its potential predictive role in determining cervical surgical outcomes. Finally, our study intends to estimate associated complications. METHODS: A pain management database registry was used to identify patients who were referred by spine surgeons for diagnostic CTFESIs in preparation for possible surgery between January 2001 and December 2009. Outcomes were defined as the incidence of cervical surgery after diagnostic injection and the associated pain relief. A Poisson distribution was used to obtain a 95% confidence interval for the incidence of complications. RESULTS: Sixty-four patients met the inclusion and exclusion criteria. After diagnostic CTFESIs, 45 (70.3%) of the observed 64 patients did not require cervical spine surgery whereas 19 (29.7%) still did. The mean pain reduction was 4.4 units on the numeric rating scale, with no observed complications. CONCLUSIONS: This retrospective analysis further demonstrates the safety, diagnostic value, and possible therapeutic role of CTFESIs. A larger, controlled, randomized study is needed to assess definitively the procedure's efficacy and safety.

Chronic intermittent hypoxia is independently associated with reduced postoperative opioid consumption in bariatric patients suffering from sleep-disordered breathing.

BACKGROUND: Evidence suggests that recurrent nocturnal hypoxemia may affect pain response and/or the sensitivity to opioid analgesia. We tested the hypothesis that nocturnal hypoxemia, quantified by sleep time spent at an arterial saturation (SaO2) < 90% and minimum nocturnal SaO2 on polysomnography, are associated with decreased pain and reduced opioid consumption during the initial 72 postoperative hours in patients having laparoscopic bariatric surgery. METHODS: With Institutional Review Board approval, we examined the records of all patients who underwent laparoscopic bariatric surgery between 2004 and 2010 and had an available nocturnal polysomnography study. We assessed the relationships between the time-weighted average of pain score and total opioid consumption during the initial 72 postoperative hours, and: (a) the percentage of total sleep time spent at SaO2 < 90%, (b) the minimum nocturnal SaO2, and (c) the number of apnea/hypopnea episodes per hour of sleep. We used multivariable regression models to adjust for both clinical and sleep-related confounders. RESULTS: Two hundred eighteen patients were included in the analysis. Percentage of total sleep time spent at SaO2 < 90% was inversely associated with total postoperative opioid consumption; a 5-%- absolute increase in the former would relatively decrease median opioid consumption by 16% (98.75% CI: 2% to 28%, P = 0.006). However, the percentage of total sleep time spent at SaO2 < 90% was not associated with pain. The minimum nocturnal SaO2 was associated neither with total postoperative opioid consumption nor with pain. In addition, neither pain nor total opioid consumption was significantly associated with the number of apnea/hypopnea episodes per hour of sleep. CONCLUSIONS: Preoperative nocturnal intermittent hypoxia may enhance sensitivity to opioids.

Double-Opposing Z-Palatoplasty for Secondary Surgical Management of Velopharyngeal Incompetence in the Absence of a Primary Furlow Palatoplasty.

OBJECTIVE: The present study was performed to identify factors that lead to a favorable outcome of postpalatoplasty velopharyngeal incompetence using the double-opposing Z-palatoplasty. DESIGN: A retrospective analysis was performed on 23 consecutive nonsyndromic patients who underwent secondary surgical management of velopharyngeal incompetence using a double-opposing Z-palatoplasty technique following primary, non-Furlow palatoplasty for overt cleft palate. MAIN OUTCOME MEASURES: All subjects were evaluated preoperatively using a perceptual speech assessment scale, nasendoscopy, and videofluoroscopy. Inclusion criteria consisted of a velopharyngeal gap of 9 mm or less on phonation. Patients were followed with perceptual speech assessment for at least 1 year following secondary surgery. RESULTS: The perceptual speech assessment score for all patients decreased from 6.48 ± 2.26 (mean ± standard deviation; range, 3 to 11) to 1.90 ± 1.51 (range, 0 to 6) at 6 months or more postoperatively (P < .0001). Of the 21 patients with follow-up data 1 year or more post-op, 16 (76%) achieved velopharyngeal competence and five (24%) had borderline competence. Preoperative assessment factors associated with compromised outcome included a large velopharyngeal gap of 7 to 9 mm, poor lateral wall motion of 40% or less, and an elevated perceptual speech assessment score. CONCLUSION: Double-opposing Z-palatoplasty is a surgical technique that can be used successfully to correct velopharyngeal incompetence in selected secondary palatoplasty patients. This technique permits correction of velopharyngeal incompetence and restoration of the velopharyngeal mechanism irrespective of prior intravelar veloplasty and without accompanying loss in the nasal airway. Preoperative assessment can better identify those patients who are less likely to achieve velopharyngeal competence following double-opposing Z-palatoplasty alone.

Relationship between chronic intermittent hypoxia and intraoperative mean arterial pressure in obstructive sleep apnea patients having laparoscopic bariatric surgery.

BACKGROUND: Recurrent nocturnal hypoxemia in obstructive sleep apnea enhances sympathetic function, decreases baroreceptor sensitivity, and weakens peripheral vascular responses to adrenergic signals. The authors hypothesized that the percentage of total sleep time spent at oxyhemoglobin saturation (SaO2) less than 90% and minimum nocturnal SaO2 on preoperative polysomnography are associated with decreased intraoperative mean arterial pressure. METHODS: The authors examined the records of all patients who had laparoscopic bariatric surgery at Cleveland Clinic between 2005 and 2009 and an available polysomnography study. The authors assessed the relationships between the percentage of total sleep time spent at SaO2 less than 90% and minimum nocturnal SaO2, and the time-weighted average of mean arterial pressure. The authors used multivariable regression models to adjust for prespecified clinical confounders. RESULTS: Two hundred eighty-one patients were included in the analysis. The average change in the time-weighted average of mean arterial pressure was -0.02 (97.5% CI, -0.08, 0.04) mmHg for each 1% absolute increase in the percentage of sleep time spent at SaO2 less than 90% (P = 0.50). The average change was -0.13 (97.5% CI, -0.27, 0.01) mmHg, for each 1% absolute decrease in the minimum SaO2 (P = 0.04 > significance criterion of 0.025, Bonferroni correction). An unplanned analysis estimated 1% absolute decrease in minimum SaO2 was associated with -0.22 (98.75% CI, -0.39, -0.04) mmHg, change in mean arterial pressure (P = 0.002) in the time period between endotracheal intubation and trocar insertion. CONCLUSION: Recurrent nocturnal hypoxemia in obstructive sleep apnea is not a risk marker for intraoperative hypotension.

An evaluation of a zero-heat-flux cutaneous thermometer in cardiac surgical patients.

BACKGROUND: Although core temperature can be measured invasively, there are currently no widely available, reliable, noninvasive thermometers for its measurement. We thus compared a prototype zero-heat-flux thermometer with simultaneous measurements from a pulmonary artery catheter. Specifically, we tested the hypothesis that zero-heat-flux temperatures are sufficiently accurate for routine clinical use. METHODS: Core temperature was measured from the thermistor of a standard pulmonary artery catheter and with a prototype zero-heat-flux deep-tissue thermometer in 105 patients having nonemergent cardiac surgery. Zero-heat-flux probes were positioned on the lateral forehead and lateral neck. Skin surface temperature probes were attached to the forehead just adjacent to the zero-heat-flux probe. Temperatures were recorded at 1-minute intervals, excluding the period of cardiopulmonary bypass, and for the first 4 postoperative hours. Zero-heat-flux and pulmonary artery temperatures were compared with bias analysis; differences exceeding 0.5°C were considered to be potentially clinically important. RESULTS: The mean duration in the operating room was 279 ± 75 minutes, and the mean cross-clamp time was 118 ± 50 minutes. All subjects were monitored for an additional 4 hours in the intensive care unit. The average overall difference between forehead zero-heat-flux and pulmonary artery temperatures (i.e., forehead minus pulmonary artery) was -0.23°C (95% limits of agreement of ±0.82); 78% of the differences were ≤0.5°C. The average intraoperative temperature difference was -0.08°C (95% limits of agreement of ±0.88); 84% of the differences were ≤0.5°C. The average postoperative difference was -0.32°C (95% limits of agreement of ±0.75); 84% of the differences were ≤0.5°C. Bias and precision values for neck site were similar to the forehead values. Uncorrected forehead skin temperature showed an increasing negative bias as core temperature decreased. CONCLUSIONS: Core temperature can be noninvasively measured using the zero-heat-flux method. Bias was small, but precision was slightly worse than our designated 0.5°C limits compared with measurements from a pulmonary artery catheter.

The frequency of surgical maneuvers during open rhinoplasty.

BACKGROUND: The improved exposure afforded by the external rhinoplasty approach has allowed for more precise surgical maneuvers and makes more consistent results possible. This study examines the frequency and array of surgical maneuvers during primary aesthetic rhinoplasty in a single surgeon's practice. METHODS: A retrospective review of 100 consecutive primary external cosmetic rhinoplasty patients with a minimum follow-up of approximately 1 year was conducted. Surgical maneuvers were reviewed and tabulated. Special attention was devoted to the number of cartilage grafts and suturing techniques used. Operative times and incidence of revision surgery were investigated. RESULTS: The mean duration of surgery was 1 hour 50 minutes. The majority of rhinoplasties involved concomitant septal surgery for deviation and airway occlusion or cartilage harvesting. Osteotomies were performed on over 95 percent of patients. The dorsal hump was removed on 84 percent of the patients. The most common grafts used included alar rim grafts in 88 percent, subdomal grafts in 77 percent, and spreader grafts in 74 percent. Sutures used to contour the cartilage included transdomal sutures in 62 percent, followed by footplate approximation sutures in 32 percent. Seventy-seven patients had interdomal sutures placed as a component of subdomal grafting. CONCLUSIONS: The senior surgeon has found that common incorporation of certain maneuvers offers more consistent, aesthetically pleasing, and superior functional outcomes. Careful review of this article may guide the reader to consider the more frequent use of some maneuvers or reduction of other maneuvers to reflect that of a streamlined and higher-volume rhinoplasty practice.

Nonviral transfection of mouse calvarial organ in vitro using Accell-modified siRNA.

BACKGROUND: Understanding the biology of cranial suture fusion and the precise role of involved molecules implicated in the process will help to identify key factors involved in regulation of suture fusion. Modulation of these key factors may serve as a tissue-engineering technique to replace the traditional surgical procedures for the correction of premature suture fusion. Modulation of gene expression by RNA interference is a widely used technique with high potential. Because there is no available report of calvarial organ transfection in vitro, the authors studied the development of a successful nonviral delivery technique of small inhibitory RNA (siRNA) to an in vitro calvarial organ culture system. METHODS: In this study, 19-day-old male CD1 mice were euthanized and parallel craniotomies made through the parietal and frontal calvaria, 2 mm to either side of the sagittal suture, with care taken to preserve the underlying dura mater. Organs grown in vitro in a defined medium were transfected with transforming growth factor-beta1-specific Accell-modified siRNA followed by RNA isolation and quantitative polymerase chain reaction analysis. RESULTS: Transfection of a calvarial organ with transforming growth factor-beta1-specific Accell-modified siRNA effectively knocks down the mRNA level. CONCLUSIONS: Observations from this study indicate that in an in vitro calvarial organ culture system, a specific, efficient, and durable RNA interference activity can be achieved when Accell-modified siRNA is used. In addition to bypassing the need for toxic lipid carriers, the modifications introduced in Accell-modified siRNAs make it more stable and less off-target. This technique can potentially be used for in vivo studies once the initial effect of gene-specific siRNA on in vitro suture fusion has been determined.

Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study.

BACKGROUND: The Tranquilli-Leali and Atasoy volar V-Y advancement flaps are considered workhorse flaps in the reconstruction of fingertip amputations. However, their description in the literature in terms of surgical dissection and blood supply is often indistinct. This study describes the differences between the two flaps and highlights their unique blood supply based on a thorough cadaveric study and review of the literature. METHODS: Using 16 fresh cadaveric fingers, eight Tranquilli-Leali and eight Atasoy volar V-Y advancement flaps were dissected, mapping the arterial blood supply using an injectable blue resin. In addition, a thorough literature search on the subject was done. RESULTS: In all eight fingertips dissected as decribed by Tranquilli-Leali, the flap was supplied by the anastomotic connections between the terminal branches of the palmar digital arteries and dorsal nail-bed arcades via the fibro-osseous hiatus. In contrast, in all eight fingertips which were dissected as described by Atasoy, the flaps were perfused through the terminal branches of the palmar digital arteries. CONCLUSIONS: The Tranquilli-Leali and Atasoy volar V-Y advancement flaps, used to reconstruct fingertip amputations, are distinct from one another in several ways. The most obvious difference is their technique of flap dissection, which, in turn, dictates a unique blood supply. Through careful dissection and a review of the literature, this anatomical study has brought to light the specific vascular supply to each flap that was evaluated.

Serum levels of TNF-alpha, TNF-alphaRI, TNF-alphaRII and IL-12 in treated rheumatoid arthritis patients.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic multisystem autoimmune disease common in all races and ethnics. Cytokines and cytokines receptors play an important role in RA pathogenesis and clinical presentation. OBJECTIVE: To investigate the serum levels of TNF-alpha, TNF-alpha RI, TNF-alpha RII and IL-12 in RA patients and healthy control group. METHODS: In this study 43 patients fulfilling the revised criteria of American College of Rheumatology (ACR) for RA and 13 healthy cases as a control group were selected for TNF-alpha, TNF-alphaRI, TNF-alphaRII and IL-12 serum level analysis. The patients' age was 42.2 +/- 22 and the age of healthy group was 40.1 +/- 19.2 years (p=0.1). The patients had an active disease with at least six swollen and ten tender joints. Minimum ESR was 28 mm at first hours of the morning. Early morning stiffness in patients lasted longer than 45 minutes. RESULTS: Our study showed that IL-12 serum level of the patients (91.69 +/- 43.07 rhog/ml) and control (61.79 +/- 40.08 rhog/ml) group was significantly different (p<0.001). The serum level of TNF-alphaRI was 2.36 +/- 0.77 ng/ml in the patient and 1.73 +/- 0.37 ng/ml in the control group (p<0.01). TNF-alphaRII serum concentration in patients was 8.89 +/- 2.3 ng/ml, while that of control group was 7.06+/-1.30 ng/ml (p=0.03). The serum level of TNF-alpha in patients was 32.90 +/- 19.27 rhog/ml and that of the control group was 24.27+/- 8.28 rhog/ml (p=0.08) with no significant difference between the two. CONCLUSIONS: It is concluded that IL-12, TNF-alphaRI and TNF- alphaRII serum concentrations are more important and better predictive factors than TNF-alpha in RA course and in the active forms of the disease.

Factors contributing to the facial aging of identical twins.

BACKGROUND: The purpose of this study was to identify the environmental factors that contribute to facial aging in identical twins. METHODS: During the Twins Day Festival in Twinsburg, Ohio, 186 pairs of identical twins completed a comprehensive questionnaire, and digital images were obtained. A panel reviewed the images independently and recorded the differences in the perceived twins' ages and their facial features. The perceived age differences were then correlated with multiple factors. RESULTS: Four-point higher body mass index was associated with an older appearance in twins younger than age 40 but resulted in a younger appearance after age 40 (p = 0.0001). Eight-point higher body mass index was associated with an older appearance in twins younger than age 55 but was associated with a younger appearance after age 55 (p = 0.0001). The longer the twins smoked, the older they appeared (p < 0.0001). Increased sun exposure was associated with an older appearance and accelerated with age (p = 0.015), as was a history of outdoor activities and lack of sunscreen use. Twins who used hormone replacement had a younger appearance (p = 0.002). Facial rhytids were more evident in twins with a history of skin cancer (p = 0.05) and in those who smoked (p = 0.005). Dark and patchy skin discoloration was less prevalent in twins with a higher body mass index (p = 0.01) and more common in twins with a history of smoking (p = 0.005) and those with sun exposure (p = 0.005). Hair quantity was better with a higher body mass index (p = 0.01) although worse with a history of skin cancer (p = 0.005) and better with the use of hormones (p = 0.05). CONCLUSION: This study offers strong statistical evidence to support the role of some of the known factors that govern facial aging.

Effect of different suture materials on cartilage reshaping.

BACKGROUND: Suturing techniques are one of the most commonly used means to reshape the nasal cartilage; however, no data exist regarding the optimal suture material and its long-term effect. OBJECTIVES: The aim of the present study was to determine whether any absorbable materials will provide the same long-lasting effect on cartilage reshaping as permanent materials. METHODS: Thirty-six New Zealand white rabbits were divided into three groups of 12. A 3 mm x 4 mm cartilaginous fold was created on a 5 mm x 10 mm in situ strip of cartilage on the posteromedial surface of each ear with different suture materials to simulate transdomal sutures. Nylon was used as a control suture material on the right ear of every rabbit, while plain catgut, monocryl, or polydioxanone (PDS) was used on the left ear, depending on the study group. At the end of 3 months, the folds were harvested and their dimensions and histology were compared. RESULTS: The cartilaginous folds were graded on a scale of 1 to 4 based on the final fold height measurement. The mean grades were 3.51 for nylon, 3.50 for PDS, 2.08 for monocryl, and 1.83 for plain catgut. Nylon provided a significantly better fold grade compared to monocryl and plain catgut (P < .05 for both groups), whereas there was no difference between the fold created with nylon and PDS (P > .05). Among the pathologic factors examined, only the amount of adipose tissue between the fold correlates with a higher fold grade (P < .05). CONCLUSIONS: Cartilaginous folds created using PDS are comparable to those created using nylon and are significantly better than monocryl and plain catgut materials. On this animal model, it appears that permanent suture material is not required to maintain a long lasting cartilaginous fold as long as the suture material holds the fold in shape for a certain period of time.

Review of pediatric migraine headaches refractory to medical management.

OBJECTIVE: The surgical treatment of migraine headache is a recent innovation that has broadened the potential patient population who may benefit from craniofacial surgical techniques to millions of affected adults. However, the population at risk in the pediatric age group has not been clearly established. The present retrospective review was performed to provide demographic information of the adolescent migraine in a major children's hospital. This information is essential before considering surgical treatment of migraine in this age group. METHODS: Five hundred eighty-eight charts of patients aged 12 to 18 years who presented to the pediatric neurology clinic with headache in 2006 were retrospectively reviewed to evaluate for the diagnosis of migraine. Data collected included headache location, frequency, duration, intensity, associated migraine symptoms, and headache precipitants, as well as the response to medical treatment. RESULTS: Two hundred ten (36%) of 588 patients had the diagnosis of migraine headache, and 51 patients (24%) were considered refractory to the medical treatment offered. In 101 of the 210 migraine patients, anatomic location of the headaches could be identified. Thirty-nine children (19%) with refractory migraines (mean age, 14.7 years [SD, 0.3 years]) reported definitive migraine triggers. CONCLUSIONS: A significant percentage of pediatric patients with migraine headache remain refractory to medical treatment. At present, there is no good treatment regimen for migraine headaches in the pediatric population. We believe that surgical treatment of migraine headaches may be a realistic option for these patients.

Von Willebrand disease: screening, diagnosis, and management.

Von Willebrand disease (vWD), a hemorrhagic disorder mimicking a defect in platelet function, is the most commonly inherited coagulopathy, resulting in a deficiency that may prolong bleeding time and increase risk for major bleeding complications during surgery. Von Willebrand factor (vWF) serves a dual role in hemostasis: mediating the initial platelet adhesion to damaged endothelium at the site of vessel injury and stabilizing coagulation factor VIII, an important cofactor in the generation of a fibrin clot. Although quantitative or qualitative defects in vWF protein can manifest as a mild to severe bleeding disorder, many cases of vWD remain subclinical, barring major invasive stimuli, and undetected by either patient or clinician. Nevertheless, the frequency of this coagulation disorder would almost ensure that every plastic surgeon will encounter affected patients, making a thorough understanding of vWD and its management absolutely necessary. Surprisingly, there is little information concerning vWD in the plastic surgery literature. Our goal is to familiarize the plastic surgeon with vWD, including physiology, diagnostic criteria, classification, and molecular basis for multiple vWD variants, and diagnosis and management.