High-Value Epilepsy Care in the United States: Predictors of Increased Costs and Complications from the National Inpatient Sample Database 2016-2019.

BACKGROUND: For patients with medically refractory epilepsy, newer minimally invasive techniques such as laser interstitial thermal therapy (LITT) have been developed in recent years. This study aims to characterize trends in the utilization of surgical resection versus LITT to treat medically refractory epilepsy, characterize complications, and understand the cost of this innovative technique to the public. METHODS: The National Inpatient Sample database was queried from 2016 to 2019 for all patients admitted with a diagnosis of medically refractory epilepsy. Patient demographics, hospital length of stay, complications, and costs were tabulated for all patients who underwent LITT or surgical resection within these cohorts. RESULTS: A total of 6019 patients were included, 223 underwent LITT procedures, while 5796 underwent resection. Significant predictors of increased patient charges for both cohorts included diabetes (odds ratio: 1.7, confidence interval [CI]: 1.44-2.19), infection (odds ratio: 5.12, CI 2.73-9.58), and hemorrhage (odds ratio: 2.95, CI 2.04-4.12). Procedures performed at nonteaching hospitals had 1.54 greater odds (CI 1.02-2.33) of resulting in a complication compared to teaching hospitals. Insurance status did significantly differ (P = 0.001) between those receiving LITT (23.3% Medicare; 25.6% Medicaid; 44.4% private insurance; 6.7 Other) and those undergoing resection (35.3% Medicare; 22.5% Medicaid; 34.7% private Insurance; 7.5% other). When adjusting for patient demographics, LITT patients had shorter length of stay (2.3 vs. 8.9 days, P < 0.001), lower complication rate (1.9% vs. 3.1%, P = 0.385), and lower mean hospital ($139,412.79 vs. $233,120.99, P < 0.001) and patient ($55,394.34 vs. $37,756.66, P < 0.001) costs. CONCLUSIONS: The present study highlights LITT's advantages through its association with lower costs and shorter length of stay. The present study also highlights the associated predictors of LITT versus resection, such as that most LITT cases happen at academic centers for patients with private insurance. As the adoption of LITT continues, more data will become available to further understand these issues.

Staged Open Cranial Surgery for Primary Intra-axial Neoplasms: A Systematic Review.

BACKGROUND: Staged surgery for skull base lesions has been utilized to facilitate maximal safe resection and optimize outcomes while minimizing morbidity and complications. Conversely, staged surgery for primary intraparenchymal neoplasms is less commonly performed and has not been reported as extensively within the literature. As such, we performed a systematic review to examine the unique surgical indications for staging, timing between stages, specific surgical approaches utilized, and postoperative complications of staged surgery for primary intra-axial neoplasms. METHODS: A literature search was conducted in August 2021 using PubMed, Web of Science, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. Titles and abstracts were evaluated independently by 2 authors, after which articles were selected for final analysis based on application of strict inclusion criteria during full text screen. Each included article was then qualitatively assessed and relevant variables-including operative approaches, timing, and outcomes-were extracted for synthesis. RESULTS: Of 115 results, 7 articles were included for final analysis and consisted of 17 pediatric and 4 adult patients. Staged approaches were more commonly utilized in the pediatric patient population for resection of astrocytoma and glioma. Pediatric patients had a timing of surgeries ranging from 5-10 days between operations, compared with 18 days to 4 months in adult patients. Complications in pediatric patients were most commonly hemiparesis, hydrocephalus, cranial nerve VI and VII palsies, truncal ataxia, and cerebellar mutism, while complications in adult patients included language and abstract thinking deficits, respiratory failure, and motor weakness. CONCLUSIONS: This study reports the first comprehensive review of staged surgical procedures for primary, intra-axial cranial neoplasms. There exists a large degree of heterogeneity in complications resulting from staged surgeries for intra-axial neoplasms, which are similar to complications associated with single-stage surgery for intraparenchymal lesions as well as multi-stage surgeries for skull base lesions.

Advances in Technical Aspects of Deep Brain Stimulation Surgery.

BACKGROUND: Deep brain stimulation has become an established technology for the treatment of patients with a wide variety of conditions, including movement disorders, psychiatric disorders, epilepsy, and pain. Surgery for implantation of DBS devices has enhanced our understanding of human physiology, which in turn has led to advances in DBS technology. Our group has previously published on these advances, proposed future developments, and examined evolving indications for DBS. SUMMARY: The crucial roles of structural MR imaging pre-, intra-, and post-DBS procedure in target visualization and confirmation of targeting are described, with discussion of new MR sequences and higher field strength MRI enabling direct visualization of brain targets. The incorporation of functional and connectivity imaging in procedural workup and their contribution to anatomical modelling is reviewed. Various tools for targeting and implanting electrodes, including frame-based, frameless, and robot-assisted, are surveyed, and their pros and cons are described. Updates on brain atlases and various software used for planning target coordinates and trajectories are presented. The pros and cons of asleep versus awake surgery are discussed. The role and value of microelectrode recording and local field potentials are described, as well as the role of intraoperative stimulation. Technical aspects of novel electrode designs and implantable pulse generators are presented and compared.

A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation.

OBJECTIVE: The human myotome is fundamental to the diagnosis and treatment of neurological disorders. However, this map was largely constructed decades ago, and its breadth, variability, and reliability remain poorly described, limiting its practical use. METHODS: The authors used a novel method to reconstruct the myotome map in patients (n = 42) undergoing placement of dorsal root ganglion electrodes for the treatment of chronic pain. They electrically stimulated nerve roots (n = 79) in the intervertebral foramina at T12-S1 and measured triggered electromyography responses. RESULTS: L4 and L5 stimulation resulted in quadriceps muscle (62% and 33% of stimulations, respectively) and tibialis anterior (TA) muscle (25% and 67%, respectively) activation, while S1 stimulation resulted in gastrocnemius muscle activation (46%). However, L5 and S1 both resulted in abductor hallucis (AH) muscle activation (17% and 31%), L5 stimulation resulted in gastrocnemius muscle stimulation (42%), and S1 stimulation in TA muscle activation (38%). The authors also mapped the breadth of the myotome in individual patients, finding coactivation of adductor and quadriceps, quadriceps and TA, and TA and gastrocnemius muscles under L3, L4, and both L5 and S1 stimulation, respectively. While the AH muscle was commonly activated by S1 stimulation, this rarely occurred together with TA or gastrocnemius muscle activation. Other less common coactivations were also observed throughout T12-S1 stimulation. CONCLUSIONS: The muscular innervation of the lumbosacral nerve roots varies significantly from the classic myotome map and between patients. Furthermore, in individual patients, each nerve root may innervate a broader range of muscles than is commonly assumed. This finding is important to prevent misdiagnosis of radicular pathologies.

High Frequency 10 kHz Spinal Cord Stimulation as a First Line Programming Option for Patients With Chronic Pain: A Retrospective Study and Review of the Current Evidence.

Introduction Neuromodulation is an evolving and increasingly popular therapy for chronic pain management. Recent data suggest that novel waveforms have demonstrated greater benefit over traditional spinal cord stimulation (SCS). The authors conducted a retrospective review of patients undergoing high-frequency 10 kHz SCS at a single tertiary medical center for the purpose of contributing further evidence to this growing body of data. The literature of high-frequency SCS published to date was also reviewed. Methods A retrospective chart review was performed for patients with chronic pain syndrome, including failed back surgery syndrome and sciatica alone, who underwent high-frequency SCS at 10 kHz. This data was analyzed using R software (R Foundation for Statistical Computing, Vienna, Austria) for statistical analysis. The PubMed database was searched for relevant articles using the search terms "high frequency," "10 kHz," and "spinal cord stimulation." All relevant studies conducted to date were included in this literature review. Results Twenty-one patients had complete follow-up data and were included in this study. Of the 21 patients, 85.7% subjectively reported post-operative pain relief while 71.4% of the total patients reported pain relief by ≥ 50%. There was a statistically significant decrease in mean VAS scores from pre-operative to 12-months post-operative (8.52 vs 4.37, p < 0.001). Additionally, 76.5% of patients subjectively reported improvements in sleep and activities of daily living. Recent studies indicate that high-frequency SCS appears to be a viable option for delivering quality pain relief in patients for chronic regional pain syndrome, failed back surgery syndrome, sciatica, and also pain in the upper cervical region of the spine. Conclusion This article provides evidence both with the authors' own institutional data and from the currently published literature for the efficacy of using high-frequency SCS at 10 kHz as a first-line programming option for patients undergoing SCS.

Complications associated with deep brain stimulation for Parkinson's disease: a MAUDE study.

INTRODUCTION: Deep brain stimulation (DBS) is a common surgical option for the treatment of medically refractory Parkinson's disease (PD). Manufacturer and User Facility Device Experience (MAUDE), a United States Food and Drug Administration (FDA)-compiled database of adverse event reports related to medical devices, is a public resource that can provide insight into the relative frequency of complications and patient complaints. MATERIALS AND METHODS: We accessed the MAUDE database and queried for adverse reports for deep brain stimulators implanted for PD from January 1, 2009 to December 31, 2018. Complaints were classified into device malfunction, patient non-compliance, patient complaint, surgically managed complications (i.e. complications that are corrected via surgery), and death. Patient complaints were further stratified into ineffective stimulation, shock, overstimulation, battery-related problems, or pain at the pulse generator site. Surgically managed complications were classified as intraoperative complications, impedance, migration, erosion, infection, lead fracture, and lead disconnection. Each event could receive multiple classifications and subclassifications. RESULTS: A total of 4,189 adverse event reports was obtained. These encompassed 2,805 patient complaints. Within this group, 797 (28%) events were classified as ineffective stimulation. There were 1,382 surgically managed complications, 104 (8%) of which were intraoperative complications, 757 (55%) documented impedance issues, 381 (28%) infections, and 413 (30%) lead-related issues. There were 53 documented deaths. CONCLUSIONS: The MAUDE database has potential use as a real time monitor for elucidating the relative occurrence of complications associated with deep brain stimulation. It also allows for the analysis of device-related complications in specific patient populations. Although the database is useful in this endeavor, it requires improvements particularly in the standardization of reporting adverse events.

Surgical Outcomes After Single-Level Endoscopic Transforaminal Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis.

Background and objective Novel surgical advancements have introduced endoscopic operative techniques for low back surgery, including transforaminal lumbar interbody fusion (TLIF), which theoretically allows for improved decompression with minimal invasiveness. In addition, endoscopically performed TLIF has allowed for the use of local anesthesia as an alternative method to general anesthesia for patients. We aimed to evaluate the clinical outcomes in patients undergoing endoscopic TLIF and also compare the outcomes in patients undergoing general versus local anesthesia. Methods The databases of PubMed, Medline, Embase, and the Cochrane Library were queried for all studies involving patients undergoing endoscopic TLIF. After the extraction of the data and assessment of study quality via the Newcastle-Ottawa Scale, statistical analysis was performed with the R software (The R Foundation, Vienna, Austria) metafor package. The random-effects model was used as the data was largely heterogeneous (I2 >50%). Results In total, 15 studies involving a total of 441 patients were selected for the final quantitative meta-analysis. The overall mean difference between the postoperative visual analog scale (VAS) leg scores and preoperative VAS scores was 3.45 (95% CI: 4.93-1.97, p: <0.01). Postoperative VAS low back scores revealed a mean difference of 3.36 (95% CI: 5.09-1.63, p: <0.01). The overall mean difference of ODI scores was 4.58 (95% CI: 6.76-2.40, p: <0.01). Mean blood loss was 136.32 mL and the mean operative time was 149.15 minutes. The mean length of stay postoperatively was lower in the local anesthesia group compared to the general anesthesia group (1.40 vs 5.99 days respectively). There were no outcome variables of patients undergoing general anesthesia versus local anesthesia that showed statistically significant differences in this analysis due to the small amount of data published on patients undergoing endoscopic TLIF with local anesthesia. In addition, the failure of studies in reporting standard deviations as data parameters further limited the quantitative analysis. Conclusion Endoscopic TLIF appears to be a viable option for patients undergoing lumbar interbody fusion. Initial data reveal that endoscopic TLIF with local anesthesia may offer patients outcomes similar to those in patients undergoing endoscopic TLIF with general anesthesia, with lower operative times and length of stay.

Health literacy among neurosurgery and other surgical subspecialties: Readability of online patient materials found with Google.

OBJECTIVE: To both determine whether the most high-yield online patient materials for surgical specialties meet the 6th grade readability level recommended by the National Institutes of Health (NIH) and American Medical Association (AMA), and to discover differences in readability across specialties. We hypothesize average readability scores will exceed an 11th grade level. METHODS: The top five most common procedures for each of seven surgical specialties (neurological, orthopedic, plastic, general, thoracic, pediatric, and vascular) were searched using an incognito Google query to minimize location bias. The text from the top five patient-relevant links per procedure, excluding Wikipedia, journal articles, and videos, was extracted and inserted into Readability Studio Software for analysis. RESULTS: The combined average grade level of materials (± standard deviation) was: 10.47 ±â€¯2.51 Flesh-Kincaid Grade Level (FKGL), 11-12 New Dale-Chall (NDC), 10.09 ±â€¯1.97 Simple Measure of Gobbledygook (SMOG), 12 Fry Graph (FG). Thoracic, neurologic, vascular, plastic, and orthopedic were least readable (grade level 10+ by all metrics). CONCLUSIONS: High readability of procedure materials for patients is not unique to neurosurgery: all specialties exceeded the recommended 6th grade level by three or more grades. Online patient education materials related to surgical subspecialties must be written more comprehensibly.

Paediatric deep brain stimulation: ethical considerations in malignant Tourette syndrome.

Gilles de la Tourette syndrome (TS) is a childhood neuropsychiatric disorder characterised by the presence of motor and vocal tics. Patients with malignant TS experience severe disease sequelae; risking morbidity and mortality due to tics, self-harm, psychiatric comorbidities and suicide. By definition, those cases termed 'malignant' are refractory to all conventional psychiatric and pharmacological regimens. In these instances, deep brain stimulation (DBS) may be efficacious. Current 2015 guidelines recommend a 6-month period absent of suicidal ideation before DBS is offered to patients with TS. We therefore wondered whether it may be ethically justifiable to offer DBS to a minor with malignant TS. We begin with a discussion of non-maleficence and beneficence. New evidence suggests that suicide risk in young patients with TS has been underestimated. In turn, DBS may represent an invaluable opportunity for children with malignant TS to secure future safety, independence and fulfilment. Postponing treatment is associated with additional risks. Ultimately, we assert this unique risk-benefit calculus justifies offering DBS to paediatric patients with malignant TS. A multidisciplinary team of clinicians must determine whether DBS is in the best interest of their individual patients. We conclude with a suggestion for future TS-DBS guidelines regarding suicidal ideation. The importance of informed consent and assent is underscored.

Endoscopic Infraorbital Microdissection for Localized V2 Trigeminal Neuralgia.

Trigeminal neuralgia is a chronic and debilitating syndrome characterized by short paroxysms of lancinating facial pain. Patients may be medically managed; however, in cases of medically refractory trigeminal neuralgia, surgical management is often required. Our objective was to present and describe a technique for endoscopic microdissection of the infraorbital nerve, a peripheral method of management for refractory V2 trigeminal neuralgia in patients without evidence of neurovascular compression. The technique is designed to spare sensation in unaffected portions of the V2 distribution. We present 2 patients with medically refractory V2 trigeminal neuralgia localized to the lateral midface who underwent infraorbital microdissection. After first confirming that there was no neurovascular compression on imaging in these patients, we administered infraorbital bupivacaine injections to localize the symptomatic nerve. The nerve was then accessed via a 1.5-cm buccogingival incision, and the connective tissue sheath was incised. The nerve fascicles were bluntly separated, and the symptomatic branches were cauterized with fine-tipped monopolar cautery. Both patients reported complete resolution of their pain postoperatively and were pain free at last follow-up. They reported some hypoesthesia in the lateral face; however, they retained some sensation in the medial upper lip, midface, and nose. Infraorbital microdissection is a safe and effective technique for symptomatic management of V2 trigeminal neuralgia while sparing sensation in asymptomatic portions of the dermatome.

Minimally invasive trigeminal ablation in patients with refractory trigeminal neuralgia who are ineligible for intracranial intervention.

We describe the use of minimally invasive trigeminal ablation, an endoscopic ablative technique to treat trigeminal neuralgia in patients who are traditionally poor surgical candidates. We present 4 patients who presented with refractory unilateral trigeminal neuralgia. Three of the patients had previously failed stereotactic radiosurgery and three of them have multiple sclerosis. Due either to lack of neurovascular compression, minimally invasive trigeminal ablation was offered. Intraoperatively, an incision is made along the buccal mucosa or mid-brow and the tissue is endoscopically dissected in a plane towards the symptomatic nerve. Once isolated, the epineurium is partially ablated with thermocautery and the tissue surrounding the nerve is decompressed. All patients reported resolution of their pain post-operatively and were pain free at last follow up. Two patients had mild hypesthesia over the ablated nerve territory. Minimally invasive trigeminal ablation is a safe and effective technique for symptomatic control of trigeminal neuralgia. The efficacy, low risk, and relative ease of the procedure makes it ideal for use in patients who are refractory to medical management and have no neurovascular compression, are unable to tolerate traditional surgery or have failed other therapies.

The Educational Quality of Neurosurgical Resources on YouTube.

BACKGROUND: YouTube has rapidly become one of the most widely accessed educational platforms of our time. Over 1 billion hours of YouTube content are viewed every day, including neurosurgical videos. To date, there has never been a qualitative analysis of neurosurgical content on YouTube. METHODS: By evaluating the search interest of neurosurgical terms via Google Trends, we selected 8 search terms to assess on YouTube. For each term, we selected the top 20 videos, 10 when sorting by view count and 10 when sorting by relevance. Using the DISCERN criteria, we evaluated 131 unique YouTube videos to assess bias and overall educational quality. In addition, we categorized each video based on its intended utility and the credentials of the video's commentator. The number of views, average DISCERN scores, and bias scores were compared between search terms and between video categories. RESULTS: There were 131 unique and 29 duplicate videos. The videos received 143,538,363 combined views (1,104,141 average). The average video age was 4.6 years (range, 66 days to 12.5 years). The term "brain surgery" received the most total views (62,339,885), with an average DISCERN score of 1.65 overall and 2 for bias. The average DISCERN score was 2.02 overall and 2.39 for bias. There were 45 advertisements for either hospitals, physicians, or companies, totaling 18,052,873 views and averaging a DISCERN score of 2.04. CONCLUSIONS: YouTube is a frequently viewed but biased source for neurosurgical information. Advertisements are frequently disguised as educational material, and few videos provide references or sources for their information.

Risk Factors Associated with Lead Migration Requiring Revision in Dorsal Root Ganglion Stimulation.

BACKGROUND: Neuromodulation is an evolving therapy for chronic pain. Aiming to meet the limitations of traditional spinal cord stimulation, dorsal root ganglion (DRG) stimulation targets pain in a dermatomal distribution at the site of pain transmission. Despite these advantages, lead migration is a significant complication that hinders the long-term efficacy of DRG stimulation. This study aims to identify risk factors for lead migration requiring revision in DRG stimulation. METHODS: We performed a retrospective review of all subjects who had DRG stimulators implanted at T10-S2 by a single physician over a 2-year period. Their history was reviewed for the following: age, sex, diagnosis, lead placement, reported symptom relief, complications, and postoperative activity. RESULTS: In total, 19 cases of DRG stimulator implantation were identified. All patients reported pain relief, with 84.2% (16/19) describing >50% relief. In total, 31.6% of patients (6/19) developed lead migration and 15.8% of total implanted leads (9/57) migrated. Of the migrated leads, 4% (4/9) occurred at S1 and 33.3% (3/9) occurred at L4. The underlying etiology of lead migration was clear and preventable in 66.7% of patients (4/6). All patients who developed lead migration were women. CONCLUSIONS: Premature activity, hardware manipulation, and female sex appear to be associated with an increased risk for lead migration. Leads on the S1 and L4 locations may be more likely to migrate. Large trials are necessary to gain a more conclusive understanding of these risk factors for lead migration.

Minimally Invasive Trigeminal Ablation: Transoral Approach for Targeting V2.

BACKGROUND: Trigeminal neuralgia (TN) is a chronic orofacial pain syndrome, which manifests as severe pain in the distribution of any trigeminal nerve branch. Though traditionally responsive to anticonvulsant therapy, TN can become refractory to medications and require surgical intervention. CASE DESCRIPTION: We present a case of V2 TN that was treated with minimally invasive trigeminal ablation. The patient presented with a 6-year history of type 1 TN and had failed the maximum tolerated doses of carbamazepine and gabapentin. There was no evidence of vascular compression on neuroimaging. After the patient refused stereotactic radiosurgery, she was offered minimally invasive trigeminal ablation. At 5 months postoperatively the patient reported complete alleviation of pain with tolerable sensorineural numbness. CONCLUSIONS: The endoscopic approach allows for precise targeting of V2, which is ideal in patients undergoing targeted neuroablation for pain. This is the first documented case of a transoral endoscopic approach toward ablative V2 TN management.

Endoscopic Pericranial Flap Repair of Occipital-Frontal Electrode Erosion.

INTRODUCTION: Occipital-frontal nerve stimulation is an off-label therapy for treating chronic refractory migraine and orofacial pain. Though effective, patients experience a high rate of complications including lead migration and erosion through the overlying skin. CASE DESCRIPTION: We present a case of frontal electrode erosion that was revised via pericranial flap repair. The patient presented with multiple lead migrations, necessitating multiple revision surgeries with eventual frontal wound dehiscence. The choice was made to wrap the electrode in a pericranial flap to prevent recurrent lead migration. Two weeks postoperatively, the wound was well healed and the patient reported that the midline electrode was functioning properly. DISCUSSION: Pericranial flap revision confers little additional risk when compared with simple wound closure, and the surgeon can proceed without total electrode removal, additional incisions, or lead tunneling. The flap provides a highly vascular additional layer of stability to the electrode, reducing the likelihood of further lead exposure without compromising the efficacy of the device. These results suggest that endoscopic pericranial flap revision is a viable technique for the repair of occipital nerve stimulation lead erosions.

Novel Association Between Intrathecal Drug Administration and Arachnoiditis Ossificans.

BACKGROUND: We present a case of delayed progression of adhesive arachnoiditis to arachnoiditis ossificans (AO) in a patient being treated with a high-dose polypharmaceutical intrathecal regimen. CASE DESCRIPTION: The patient is a 39-year-old Caucasian male who was implanted with an intrathecal pump in 2006 to control severe low back pain and administered intrathecal pain medication for a period of 10 years. In 2016, he developed new-onset radicular pain and worsened sensation in his lower extremities. Computed tomography scan of the lumbar spine at that time demonstrated profound calcification of the arachnoid consistent with a diagnosis of AO. It was presumed that prolonged high-dose intrathecal medication precipitated this condition, and his intrathecal medications were titrated down with removal of the pump. CONCLUSIONS: It is unlikely that his condition occurred as a result of prior surgery, with the more likely cause being hyperplasia of the spinal arachnoid, leading to scarring and calcification, due to the high-dose intrathecal regimen. This case highlights the delayed progression from stable arachnoiditis to AO concurring with a regimen of high-dose intrathecal medications. Clinicians should closely monitor patients undergoing intrathecal drug administration, particularly at elevated doses, for indications of damage to the spinal arachnoid mater.

Potential Uses of Isolated Toxin Peptides in Neuropathic Pain Relief: A Literature Review.

Neuropathic pain is a subset of chronic pain that is caused by neurons that are damaged or firing aberrantly in the peripheral or central nervous systems. The treatment guidelines for neuropathic pain include antidepressants, calcium channel α2 delta ligands, topical therapy, and opioids as a second-line option. Pharmacotherapy has not been effective in the treatment of neuropathic pain except in the treatment of trigeminal neuralgia with carbamazepine. The inability to properly treat neuropathic pain causes frustration in both the patients and their treating physicians. Venoms, which are classically believed to be causes of pain and death, have peptide components that have been implicated in pain relief. Although some venoms are efficacious and have shown benefits in patients, their side-effect profile precludes their more widespread use. This review identifies and explores the use of venoms in neuropathic pain relief. This treatment can open doors to potential therapeutic targets. We believe that further research into the mechanisms of action of these receptors as well as their functions in nature will provide alternative therapies as well as a window into how they affect neuropathic pain.

Pain-Free Outcomes and Durability of Surgical Intervention for Trigeminal Neuralgia: A Comparison of Gamma Knife and Microvascular Decompression.

OBJECTIVE: Treatment options for trigeminal neuralgia include microvascular decompression (MVD) and Gamma Knife surgery (GKS). There is no consensus which option is more effective at providing immediate and long-lasting pain relief. This study evaluated the differences between these 2 options in terms of rates of complete pain relief and pain-free recurrence. METHODS: A systematic review was conducted of published studies of MVD and GKS for treatment of trigeminal neuralgia from 2004 to 2014. Studies were selected using a MEDLINE/PubMed search and from subsequent inspection of references from articles found in the initial search. Common outcome measures reported in the studies were used for meta-analysis to make conclusions based on current available data. RESULTS: The MVD group included 18 articles with 2650 patients, and the GKS group included 25 articles with 2846 patients. MVD was found to have a significantly higher rate of initial pain-free outcomes (Barrow Neurological Institute grade I) compared with GKS (92.22% vs. 61.46%, P < 0.0001). MVD was also found to have a significantly higher rate of long-term pain-free outcomes at last follow-up compared with GKS (79.37% vs. 41.62%, P < 0.0001). MVD was found to have a similar rate of pain-free recurrence compared with GKS (14.93% vs. 19.38%, P = 0.2536). CONCLUSIONS: MVD may be a more effective intervention than GKS owing to higher rates of initial pain-free outcomes and long-term pain-free outcomes. There is a need for more consistent data reporting of outcomes for treatment of trigeminal neuralgia.

Thoracic Radiculopathy following Spinal Cord Stimulator Implantation Treated with Corticosteroids.

INTRODUCTION: Spinal cord stimulation has been used since 1967 to manage chronic neuropathic pain. Although effective, the literature describes the complication rate to be as high as 35%. One rare complication following spinal cord stimulator (SCS) implantation is the development of radicular pain. We present a case series of 2 patients implanted with SCSs who developed thoracic radiculopathy following implantation that resolved with corticosteroids. CASE DETAILS: Although this complication was previously thought to require surgical intervention, this case series describes the use of corticosteroids to resolve postimplantation thoracic radiculopathy. Two patients were studied in this case series who received permanent thoracic implantation of a paddle lead SCS. Several days later, both developed back pain radiating toward the umbilicus in a dermatomal pattern consistent with thoracic radiculopathy. Corticosteroids were administered to relieve this pain. One received 6 mg dexamethasone intravenously every 6 hours followed by an oral dexamethasone taper for 1 week. The other was treated with an oral methylprednisolone taper for 2 weeks. RESULTS: Upon follow-up, both patients no longer complained of the thoracic radiculopathy and were satisfied with the pain relief the stimulators provided. CONCLUSION: In conclusion, postsurgical radicular pain is a rare but troubling complication of SCS implantation. In order to avoid further surgical complications or the need to explant a device that provides satisfactory paresthesia coverage, pharmacologic management is desirable. This case series has demonstrated that the use of corticosteroids can effectively resolve postimplantation thoracic radicular pain in a specific subgroup of patients.

Schizophrenia and neurosurgery: A dark past with hope of a brighter future.

Schizophrenia is a chronic and progressive psychiatric disease that remains difficult to manage in the 21st century. Current medical therapies have been able to give reprieve and decrease incidence of psychotic episodes. However, as the disease progresses, patients can become ever more refractory to current pharmaceutical agents and the polypharmacy that is attempted in treatment. Additionally, many of these drugs have significant adverse effects, leaving the practitioner in a difficult predicament for treating these patients. The history of neurosurgery for schizophrenia, among other psychiatric diseases, has a very dark past. Therefore, this review examines peer-reviewed studies on the history of schizophrenia, its medical and surgical therapies, financial costs, and future directions for disease management. We highlight the historically poor relationship between neurosurgery and psychiatric disease and discuss current research in the understandings of schizophrenia. Guided by a strong code of ethics and new technology, including the use of stereotaxis and deep brain stimulation (DBS), the medical communities treating psychiatric disease are beginning to overcome the horrors of the past. DBS is currently being used with moderate success in the treatment of depression, obsessive compulsive disorder, Tourette's syndrome, and anorexia nervosa. With greater understanding of the neural circuitry of schizophrenia and the evolving role for DBS in psychiatric disease, the authors believe that schizophrenia, like other psychiatric diseases, can be treated with DBS.