RESUMEN
Functional neurosurgery encompasses surgical procedures geared towards treating movement disorders (such as Parkinson's disease and essential tremor), drug-resistant epilepsy, and various types of pain disorders. It is one of the most rapidly expanding fields within neurosurgery and utilizes both traditional open surgical methods such as open temporal lobectomy for epilepsy as well as neuromodulation-based treatments such as implanting brain or nerve stimulation devices. This review outlines the role functional neurosurgery plays in treatment of epilepsy, movement disorders, and pain, and how it is being implemented at the University of Missouri by the Department of Neurosurgery.
Asunto(s)
Dolor Crónico , Epilepsia , Trastornos del Movimiento , Procedimientos Neuroquirúrgicos , Humanos , Dolor Crónico/cirugía , Trastornos del Movimiento/cirugía , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/tendencias , Epilepsia/cirugía , Missouri , Estimulación Encefálica Profunda/métodos , Resultado del TratamientoRESUMEN
Selection of targets for deep brain stimulation (DBS) has been based on clinical experience, but inconsistent and unpredictable outcomes have limited its use in patients with heterogeneous or rare disorders. In this large case series, a novel staged procedure for neurophysiological assessment from 8 to 12 temporary depth electrodes is used to select targets for neuromodulation that are tailored to each patient's functional needs. Thirty children and young adults underwent deep brain stimulation target evaluation with the new procedure: Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation (SABERS). Testing is performed in an inpatient neuromodulation monitoring unit over 5-7 days, and results guide the decision to proceed and the choice of targets for permanent deep brain stimulation implantation. Results were evaluated 3-6 months postoperatively with the Burke-Fahn-Marsden Dystonia Rating Scale and the Barry-Albright Dystonia Scale. Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation testing allowed modulation to be tailored to specific neurologic deficits in a heterogeneous population, including subjects with primary dystonia, secondary dystonia, and Tourette syndrome. All but one subject were implanted with 4 permanent deep brain stimulation leads. Results showed significant improvement on both scales at postoperative follow-up. No significant adverse events occurred. Use of the Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation protocol with evaluation in the neuromodulation monitoring unit is feasible and results in significant patient benefit compared with previously published results in these populations. This new technique supports a significant expansion of functional neurosurgery to predict effective stimulation targets in a wide range of disorders of brain function, including those for which the optimal target is not yet known.
Asunto(s)
Ganglios Basales , Estimulación Encefálica Profunda , Humanos , Estimulación Encefálica Profunda/métodos , Niño , Masculino , Femenino , Adolescente , Adulto Joven , Ganglios Basales/fisiopatología , Técnicas Estereotáxicas , Trastornos del Movimiento/terapia , Trastornos del Movimiento/cirugía , Trastornos del Movimiento/fisiopatología , Trastornos Mentales/terapia , Trastornos Mentales/fisiopatología , Resultado del Tratamiento , Vigilia/fisiología , Adulto , Electrodos Implantados , PreescolarRESUMEN
BACKGROUND AND OBJECTIVES: Radiofrequency ablation (RFA) is a destructive therapy which causes target tissue destruction by application of a thermal dose. Neurosurgical applications of RFA are well-described for myriad chronic pain and movement disorder diagnoses. In fact, RFA pallidotomy and thalamotomy are the initial procedures from which the field of neurosurgical management for movement disorders emerged. RFA rhizotomy for post-traumatic spasms was popular in the 1970s and 1980s, although it was largely abandoned after the invention and Food and Drug Administration approval of intrathecal baclofen therapy. RFA has not been described as a primary treatment of hypertonia in nonambulatory children. METHODS: We report a case of computer-navigated, nonselective RFA peripheral rhizotomy for a nonambulatory child with a history of severe scoliosis and spinal fusion, where an open rhizotomy was technically impractical. RESULTS: Navigation to and ablation of the bilateral L1-L5 peripheral nerves with this approach was successful, and the patient experienced bilateral lower extremity tone improvement. CONCLUSION: We use this case to highlight considerations in indications, our applied operative technique, and lessons learned from this novel application of RFA peripheral rhizotomy in children.
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Trastornos del Movimiento , Ablación por Radiofrecuencia , Fusión Vertebral , Estados Unidos , Niño , Humanos , Rizotomía/métodos , Espasticidad Muscular/cirugía , Trastornos del Movimiento/cirugía , Hipertonía Muscular/cirugíaRESUMEN
BACKGROUND: Non-spastic movement disorders in children are common, although true epidemiologic data is difficult to ascertain. Children are more likely than adults to have hyperkinetic movement disorders defined as tics, dystonia, chorea/athetosis, or tremor. These conditions manifest from acquired or heredodegenerative etiologies and often severely limit function despite medical and surgical management paradigms. Neurosurgical management for these conditions is highlighted. METHODS: We performed a focused review of the literature by searching PubMed on 16 May 2023 using key terms related to our review. No temporal filter was applied, but only English articles were considered. We searched for the terms (("Pallidotomy"[Mesh]) OR "Rhizotomy"[Mesh]) OR "Deep Brain Stimulation"[Mesh], dystonia, children, adolescent, pediatric, globus pallidus, in combination. All articles were reviewed for inclusion in the final reference list. RESULTS: Our search terms returned 37 articles from 2004 to 2023. Articles covering deep brain stimulation were the most common (n = 34) followed by pallidotomy (n = 3); there were no articles on rhizotomy. DISCUSSION: Non-spastic movement disorders are common in children and difficult to treat. Most of these patients are referred to neurosurgery for the management of dystonia, with modern neurosurgical management including pallidotomy, rhizotomy, and deep brain stimulation. Historically, pallidotomy has been effective and may still be preferred in subpopulations presenting either in status dystonicus or with high risk for hardware complications. Superiority of DBS over pallidotomy for secondary dystonia has not been determined. Rhizotomy is an underutilized surgical tool and more study characterizing efficacy and risk profile is indicated.
Asunto(s)
Estimulación Encefálica Profunda , Distonía , Trastornos Distónicos , Trastornos del Movimiento , Adulto , Adolescente , Humanos , Niño , Distonía/cirugía , Trastornos del Movimiento/cirugía , Temblor/cirugía , Trastornos Distónicos/cirugía , Procedimientos Neuroquirúrgicos , Globo Pálido/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Deep brain stimulation (DBS) is a neurosurgical treatment used for the treatment of movement disorders. Surgical and perioperative complications, although infrequent, can result in clinically significant neurological impairment. OBJECTIVES: In this study, we evaluated the incidence and risk factors of intracranial bleeding in DBS surgery. METHOD: Medline, EMBASE, and Cochrane were screened in line with PRISMA 2020 guidelines to capture studies reporting on the incidence of hemorrhagic events in DBS. After removing duplicates, the search yielded 1,510 papers. Abstracts were evaluated by two independent reviewers for relevance. A total of 386 abstracts progressed to the full-text screen and were assessed against eligibility criteria. A total of 151 studies met the criteria and were included in the analysis. Any disagreement between the reviewers was resolved by consensus. Relevant data points were extracted and analyzed in OpenMeta [Analyst] software. RESULTS: The incidence of intracranial bleeding was 2.5% (95% CI: 2.2-2.8%) per each patient and 1.4% (95% CI: 1.2-1.6%) per each implanted lead. There was no statistically significant difference across implantation targets and clinical indications. Patients who developed an intracranial bleed were on average 5 years older (95% CI: 1.26-13.19), but no difference was observed between the genders (p = 0.891). A nonsignificant trend was observed for a higher risk of bleeding in patients with hypertension (OR: 2.99, 95% CI: 0.97-9.19) (p = 0.056). The use of microelectrode recording did not affect the rate of bleeding (p = 0.79). CONCLUSIONS: In this review, we find that the rate of bleeding per each implanted lead was 1.4% and that older patients had a higher risk of hemorrhage.
Asunto(s)
Estimulación Encefálica Profunda , Trastornos del Movimiento , Humanos , Masculino , Femenino , Estimulación Encefálica Profunda/efectos adversos , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/etiología , Trastornos del Movimiento/cirugía , Factores de RiesgoRESUMEN
AIM: To evaluate clinical phenotype and molecular findings of 157 cases with GNAO1 pathogenic or likely pathogenic variants delineating the clinical spectrum, course, and response to treatments. METHOD: Clinical phenotype, genetic data, and pharmacological and surgical treatment history of 11 novel cases and 146 previously published patients were analyzed. RESULTS: Complex hyperkinetic movement disorder (MD) characterizes 88% of GNAO1 patients. Severe hypotonia and prominent disturbance of postural control seem to be hallmarks in the early stages preceding the hyperkinetic MD. In a subgroup of patients, paroxysmal exacerbations became so severe as to require admission to intensive care units (ICU). Almost all patients had a good response to deep brain stimulation (DBS). Milder phenotypes with late-onset focal/segmental dystonia, mild to moderate intellectual disability, and other minor neurological signs (i.e., parkinsonism and myoclonus) are emerging. MRI, previously considered noncontributory to a diagnosis, can show recurrent findings (i.e., cerebral atrophy, myelination and/or basal ganglia abnormalities). Fifty-eight GNAO1 pathogenic variants, including missense changes and a few recurrent splice site defects, have been reported. Substitutions at residues Gly203, Arg209 and Glu246, together with the intronic c.724-8G > A change, account for more than 50% of cases. INTERPRETATION: Infantile or childhood-onset complex hyperkinetic MD (chorea and/or dystonia) with or without paroxysmal exacerbations, associated hypotonia, and developmental disorders should prompt research for GNAO1 mutations. DBS effectively controls and prevents severe exacerbations and should be considered early in patients with specific GNAO1 variants and refractory MD. Prospective and natural history studies are necessary to define genotype-phenotype correlations further and clarify neurological outcomes.
Asunto(s)
Trastornos del Movimiento , Humanos , Masculino , Femenino , Niño , Trastornos del Movimiento/tratamiento farmacológico , Trastornos del Movimiento/patología , Trastornos del Movimiento/fisiopatología , Trastornos del Movimiento/cirugía , Hipotonía Muscular , Discapacidades del Desarrollo , Informes de Casos como AsuntoRESUMEN
OBJECTIVE AND IMPORTANCE: With an aging population and increasing utilization of both cochlear implants (CI) to treat hearing loss and deep brain stimulation (DBS) to treat neurodegenerative movement disorders, more patients will be sequentially implanted with the two devices. As such, understanding both presurgical evaluations and surgical procedures will be of great importance to the treating cochlear implant surgeon and neurosurgeon in optimizing outcomes for both conditions. CLINICAL PRESENTATION: Two illustrative cases of sequential CI followed by DBS are reviewed. Relevant pre-, intra-, and postoperative issues are discussed for both DBS following CI surgery and CI following DBS surgery. CONCLUSION: Despite the potential for challenges, sequential CI and DBS (and vice versa) can provide substantial benefit to those individuals with severe hearing loss and movement disorders. A thorough understanding of both devices is critical to ensuring optimal outcomes.
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Implantación Coclear , Implantes Cocleares , Sordera , Estimulación Encefálica Profunda , Trastornos del Movimiento , Humanos , Anciano , Implantación Coclear/métodos , Estimulación Encefálica Profunda/métodos , Trastornos del Movimiento/cirugía , Sordera/cirugía , Encéfalo/cirugíaRESUMEN
Background: Rare movement disorders (RMDs) throw remarkable challenges to their appropriate management particularly when they are medically refractory. We studied the outcome of functional neurosurgery among patients with RMDs. Methods: Retrospective chart-review from 2006 to 2021 of patients with RMDs who underwent either Deep brain Stimulation (DBS) or lesional surgeries in the department of Neurology and Neurosurgery at a tertiary care centre. Results: Seventeen patients were included. Generalized dystonia (11 patients, 64.7%) and tremor (5 patients, 29.4%) were the most common indication for surgery whereas, Wilson's disease (8 patients, 47.1%) and Neurodegeneration with brain iron accumulation (5 patients, 29.4%) were the most common aetiology. Sixteen patients (94.1%) had objective clinical improvement. Significant improvement was noted in the dystonia motor scores both at 6-months and 12-months follow-up (n = 11, p-value of <0.01 and 0.01 respectively). Comparison between DBS and lesional surgery showed no significant difference in the outcomes (p = 0.95 at 6-months and p = 0.53 at 12-months), with slight worsening of scores in the DBS arm at 12-months. Among five patients of refractory tremor with Wilson's disease, there was remarkable improvement in the tremor scores by 85.0 ± 7.8% at the last follow-up. Speech impairment was the main complication observed with most of the other adverse events either transient or reversible. Discussion: Surgical options should be contemplated among patients with disabling medically refractory RMDs irrespective of the aetiology. Key to success lies in appropriate patient selection. In situations when DBS is not feasible, lesional surgeries can offer an excellent alternative with comparable efficacy and safety.
Asunto(s)
Estimulación Encefálica Profunda , Distonía , Trastornos Distónicos , Degeneración Hepatolenticular , Trastornos del Movimiento , Estimulación Encefálica Profunda/efectos adversos , Distonía/etiología , Trastornos Distónicos/terapia , Humanos , India , Trastornos del Movimiento/etiología , Trastornos del Movimiento/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Temblor/etiología , Temblor/cirugíaRESUMEN
AIM: To review both the surgical-related, and hardware-related adverse effects of deep brain stimulation (DBS) in a single center over the last five years. MATERIAL AND METHODS: All patients who underwent DBS electrode implantation at the Akdeniz University Hospital during the last five years participated in this study. Demographic information (sex, age, diagnosis, the duration between diagnosis and surgery, comorbid disease) and the date of surgery were collected from an electronic medical database. The adverse effects of DBS were classified into two: surgery-related and hardware-related effects, which were further subdivided based on whether they occurred intraoperatively, in the early postoperative stage, or over a long period time. RESULTS: A database of 47 patients with 90 DBS electrode implants was analyzed in the study. The median age at the time of surgery of all patients was 54 years (range 11-75). Comorbid diseases were recorded in 16 (34%) patients. Out of the total, 33 patients (70.2%) had no adverse effects related to DBS. Surgical-related adverse effects were observed in five patients and of these, one haD an asymptomatic intracerebral hemorrhage (ICH), one had symptomatic ICH, one had both a seizure intraoperatively and an asymptomatic subdural hematoma whereas the other two had non-infectious peri-electrode edema. Hardware-related adverse effects were recorded in nine patients (19.1%). We recorded infections in six (12.7%) patients, erosion without infection in two (4.2%), and both lead fracture and lead malposition in one patient. All long-lasting adverse effects were hardware-related and recorded in eight (19%) patients. CONCLUSION: DBS has been a well-established treatment for movement disorders but is associated with an increased risk of some adverse events which have been analyzed in this study.
Asunto(s)
Estimulación Encefálica Profunda , Trastornos del Movimiento , Adolescente , Adulto , Anciano , Hemorragia Cerebral/etiología , Niño , Estimulación Encefálica Profunda/efectos adversos , Electrodos Implantados/efectos adversos , Hematoma Subdural/etiología , Humanos , Persona de Mediana Edad , Trastornos del Movimiento/cirugía , Trastornos del Movimiento/terapia , Estudios Retrospectivos , Adulto JovenRESUMEN
Moyamoya disease is a cerebral angiopathy characterized by bilateral progressive narrowing of internal carotid arteries, developing collateral vessels with the aspect of a "puff of smoke." The presentation with movement disorders is extremely rare. We present the case of an 11-year-old girl with low academic performance who complained of involuntary movements starting in her right hand. Neurologic examination showed preserved muscle strength and right hemichoreoathetosis. Neuroimaging showed left hemisphere hypoperfusion and a hypertrophic distal lenticulostriate artery. The symptoms were controlled with medications, and cerebral revascularization was performed. Although movement disorders are usually related to cerebral lesions or hypoperfusion, cases without these etiologies were described. Thus the finding of asymmetric lenticulostriate arteries improving after asymmetry reduction suggests a possible role in the pathogenesis. Further studies are needed to fully elucidate the mechanisms between moyamoya disease and movement disorders.
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Discinesias/diagnóstico por imagen , Discinesias/cirugía , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Niño , Discinesias/etiología , Femenino , Humanos , Trastornos del Movimiento/diagnóstico por imagen , Trastornos del Movimiento/etiología , Trastornos del Movimiento/cirugía , Enfermedad de Moyamoya/complicacionesRESUMEN
The evaluation and management of patients with movement disorders has evolved considerably due to the COVID-19 pandemic, including the assessment of candidates for deep brain stimulation (DBS) therapy. Members of the Neuropsychology Focus Group from the Parkinson Study Group Functional Neurosurgical Working Group met virtually to discuss current practices and solutions, build consensus, and to inform the DBS team and community regarding the complexities of performing DBS neuropsychological evaluations during COVID-19. It is our viewpoint that the practice of neuropsychology has adapted successfully to provide tele-neuropsychological pre-DBS evaluations during the global pandemic, thus permanently changing the landscape of neuropsychological services.
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COVID-19 , Estimulación Encefálica Profunda/tendencias , Trastornos del Movimiento/psicología , Trastornos del Movimiento/cirugía , Pruebas Neuropsicológicas , Neuropsicología/tendencias , Neurocirugia/tendencias , Pandemias , Enfermedad de Parkinson/psicología , Enfermedad de Parkinson/cirugía , Estimulación Encefálica Profunda/estadística & datos numéricos , Humanos , TelemedicinaRESUMEN
Forel-H-tomy for intractable epilepsy was introduced by Dennosuke Jinnai in the 1960s. Recently, Forel-H-tomy was renamed to "pallidothalamic tractotomy" and revived for the treatment of Parkinson's disease and dystonia. Two of our patients with movement disorders and comorbid epilepsy experienced significant seizure reduction after pallidothalamic tractotomy, demonstrating the efficacy of this method. The first was a 29-year-old woman who had temporal lobe epilepsy with focal impaired awareness seizure once every three months and an aura 10-20 times daily, even with four antiseizure medicines. For the treatment of hand dyskinesia, she underwent left pallidothalamic tractotomy and her right-hand dyskinesia significantly improved. Fourteen months later, she had experienced no focal impaired awareness seizure and the aura decreased to one to three times per month. The second case was that of a 15-year-old boy diagnosed with progressive myoclonic epilepsy, who developed generalized tonic-clonic seizure, which manifested once every month, despite treatment with five antiseizure medicines. After surgery, myoclonic movements in his right hand slightly improved. A one-year follow-up revealed that he had not experienced a generalized tonic-clonic seizure. The lesion locations in the two cases were close to the vicinity of Jinnai's Forel-H-tomy. Forel's field H deserves reconsideration as a treatment target for intractable epilepsy.
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Trastornos del Movimiento/cirugía , Palidotomía , Convulsiones/terapia , Subtálamo/cirugía , Adolescente , Adulto , Distonía/cirugía , Epilepsia del Lóbulo Temporal/cirugía , Epilepsia Tónico-Clónica/cirugía , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Procedimiento de Escisión Encefálica , Técnicas Estereotáxicas , Adulto JovenRESUMEN
BACKGROUND: Intraoperative research during deep brain stimulation (DBS) surgery has enabled major advances in understanding movement disorders pathophysiology and potential mechanisms for therapeutic benefit. In particular, over the last decade, recording electrocorticography (ECoG) from the cortical surface, simultaneously with subcortical recordings, has become an important research tool for assessing basal ganglia-thalamocortical circuit physiology. OBJECTIVE: To provide confirmation of the safety of performing ECoG during DBS surgery, using data from centers involved in 2 BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative-funded basic human neuroscience projects. METHODS: Data were collected separately at 4 centers. The primary endpoint was complication rate, defined as any intraoperative event, infection, or postoperative magnetic resonance imaging abnormality requiring clinical follow-up. Complication rates for explanatory variables were compared using point biserial correlations and Fisher exact tests. RESULTS: A total of 367 DBS surgeries involving ECoG were reviewed. No cortical hemorrhages were observed. Seven complications occurred: 4 intraparenchymal hemorrhages and 3 infections (complication rate of 1.91%; CI = 0.77%-3.89%). The placement of 2 separate ECoG research electrodes through a single burr hole (84 cases) did not result in a significantly different rate of complications, compared to placement of a single electrode (3.6% vs 1.5%; P = .4). Research data were obtained successfully in 350 surgeries (95.4%). CONCLUSION: Combined with the single report previously available, which described no ECoG-related complications in a single-center cohort of 200 cases, these findings suggest that research ECOG during DBS surgery did not significantly alter complication rates.
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Estimulación Encefálica Profunda , Electrocorticografía , Trastornos del Movimiento , Encéfalo/fisiopatología , Encéfalo/cirugía , Estimulación Encefálica Profunda/efectos adversos , Estimulación Encefálica Profunda/métodos , Electrocorticografía/efectos adversos , Electrocorticografía/métodos , Humanos , Trastornos del Movimiento/diagnóstico , Trastornos del Movimiento/fisiopatología , Trastornos del Movimiento/cirugía , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed. METHODS: After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery. RESULTS: Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings. CONCLUSIONS: Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings. LEVEL OF EVIDENCE: Level III-case series.
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Trastornos Neurológicos de la Marcha/cirugía , Marcha , Extremidad Inferior/cirugía , Trastornos del Movimiento/cirugía , Procedimientos Ortopédicos/métodos , Adolescente , Niño , Femenino , Humanos , Extremidad Inferior/diagnóstico por imagen , Masculino , Procedimientos Ortopédicos/estadística & datos numéricos , Radiografía , Estudios Retrospectivos , Dedos del Pie , Resultado del Tratamiento , CaminataRESUMEN
Deep brain stimulation (DBS) is a complex surgical procedure that requires detailed anatomical knowledge. In many fields of neurosurgery navigation systems are used to display anatomical structures during an operation to aid performing these surgeries. In frame-based DBS, the advantage of visualization has not yet been evaluated during the procedure itself. In this study, we added live visualization to a frame-based DBS system, using a standard navigation system and investigated its accuracy and potential use in DBS surgery. As a first step, a phantom study was conducted to investigate the accuracy of the navigation system in conjunction with a frame-based approach. As a second step, 5 DBS surgeries were performed with this combined approach. Afterwards, 3 neurosurgeons and 2 neurologists with different levels of experience evaluated the potential use of the system with a questionnaire. Moreover, the additional personnel, costs and required set up time were noted and compared to 5 consecutive standard procedures. In the phantom study, the navigation system showed an inaccuracy of 2.1 mm (mean SD 0.69 mm). In the questionnaire, a mean of 9.4/10 points was awarded for the use of the combined approach as a teaching tool, a mean of 8.4/10 for its advantage in creating a 3-dimensional (3-D) map and a mean of 8/10 points for facilitating group discussions. Especially neurosurgeons and neurologists in training found it useful to better interpret clinical results and side effects (mean 9/10 points) and neurosurgeons appreciated its use to better interpret microelectrode recordings (mean 9/10 points). A mean of 6/10 points was awarded when asked if the benefits were worth the additional efforts. Initially 2 persons, then one additional person was required to set up the system with no relevant added time or costs. Using a navigation system for live visualization during frame-based DBS surgery can improve the understanding of the complex 3-D anatomy and many aspects of the procedure itself. For now, we would regard it as an excellent teaching tool rather than a necessity to perform DBS surgeries.
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Estimulación Encefálica Profunda/normas , Neuronavegación/normas , Neurocirujanos/normas , Técnicas Estereotáxicas/normas , Estimulación Encefálica Profunda/métodos , Electrodos Implantados/normas , Femenino , Humanos , Imagenología Tridimensional/métodos , Imagenología Tridimensional/normas , Masculino , Microelectrodos/normas , Trastornos del Movimiento/diagnóstico por imagen , Trastornos del Movimiento/cirugía , Neuronavegación/métodos , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/normas , Fantasmas de Imagen/normasRESUMEN
The paper invites to reappraise the role of psychosurgery for and within the development of functional stereotactic neurosurgery. It highlights the significant and long-lived role of stereotactic neurosurgery in the treatment of severe and chronic mental disorders. Stereotactic neurosurgery developed out of psychosurgery. It was leucotomy for psychiatric disorders and chronic pain that paved the way for stereotactic dorsomedial thalamotomy in these indications and subsequently for stereotactic surgery in epilepsy and movement disorders. Through the 1960s stereotactic psychosurgery continued to progress in silence. Due to the increased applications of stereotactic surgery in psychiatric indications, psychosurgery's renaissance was proclaimed in the early 1970s. At the same time, however, a public fearing mind control started to discredit all functional neurosurgery for mental disorders, including stereotactic procedures. In writing its own history, stereotactic neurosurgery's identity as a neuropsychiatric discipline became subsequently increasingly redefined as principally a sort of "surgical neurology," cut off from its psychiatric origin.
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Trastornos Mentales/historia , Neurocirugia/historia , Psicocirugía/historia , Técnicas Estereotáxicas/historia , Dolor Crónico/historia , Dolor Crónico/cirugía , Epilepsia/historia , Epilepsia/cirugía , Historia del Siglo XX , Humanos , Trastornos Mentales/cirugía , Trastornos del Movimiento/historia , Trastornos del Movimiento/cirugíaRESUMEN
BACKGROUND: The use of sham interventions in randomized controlled trials (RCTs) is essential to minimize bias. However, their use in surgical RCTs is rare and subject to ethical concerns. To date, no studies have looked at the use of sham interventions in RCTs in neurosurgery. METHODS: This study evaluated the frequency, type, and indication of sham interventions in RCTs in neurosurgery. RCTs using sham interventions were also characterized in terms of design and risk of bias. RESULTS: From a total of 1,102 identified RCTs in neurosurgery, 82 (7.4%) used sham interventions. The most common indication for the RCT was the treatment of pain (67.1%), followed by the treatment of movement disorders and other clinical problems (18.3%) and brain injuries (12.2%). The most used sham interventions were saline injections into spinal structures (31.7%) and peripheral nerves (10.9%), followed by sham interventions in cranial surgery (26.8%), and spine surgery (15.8%). Insertion of probes or catheters for a sham lesions was performed in 14.6%.In terms of methodology, most RCTs using sham interventions were double blinded (76.5%), 9.9% were single blinded, and 13.6% did not report the type of blinding. CONCLUSION: Sham-controlled RCTs in neurosurgery are feasible. Most aim to minimize bias and to evaluate the efficacy of pain management methods, especially in spinal disorders. The greatest proportion of sham-controlled RCTs involves different types of substance administration routes, with sham surgery the less commonly performed.
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Trastornos del Movimiento/cirugía , Procedimientos Neuroquirúrgicos/métodos , Dolor/cirugía , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Método Doble Ciego , Humanos , Proyectos de InvestigaciónRESUMEN
Movement disorders are typically perceived as being gradually progressive conditions that are managed in outpatient settings. However, they may manifest de novo with an acute severe phenotype or an acute decompensation. A movement disorder becomes an emergency when it evolves acutely or subacutely over hours to days; delays in its diagnosis and treatment may cause significant morbidity and mortality. Here we address the clinical presentation, diagnosis and management of those movement disorder emergencies that are principally encountered in emergency departments, in acute receiving units or in intensive care units. We provide practical guidance for management in the acute setting where there are several treatable causes not to be missed. The suggested medication doses are predominantly based on expert opinion due to limited higher-level evidence. In spite of the rarity of movement disorder emergencies, neurologists need to be familiar with the phenomenology, potential causes and treatments of these conditions. Movement disorder emergencies divide broadly into two groups: hypokinetic and hyperkinetic, categorised according to their phenomenology. Most acute presentations are hyperkinetic and some are mixed.