Treatment of refractory headache secondary to intracranial endovascular procedure by transcutaneous electrical nerve stimulation of the occipital nerve.

This pilot study aimed at assessing the effect of transcutaneous electrical nerve stimulation (TENS) of the occipital nerve (ON) to treat chronic refractory headache secondary to intracranial endovascular procedures (iEVP) in 4 patients. The duration of ON-TENS therapy was only 1 month (n=2) or longer than 4 months (n=2). Overall, pain intensity decreased from 7.8 (on a 0-10 scale) at baseline to 0.8 at 6 months after ON-TENS therapy initiation (-90%), while drug treatment was reduced from 34.3 to 0.8 (-98%) on the medication quantification scale. ON-TENS is a simple technique that may benefit patients with post-iEVP refractory headache.

Treatment of dopplerable nummular headache with minimally invasive arterectomy under local anesthesia.

OBJECTIVE: The objective of the current study is to elucidate the potential role of surgery in the treatment of nummular headache (NH). BACKGROUND: NH is a disorder in which pain is localized to a specific area. Treatment has traditionally been medical, with the recent addition of nerve blocks and botox injection with equivocal results. DESIGN: Forty-nine patients were identified using the International Classification of Headache Disorders, third edition, beta version. Patients were asked to identify the area of maximal pain. Patients who had an associated Doppler signal within the area of pain underwent surgical arterectomy using local anesthesia. Preoperative and postoperative headache frequency, severity, duration, and headache-free days were analyzed. RESULTS: There were a total of 49 patients included in the study (42F:7M) with an average age of 45 years (21-65 years). The average follow-up period was 16 months with a range of 8-33 months. There was a significant reduction in the frequency (-10.7 days; p < 0.001), severity (-3.5; p < 0.001), and duration (-0.3 hours; p = 0.4) of the headache. There was a significant increase in the number of headache-free days per month (10 vs. 21; p < 0.001). Headache index decreased by 39.6%, from an average of 378.6 to 228.4 (p < 0.05). Twelve patients (24.5%) were free from NH and able to discontinue their medications. There were no complications identified during the follow-up period. CONCLUSION: NH, although rare, can be associated with significant disability despite current treatment modalities. In select patients, surgical arterectomy is a safe, minimally invasive, and effective treatment for NH.

[Cranial trepanation in primitive cultures]. / La trepanación craneal en las culturas primitivas.

A review is presented on cranial trepanations performed by primitive cultures. The scientific interest in this topic began after the discovery in 1965 by Ephraim G. Squier of a pre-Columbian trepanated skull, and studied by Paul Broca in Paris. Pseudotrepanation and other types of cranial manipulation are reviewed. The techniques, technology, and instruments for every type of trepanation are well known. There are a surprisingly high percentage of cases showing signs of post-trepanation survival. Indications for trepanation are speculative, perhaps magic. Although trepanation in primitive cultures is widespread around the world, and throughout time, the main fields of interest are the Neolithic Period in Europe, the pre-Columbian Period in Andean South America, and some contemporaneous Pacific and African tribes. This particular trepanation procedure has no relationship with modern Neurosurgery, or with trepanations with therapeutic purposes performed since the Greco-Roman period in Europe, and afterwards around the world.

[Laser-assisted outpatient septal spur surgery for contact point pain].

OBJECTIVE: To investigate the efficacy outcomes of laser assisted outpatient septal spur surgery for contact point pain in a carefully selected group of patients. METHOD: This investigation included 32 patients who were selected for laser-assisted septal spur surgery in an outpatient surgical suite. All had endoscopically visible spur contact as well as nansal CT scans. Patients of sinusitis were excluded. The area of the contact point was treated with decongestant and lidocaine. If the headache completely disappeared or diminished by more than 50% in intensity, subjects were considered candidates for surgery. Headache characteristics were assessed preoperatively and at follow-up (30 months after surgery) using a standardized questionare. RESULT: Nine cases (28.1%) were free from pain at the last follow-up; 19 cases (59.4%) had their headache scores improved after surgery; four cases (12.5%) had a less than 25% reduction in their headache score. No septal perforation, hematoma, was reported. CONCLUSION: For selected patients with contact point headaches, septoplasty may be useful. The positive dicaine test may indicate better effect of operation. Laser-assisted outpatient septal spur surgery for contact point pain shows good results in short-term effect, and has less complications, but long-term follow-up is required to assess its real effect.

Peripheral nerve blocks: a therapeutic alternative for hemicrania continua.

OBJECTIVES: A complete response to indomethacin is required for the diagnosis of hemicrania continua (HC). Nevertheless, patients may develop side effects leading to withdrawal of this drug. Several alternatives have been proposed with no consistent effectiveness. Both anaesthetic blocks of peripheral nerves and trochlear corticosteroid injections have been effective in some case reports. METHODS: Twenty-two patients with HC were assessed in a headache outpatient office. Physical examination included palpation of the supraorbital nerve (SON) and greater occipital nerve (GON) as well as of the trochlear area. RESULTS: In 14 patients, at least one tender point was detected. Due to indomethacin intolerance, at least one anaesthetic block of the GON or SON, or an injection of corticosteroids in the trochlear area, were performed in nine patients. Four of them were treated with a combination procedure. All these patients experienced total or partial improvement lasting from 2 to 10 months. CONCLUSION: Anaesthetic blocks or corticosteroid injections may be effective in HC patients showing tenderness of the SON, GON or trochlear area.

Implantation of a responsive neurostimulator device in patients with refractory epilepsy.

OBJECT: The authors summarize one center's experience with a novel device, the Responsive Neurostimulation (RNS) system, which is used to treat seizures, and they provide technical details regarding the implantation procedure. METHODS: The authors reviewed seizure detection, cortical stimulation, and clinical data obtained in 7 patients in whom the RNS system was implanted. Data pertaining to seizure alteration are provided for the first 4 implant-treated patients. The implantation procedure in the case of one patient with occipital lobe heterotopia is included. RESULTS: Based on patients' seizure diaries, the implanted devices functioned at a high sensitivity for clinical seizure detection. Reductions in seizure frequency, based on their diaries and on clinic follow-up notes, ranged from 50 to 75%. No adverse stimulation-induced side effects were noted, and no hardware malfunctions requiring explantation occurred. Generator replacements for battery depletion were required at 11, 17, and 20 months in 3 patients. The implantation procedure was well tolerated, and postoperative hospital stays were short. A revision cranioplasty for a skull defect was performed in the index patient, whose case will be discussed in the most detail. CONCLUSIONS: The results obtained in this small preliminary series demonstrate a safe implantation method for the responsive neurostimulation device.

Chronic subdural hematoma in capoeira sport.

Chronic subdural hematomas in young people is extremely rare and has some provoking factors such as V-P shunts, arachnoid cyst, anticoagulant drug usage, vigorous sports and coagulopathies. A static or dynamic mechanical load is almost always delivered to skull associated with either mild or severe head trauma. A 25-year old-man who was previously healthy has complained of intermittent headache for six months. He had been interested in capoiera (Brazilian exciting sport) for two years and has had no any evidence of head injury. After admission, he was operated immediately because of chronic subdural hematoma. We report a patient who is the first chronic subdural hematoma in the literature due to playing capoeira.

Middle turbinate lateralization: a simple treatment for rhinologic headache.

OBJECTIVE: To introduce a minimally invasive method to eliminate the symptoms of contact-point rhinologic cephalgia. STUDY DESIGN: A prospective study of 55 patients with chronic nasal or glabellar pain and endoscopically proven nasal origin. METHODS: All 55 patients in whom endoscopic examination demonstrated a contact point between the middle turbinate and the nasal septum were treated by fracturing the middle turbinate lateralward using a small metal tongue depressor under 10% lidocaine HCL topical anesthesia. RESULTS: Of the treated cohort, 48 (87%) of the patients had complete clinical symptom resolution after one treatment and all had resolution after two treatments. Recurrence occurred in 1 patient. There were no short-term or long-term adverse sequelae. The results persisted at a mean follow-up time of 50 months (range, 6-84 mo). CONCLUSION: Middle turbinate lateralization is safe and effective in eliminating the symptoms of rhinologic cephalgia induced by contact point between the middle turbinate and nasal septum.

Case reports: headache caused by a spinal cord stimulator in the upper cervical spine.

We report persistent headaches developing in a patient subsequent to the placement of a spinal cord stimulator in the upper cervical spine. These persistent headaches responded to dihydroergotamine and sumatriptan. Headaches ceased upon repositioning of the stimulator lower in the cervical spine. We postulate an effect of the device on the trigeminovascular system via the nucleus caudalis trigeminalis and/or spinal trigeminal tract.

[Present state of pain surgery]. / Etat actuel de la chirurgie de la douleur

This report presented to the Société de Neurochirurgie de Langue Française is based on 34 years of unique practice in neurosurgical management of pain; during that long period the author and his associates have collected an unusually large experience in almost every field of neurosurgical management of pain; they have improved or fully devised several new techniques which allow them to ground an appreciation of the procedures still worthy to be used in various pain syndromes. The first part of the report deals with "Cybernetics of pain". This rather long chapter is based both on classical data and personal observations on man during and following operations, meant to relieve pain. Though supporting HEAD and HOLMES, theory on Control of protopathic by epicritic Stimuli, the authors consider that the type of pain associated with noxious stimulation as representative of just one among other types of pain, not induced by nociception and not associated with protection reflexes. Sensory deafferentation as can be produced by amputations, herpes zoster, dorsal column or medullary lesions, cannot be included in Sherrington's scheme of psychical mechanisms associated with protection reflexes and yet is responsible for most of the chronic unbearable and often intractable pain. Moreover, an important modulation of pain as such depends on conditioning, on inherited and acquired patterns of behaviour and on a multiplicating factor which is provisionally named "algogenic neurosis". The fact that an intact nucleus ventralis posterolateralis is a necessity for a "no pain status" tends to prove that this thalamic nucleus acts as a major inhibiting relay on the pain integrating system and for several additional reasons is the level of integration of epicritic versus protopathic stimuli in case of true nociception...