Staged Bilateral Nucleus Caudalis DREZ Lesioning for Persistent Idiopathic Facial Pain: Exceptional Case Report.

Persistent idiopathic facial pain (PIFP) is a rare but challenging type of facial pain. How to manipulate such a problem becomes more contentious in cases with bilateral complaints. In situations when conventional treatments fail to reduce the pain, some treatment options like nucleus caudalis dorsal root entry zone (DREZ) lesioning shine as valuable means of managing such intractable problems. Herein, we report an individual with bilateral PIFP in which the patient suffered from intractable pain and was the first to undergo bilateral nucleus caudalis DREZ operation for PIFP. The patient was followed up and the procedure resulted in immediate and complete pain relief.

A curative treatment option for Complex Regional Pain Syndrome (CRPS) Type I: dorsal root entry zone operation (report of two cases).

Complex Regional Pain Syndrome Type I (CRPS-I) is a debated health problem concerning its pathophysiology and treatment strategies. A 12-year-old boy and a 35-year-old woman were diagnosed with CRPS-I at different times. They had previously undergone various types of interventions with no success. After one year of follow-up and observation, DREZ lesioning operation was performed. Afterwards, both cases had transient lower extremity ataxia. The first case was followed for 60 months with no recurrence and total cure. The second case was pain-free until the 6th month, when she required psychological support; she was followed for 33 months with partial satisfactory outcome. Although not a first-line option, DREZ lesioning procedure can be chosen and may be a curative option in selected cases of CRPS-I who are unresponsive to conventional therapies.

CT-guided percutaneous cordotomy for intractable pain in what is more than a disease: lung malignancies.

AIM: Lung cancer is the leading cause of cancer-related mortality worldwide. Pain is a common problem in these patients, yet inadequate or dissatisfactory management is prevalent. MATERIAL AND METHODS: Between 1987 and 2012, 224 patients with intractable pain were treated with computerized tomography (CT)- guided cordotomy. Among them, 210 had intractable pain due to malignancies. The majority of the cases were diagnosed as pulmonary malignancies (108 patients). Sixty-seven were pulmonary carcinoma, 26 mesothelioma and 15 Pancoast tumors. RESULTS: After cordotomy, 98.13% of cancer patients reported initial pain relief. Minimum and maximum preoperative scores of the Karnofsky Performance Scale were 20 and 70, versus postoperative scores of 40 and 90 (p < 0.001). The median preoperative VAS score was 8 (6-9). On the first postoperative day, the score dropped sharply to 0 (0-8) (p < 0.001). In this selected series of 108 percutaneous cordotomy procedures, as well as in the total series of 224 patients, there was no mortality or major morbidity. CONCLUSION: CT-guided percutaneous cordotomy is an effective procedure that should be used in the treatment of cancer-related pain problems. We suggest that cordotomy should be preferred as soon as possible in patients who fail to respond to the classic analgesic therapy.

Florence Nightingale: light to illuminate the world from the woman with the lantern.

The Ottoman-Russian war of 1853 to 1855 was significant not only as a war, but also in response to a reflex from the West brought with itself novel approaches related to care of patients under severe health conditions. Florence Nightingale and her associates assigned at that time to care for soldiers in Istanbul who were severely ailing as a result of battle conditions were instrumental in the emergence of a hitherto unknown profession. This article examines the progress of events in the London-Istanbul axis that led to this development.

Stem cell therapy in spinal cord injury: in vivo and postmortem tracking of bone marrow mononuclear or mesenchymal stem cells.

OBJECTIVE: The aim of this study was to address the question of whether bone marrow-originated mononuclear cells (MNC) or mesenchymal stem cells (MSC) induce neural regeneration when implanted intraspinally. MATERIALS AND METHODS: The study design included 4 groups of mice: Group 1, non-traumatized control group; Groups 2, 3 and 4 spinal cord traumatized mice with 1 g force Tator clips, which received intralesionally either no cellular implants (Group 2), luciferase (Luc) (+) MNC (Group 3) or MSC (Group 4) obtained from CMV-Luc or beta-actin Luc donor transgenic mice. Following the surgery until decapitation, periodical radioluminescence imaging (RLI) and Basso Mouse Scale (BMS) evaluations was performed to monitor neural activity. Postmortem immunohistochemical techniques were used to analyze the fate of donor type implanted cells. RESULTS: All mice of Groups 3 and 4 showed various degrees of improvement in the BMS scores, whereas there was no change in Groups 1 and 2. The functional improvement was significantly better in Group 4 compared to Group 3 (18 vs 8, p=0.002). The immunohistochemical staining demonstrated GFP(+)Luc(+) neuronal/glial cells that were also positive with one or more of these markers: nestin, myelin associated glycoprotein, microtubule associated protein or myelin oligodendrocyte specific protein, which is considered as indicator of donor type neuronal regeneration. Frequency of donor type neuronal cells; Luc + signals and median BMS scores were observed 48-64% and 68-72%; 44-80%; 8 and 18 within Groups III and IV respectively. DISCUSSION: MSCs were more effective than MNC in obtaining neuronal recovery. Substantial but incomplete functional improvement was associated with donor type in vivo imaging signals more frequently than the number of neuronal cells expressing donor markers in spinal cord sections in vitro. Our results are in favor of functional recovery arising from both donor MSC and MNCs, contributing to direct neuronal regeneration and additional indirect mechanisms.

Management of bilateral trigeminal neuralgia with trigeminal radiofrequency rhizotomy: a treatment strategy for the life-long disease.

BACKGROUND: The objective of this study was to evaluate the effectiveness of percutaneous controlled radiofrequency trigeminal rhizotomy (RF-TR) in patients with bilateral trigeminal neuralgia (BTN). Patients were analyzed after RF-TR in terms of outcome, safety and complications. METHODS: Eighty-nine BTN patients underwent 186 RF-TR procedures. Eighty-seven patients had idiopathic trigeminal neuralgia (ITN) and two patients had multiple sclerosis (2.2%). Fifty-six (62.9%) were women and 33 (37.1%) were men. Ages ranged from 29 to 85 years. Anesthesia was administered at a determined optimal level, allowing patient cooperation for controlled and selective lesioning. RESULTS: The mean follow-up period was 101.71 ± 77.7 months. Familial occurrence was seen in two (2.2%) patients. Synchronized pain was observed in 25 (28.2%) patients. Pain occurrence on the contralateral side was observed with an average duration of 124.7 ± 87.13 months. Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%). CONCLUSIONS: RF-TR is an effective, selective, well-controlled, and effortlessly repeatable procedure for treating BTN, especially in the elderly, in terms of low morbidity and mortality rates and high rate of satisfactory pain relief.

The branching pattern of the middle cerebral artery: is the intermediate trunk real or not? An anatomical study correlating with simple angiography.

OBJECT: The branching structure of the middle cerebral artery (MCA) remains a debated issue. In this study the authors aimed to describe this branching structure in detail. METHODS: Twenty-seven fresh, human brains (54 hemispheres) obtained from routine autopsies were used. The cerebral arteries were first filled with colored latex and contrast agent, followed by fixation with formaldehyde. All dissections were done under a microscope. During examination, the trunk structures of the MCA and their relations with cortical branches were demonstrated. Lateral radiographs of the same hemispheres were then obtained and comparisons were made. Angles between the MCA trunks were measured on 3D CT cerebral angiography images in 25 patients (50 hemispheres), and their correlations with the angles obtained in the cadaver brains were evaluated. RESULTS: A new classification was made in relation to the terminology of the intermediate trunk, which is still a subject of debate. The intermediate trunk was present in 61% of cadavers and originated from a superior trunk in 55% and from an inferior trunk in 45%. Cortical branches supplying the motor cortex (precentral, central, and postcentral arteries) significantly originated from the intermediate trunk, and the diameter of the intermediate trunk significantly increased when it originated from the superior trunk. In measurements of the angles between the superior and intermediate trunks, it was found that the intermediate trunk had significant dominance in supplying the motor cortex as the angle increased. The intermediate trunk was classified into 3 types based on the angle values and the distance to the bifurcation point as Group A (pseudotrifurcation type), Group B (proximal type), and Group C (distal type). Group A trunks were seemingly closer to the trifurcation structure that has been reported on in the literature and was seen in 15%. Group B trunks were the most common type (55%), and Group C trunks were characterized as the farthest from the bifurcation point. Group C trunks also had the smallest diameter and fewest cortical branches. Similarities were found between the angles in cadaver specimens and on 3D CT cerebral angiography images. Beyond the separation point of the MCA, trunk structures always included the superior trunk and inferior trunk, and sometimes the intermediate trunk. CONCLUSIONS: Interrelations of these vascular structures and their influences on the cortical branches originating from them are clinically important. The information presented in this study will ensure reliable diagnostic approaches and safer surgical interventions, particularly with MCA selective angiography.

An attempt to treat patients who have injured spinal cords with intralesional implantation of concentrated autologous bone marrow cells.

BACKGROUND AIMS: Spinal cord injury is common among young subjects involved in motor vehicle accidents. Mechanisms and attempts to reverse post-traumatic pathophysiologic consequences are still being investigated. Unfortunately no effective and well-established treatment modality has been developed so far. The regeneration capability of the human nervous system following an injury is highly limited. METHODS: The study involved four patients (two male, two female) who had suffered spinal cord injury as a result of various types of trauma. On neurologic examination, all the patients were determined to be in American Spinal Injury Association (ASIA) grade A. All patients were treated with decompression, stabilization and fusion for vertebral trauma anteriorly, as well as intralesional implantation of cellular bone marrow concentrates using a posterior approach 1 month after the first operation. The patients were then treated and followed-up in the physical rehabilitation clinic. RESULTS: At the end of the post-operative 1-year follow-up, two of the patients were classified as ASIA C while one was classified as ASIA B. One patient showed no neurologic change; none of the patients suffered from any complications or adverse effects as a result of intralesional application of bone marrow cells. CONCLUSIONS: The results of this experimental study show the potential contribution of intralesional implantation of bone marrow to neuronal regeneration in the injured spinal cord, with neuronal changes. In light of the results of this experimental study, the potential for regenerative treatment in injuries of the human spinal cord is no longer a speculation but an observation.

Trigeminal neuropathic pain following honeybee sting: a case report.

The neurological complications of bee venom poisoning vary from optic neuritis to pontine hematoma. However, to our best knowledge, trigeminal neuropathic pain secondary to bee sting has not been reported previously in the literature. We report the case of a 52-year-old male patient with right-sided trigeminal neuropathic pain that began a month earlier, following a honeybee sting to the right forehead. The patient was successfully treated by CT-guided percutaneous trigeminal tractotomy. The present report demonstrated that a honeybee sting may result in trigeminal neuropathic pain and CT-guided percutaneous trigeminal tractotomy is effective in the treatment of such cases.

Ultrastructural evaluation of Pulsed Radiofrequency and Conventional Radiofrequency lesions in rat sciatic nerve.

BACKGROUND: PRF treatment has recently been described as minimally neurodestructive alternative to radiofrequency heat lesions. Patients with some pain syndromes in whom the pain could not be controlled by alternative techniques may be treated using PRF. In the present study, our main goal was to evaluate and compare the ultrastructure of peripheral nerve tissue that was heated by PRF, CRF with 42 degrees C, and CRF with 70 degrees C. METHODS: Forty-five male rats were divided into 5 groups. In PRF group and CRF with 42 degrees C group, the sciatic nerve was heated at a temperature of 42 degrees C for 120 seconds. As a positive control, some rat sciatic nerves were treated with CRF lesions at 70 degrees C. The rats were kept alive for 21 days and then killed. Tissue was evaluated with transmission electron microscope, and grading was done to the groups. RESULTS: The unmyelinated nerve fibers were ultrastructurally normal in all groups. The results of myelinated axons indicated that PRF group had better grades, and CRF with 70 degrees C group had the worst grade. Especially, comparison of the group of PRF and CRF with 42 degrees C revealed significant difference. In PRF group, none of the myelinated axons showed severe degeneration findings, and most of the damaged myelinated axons showed only separation in myelin configuration. CONCLUSIONS: PRF treatment may cause separation in myelinated axons. However, it seems that all changes were reversible. The present study supports the hypothesis that pulsed RF treatment does not rely on thermal injury of neurologic tissue to achieve its effect.

Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy.

OBJECTIVE: Pain, usually a response to tissue damage, is accepted as an unpleasant feeling generating a desire to escape from the causative stimulus. Although, in the early stages of malignant diseases, pain is seen in 5% to 10% of cases, this rate reaches nearly 90% in the terminal stage, and pain becomes a primary symptom. Cordotomy is one of the treatment choices in pain caused by malignancies localized unilaterally to the extremities as well as the thorax and the abdomen. METHODS: The target of computed tomography (CT)-guided percutaneous cordotomy is the lateral spinothalamic tract located in the anterolateral region of the spinal cord at the C1-C2 level. Between 1987 and 2007, CT-guided percutaneous cordotomies were performed in 207 patients; most (193 patients) suffered from intractable pain related to malignancy. The patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively. RESULTS: The initial success rate of CT-guided percutaneous cordotomy was 92.5%. The success rate was higher in the malignancy group. In the cancer group, selective cordotomy (pain sensation denervated only in the painful region of the body) was achieved in 83%. In 12 cases, bilateral selective percutaneous cordotomy was successfully applied. CONCLUSION: In the treatment of intractable pain, CT-guided cordotomy is an option in specially selected cases with malignancy. In this study, anatomic and technical details of the procedure and the experience gained from treating 207 patients over a 20-year period are discussed.

Computed tomography-guided percutaneous trigeminal tractotomy-nucleotomy.

OBJECTIVE: The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia. METHODS: In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively (postoperative Day 1). RESULTS: The best results were obtained in the second-largest group (vagoglossopharyngeal neuralgia, n = 17) and in geniculate neuralgia (n = 4). Patients with atypical facial pain (n = 21; 13 women, eight men) accounted for the largest group to undergo computed tomography-guided TR-NC surgery; pain relief was achieved in 19 of these patients. In the third-largest group (craniofacial and oral cancer pain, n = 13), 11 of 13 patients were successfully treated with TR-NC. Four of five patients with failed trigeminal neuralgia were also effectively treated with TR-NC. CONCLUSION: We propose that computed tomography-guided TR-NC provides direct visualization of the target-electrode relation and can be considered a first-step procedure in patient management. In view of its high efficacy, low complication rate, and minimal invasiveness, computed tomography-guided trigeminal TR-NC is a safe and effective procedure in the treatment of intractable facial pain syndromes.

Spinal and nucleus caudalis dorsal root entry zone operations for chronic pain.

OBJECTIVE: Dorsal root entry zone (DREZ) operations came into medical practice after the demonstration of increased electrical activity in the dorsal horn of the spinal cord and brainstem in patients with deafferentation of the central nervous system after injury to these areas. The aim of the study was to describe the technique and the effectiveness of spinal DREZ and nucleus caudalis (NC) DREZ operations, which may be the treatments of choice in unique chronic pain conditions that do not respond to medical therapy or any other surgical methods. METHODS: Fifty-five patients (44 spinal, 11 NC DREZ) underwent 59 (48 spinal, 11 NC DREZ) operations. There were 44 men and 11 women with a mean age of 46.4 years (range, 24-74 yr). The mean follow-up period was 72 months (range, 6 mo-20 yr). Follow-up assessments were performed with clinical examination on the first day and in the sixth and twelfth months postoperatively. Patients' pain scores and Karnofsky Performance Scale scores were also evaluated pre- and postoperatively. RESULTS: The initial success rates for spinal and NC DREZotomy procedures were 77 and 72.5%, respectively. In the spinal DREZotomy group, mortality occurred in one patient (2.2%). There were two cases of transient muscle weakness (4.4%) and two of cerebrospinal fluid fistulae (4.4%). In the NC DREZotomy group, mortality occurred in one patient (9%). There were two cases of transient ataxia (18%) and two of transient hemiparesis (18%). CONCLUSION: Spinal and trigeminal NC DREZ operations are effective in the treatment of intractable pain syndromes, especially in traumatic brachial plexus avulsions, segmental pain after spinal cord injury, postherpetic neuralgia, topographically limited cancer pain, and atypical facial pain.

Evaluation of platybasia in patients with idiopathic trigeminal neuralgia.

BACKGROUND: Vascular compression of the trigeminal nerve is generally accepted as the primary source causing TN. To date, skull base bone deformity associated with ITN has been reported in only a number of case reports. The aim of the present study was to investigate one such skull base deformity, platybasia, in ITN patients in comparison with a randomized control population. METHODS: Basal angle values reflecting the development of platybasia were measured in 25 patients with ITN and compared with the measurements in 25 control subjects. RESULTS: Basal angle measured to investigate the existence of platybasia was found significantly wider in the ITN group (t = 3.90; P < .001), although platybasia was present in only 10 patients. Moreover, the average angle was also greater in the study group than in the control group, and the difference was statistically significant. Platybasia was found in 10 patients, whereas it was detected in only 2 control individuals; difference in platybasia incidence between the 2 groups was also statistically significant (chi(2) = 7.01; P < .01). CONCLUSION: Our data demonstrated that platybasia affecting the bony walls of the posterior fossa may play an important role in the pathogenesis if vascular abnormalities causing TN.

Süleymaniye Külliyesi: a historically important medical, scientific, and cultural center.

SCIENCE HAS MANY Western and Eastern historical roots. All of these contributed to the body of academic literature. One of the most important aspects of scientific progress is educational institutions, including hospitals, schools, and libraries. Some of these institutions may offer an identity for a city, as well as contribute to its development. Süleymaniye Külliyesi is one such institution. Süleymaniye Külliyesi, established in the 16th century, contains many centers, including a mosque, surrounded by a hospital, school of medicine, central pharmacy, and library. It once served both the Ottoman Empire and the Turkish Republic. The school of medicine of this complex was the first school of medicine in the Ottoman period that functioned in coordination with the hospital and central pharmacy. The library contains many rare books and manuscripts. Currently, it is one of the richest centers in the field of oriental studies. We conclude that Süleymaniye Külliyesi, with its health-related elements and library, contributed to the development and progress of science and deserves to be cited in the literature of the Western world.

A neurosurgical view of anatomical variations of the distal anterior cerebral artery: an anatomical study.

OBJECT: The vascularization pattern of the anatomy of the distal anterior cerebral artery (ACA) remains a subject of debate. The authors provide detailed information about the distal ACA and shed light on issues concerning it that have not previously been adequately discussed. METHODS: Fifty adult human brains (100 hemispheres) were obtained during routine autopsies. Cerebral arteries were separately cannulated and injected with latex. The vascularization patterns of the cortical branches and the variations of the arteries were investigated. The authors found that the distal ACA supplied all the inner surfaces of the frontal and parietal lobes and a median of one third of the outer surfaces. The origin of the arteries from the main trunk and their exit angles affected the vascularization patterns of the hemispheres. The authors redefine controversial terminology regarding the callosomarginal artery. CONCLUSIONS: In each hemisphere, the vascularization pattern of the distal ACA is different to a greater or lesser extent. An awareness of this fact will contribute significantly to surgical interventions.

The histopathological and electron-microscopic examination of the stereotactic pulsed radiofrequency and conventional radiofrequency thermocoagulation lesions in rat brain.

OBJECTIVE: Neurodestructive procedures have been used for treating intractable pain for a long time. Pulsed radiofrequency (RF) is a newly defined energy type. Pulsed RF may be used in the treatment of patients with some pain syndromes in whom the pain could not be controlled by the alternative techniques. The objective of the present study was to examine the histological and electron microscopical changes in rat brain after pulsed RF application. METHODS: Forty-five male rats were used in these experiments. Lesions were applied stereotactically to the target areas of the rat brains. Two different RF energy type were used as representative models of pulsed-RF and conventional-RF procedures. The rats were kept alive for 21 days and then killed. The effect of pulsed RF lesions on cerebral tissue ultrastructure was studied. RESULTS: In the pulsed RF group, intracytoplasmic edema, clarity of the mitochondrial cristas and opening in the cell membrane pores were observed on the electron microscopic examination. In the conventional RF group, these findings were more prominent. In the pulsed RF group, the ratio of the effected neurons was 5.5% on light microscopic examination. In the conventional RF group, the ratio of the effected neurons was 14.26% and central necrosis was observed additionally. DISCUSSION: Pulsed RF caused ultrastructural changes in the neurons. The pulsed RF may possibly cause a depression on the cell membrane potential by opening the cell membrane pores and resulting in the ion entrance into the cell cytoplasm and intracytoplasmic edema. However, it seems that all these changes were reversible.

Management of a hemidystonic patient with thalamotomy, campotomy and cervical dorsal root entry zone operation.

Several medical and surgical procedures have been presented for treatment of dystonia. Thalamotomy, pallidotomy, and campotomy are some of the surgical choices. This study presents a patient with dystonia who underwent a cervical dorsal root entry zone (DREZ) operation after thalamotomy and campotomy. A 23-year-old man who was resistant to medical treatment presented with left hemidystonia. Thalamotomy and campotomy were performed. The patient remarkably benefited from the procedure but dystonic complaints in his left arm continued. A cervical DREZ operation was performed 5 years after the first operation and the dystonic complaints decreased after the surgery. This article presents a new aspect for the treatment of dystonia. Based on the outcomes of the treatment, DREZ operation may be suggested as an alternative surgical treatment for patients with segmental dystonia located in the extremities.