Spinal cord stimulation as a treatment option for complex regional pain syndrome: a narrative review.

Objectives: This review aims to analyze the last years' experience of applying spinal cord stimulation (SCS) in complex regional pain syndrome (CRPS) patients with persistent or refractory chronic pain. Methods: This is a narrative review which was executed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and was carried out through the following databases: PUBMED and Cochrane Library. Also, a search for trials in the metaRegister of controlled trials (www.clinicaltrials.gov) was performed. Results: SCS provides pain reduction and improves sensory, vasomotor and sudomotor symptoms. It can reduce opioid using, offering better life quality for the patients. Conclusions: SCS found to be an excellent therapeutic alternative for patients with CRPS. It offers immediate pain relief and allows patients to regain functionality and have a better quality of life.

A Retrospective Analysis of Intrathecal Catheter Tip Position in Plain Radiography: How Much Do We Agree?

AIM: To assess interrater and intrarater reliability of postoperative plain radiographs, which are routinely performed to confirm the correct placement of the catheter tip after intrathecal drug delivery systems (IDDS) implantation. MATERIAL AND METHODS: This was a retrospective analysis of plain radiographs obtained from patients implanted with intrathecal catheters and morphine pumps. Each plain radiograph was assessed independently by three raters with varying expertise, at three different time points, to confirm the position of the intrathecal catheter tip. Krippendorff?s alpha coefficient was used to calculate both the interrater and intrarater reliability. RESULTS: There was a high level of agreement among the three raters and the three reviews of each rater separately when assessing the location of intrathecal catheter tips in plain radiographs from 126 patients. This was evidenced by the Krippendorff?s alpha value being > 0.99 in all cases, which was greater than the cutoff threshold value of 0.8. CONCLUSION: The interrater and intrarater reliability of plain radiographs for determination of catheter tip position after IDDS implantation was high. The experience and expertise of the raters did not significantly affect the assessments.

Spinal cord stimulation in the treatment of peripheral vascular disease: a systematic review - revival of a promising therapeutic option?

INTRODUCTION: Peripheral vascular disease (PVD) is caused by a blood circulation disorder of the arteries and Critical Limb Ischemia (CLI) is the advanced state of PVD. For patients with surgically non-reconstructable CLI, Spinal Cord Stimulation (SCS) appears to be an alternative therapeutic option. OBJECTIVE: The aim of our study was to investigate the efficacy of SCS in non-reconstructable CLI compared with the conservative treatment and re-appraise the existing literature in light of the recent advances in neuromodulation. METHODS: We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using electronic databases and reference lists for article retrieval. RESULTS: A total of 404 records were identified and finally 6 randomised controlled trials (RCTs), a Cochrane review and a meta-analysis were included in our systematic review. The studies assessed the efficacy of tonic SCS in the treatment of patients with non-reconstructable CLI compared with the conservative treatment. There is moderate to high quality evidence suggesting, that tonic SCS has beneficial effects for patients suffering from non-reconstructable CLI in terms of limb salvage, pain relief, clinical improvement and quality of life. The contradictory conclusions of the two meta-analyses regarding the efficacy of SCS for limb salvage at 12 months refer rather to the magnitude of the beneficial effect than to the effect itself. So far, the current literature provides evidence about the traditional tonic SCS but there is a lack of studies investigating the efficacy of new waveforms in the treatment of non-reconstructable CLI. CONCLUSION: SCS represents an alternative for PVD patients with non-reconstructable CLI and the existing literature provides encouraging clinical results, that should not be neglected. Instead, they should be re-appraised in light of the recent advances in neuromodulation with the emergence of novel waveform technologies and neuromodulation targets.

Prediction of Lumbar Disc Herniation Patients' Satisfaction with the Aid of an Artificial Neural Network.

AIM: To identify key determinants of lumbar disc herniation (LDH) patients' satisfaction and to evaluate the efficiency of an artificial neural network (ANN) model to prognosticate satisfaction derived from the hospital stay in this specific patient group. MATERIAL AND METHODS: A single item question was used to assess patient satisfaction. Principal component analysis evaluated several aspects of care (15 items). An ANN encompassed all variables and its prediction ability was tested. The ANN performance was correlated to a binary logistic regression (BLR) model. RESULTS: Higher levels of satisfaction were reported by females, older patients, Greeks, and patients with elementary education staying in not rural areas. A history of a single previous hospitalisation was correlated with more satisfaction. The accuracy of ANN was 96% for satisfaction prediction outperforming the BLR model. CONCLUSION: Satisfactory health services are influenced by sex, age, nationality, and number of prior admissions. The self-perceived health state plays also a crucial role. The current study is the first one reporting on the capability of an ANN to accurately predict the satisfaction levels of LDH patients.

An atypical meningioma demystified and advanced magnetic resonance imaging techniques.

A 40-year-old male presented with visuospatial processing disturbances. Family history was free. Conventional and advanced magnetic resonance imaging (MRI) studies were performed. On T2 and fluid attenuation inversion recovery images, an increased signal intensity extra-axial lesion was demonstrated. Post-contrast scans depicted homogeneous intense contrast medium enhancement. T2* star sequence was negative for hemorrhagic or calcification foci. Diffusion-weighted imaging findings were indicative of malignant behavior and magnetic resonance venography confirmed superior sagittal sinus infiltration. Increased cerebral blood volume values were observed and peri-lesional oedema on perfusion-weighted imaging was also demonstrated. The signal intensity-time curve depicted the characteristic meningioma pattern. Spectroscopy showed increased choline and alanine levels, but decreased N-acetyl-aspartate levels. Conventional MRI is adequate for typical types of meningiomas. However, the more atypical ones, in which even the histopathologic specimen may demonstrate characteristics of typical meningioma, could be easier diagnosed with advanced MRI techniques.

Spinal arteriovenous fistula with progressive paraplegia after spinal anaesthesia.

A case of an iatrogenic spinal arteriovenous fistula with progressive paraplegia in a young woman is reported. The fistula was eventually created after repetitive lumbar punctures performed in the process of spinal anaesthesia. Her symptoms were progressed to paraplegia over a period of 2 years. The digital subtraction angiography demonstrated a single-hole fistula, involving the anterior spinal artery and vein. The lesion was occluded by embolization with immediate improvement. The potential mechanism is discussed.

Organizational issues in stroke treatment: The Swiss paradigm - Stroke units.

Stroke represents the leading cause of acquired disability in adults and poses a tremendous socioeconomic burden both on patients and the society. In this sense, prompt diagnosis and urgent treatment are needed in order to radically reduce the devastating consequences of this disease. Herein the authors present the new guidelines recently adopted by the Swiss Stroke Society concerning the establishment of stroke units. Standardized treatment and allocation protocols along with an acute rehabilitation concept seem to be the core of the Swiss stroke management system. Coordinated multidisciplinary care provided by specialized medical, nursing and therapy staff is of utmost importance for achieving a significant dependency and death reduction. It is believed that the implementation of these guidelines in the stroke care system would be beneficial not only for the stroke patients, but also for the health system.

Virtual reality implementation in neurosurgical practice: the "can't take my eyes off you" effect.

During the last few years, virtual reality (VR) has been increasingly implemented in the neurosurgical practice. The scope of this paper is to briefly outline the educational role of this novel technology in training surgeons. At the same time, the ability of VR workstations such as the Dextroscope® to consistently simulate the surgical trajectory to the lesion-target is highlighted. The authors shed light to the current applications of VR systems in the neurosurgical field by describing not only the advantages of those systems, but their principal drawbacks as well. It seems that VR has come to stay and it is already the new best friend of residents due to its "Can't take my eyes off you effect".

Giuseppe Gradenigo: Much more than a syndrome! Historical vignette.

BACKGROUND: Giuseppe Gradenigo (1859-1926), a legendary figure of Otology, was born in Venice, Italy. He soon became a pupil to Adam Politzer and Samuel Leopold Schenk in Vienna, demonstrating genuine interest in the embryology, morphology, physiopathology, as well as the clinical manifestations of ear diseases. In this paper, the authors attempt to highlight the major landmarks during Gradenigo's career and outline his contributions to neurosciences, which have been viewed as looking forward to the 20(th) century rather than awkward missteps at the end of the 19(th). METHODS: Several rare photographs along with many non-English, more than a century old articles have been meticulously selected to enrich this historical journey in time. RESULTS: It was after Gradenigo that the well-known syndrome consisting of diplopia and facial pain due to a middle ear infection was named. However, Gradenigo was much more than a syndrome. Surprisingly, despite the fact that he is considered a pioneer of the Italian Otology of the late 19(th) and early 20(th) century, little is written of his life and his notable achievements in the English literature. CONCLUSIONS: Even though his name lives on nowadays only in the eponym "Gradenigo's syndrome," his accomplishments are much wider and cast him among the emblematic figures of science. His inherent tendency for discovering the underlying mechanisms of diseases and his vision of guaranteeing quality of services, professional proficiency, respect, and dedication toward the patients is in fact what constitutes his true legacy to the next generations.

Ponticulus posticus incidence in Brazilian Atlas vertebrae: a cadaveric study

The suboccipital segment of the vertebral artery (VA) passes around the lateral mass of atlas (C1). It is located in a groove on the superior surface of the arch of C1, the so-called vertebral artery sulcus (VAS). Occasionally, a small bony arch is found to connect the retroglenoid tubercle with the posterior arch of C1. This anatomical structure is known as ponticulus posticus (PP). The partial or total incidence of PP reported in the literature ranges from 5.14 percent to 51 percent. The clinical implication of PP includes the cervicogenic migraine, vertigo, and the Barre-Lieou syndrome. The scope of this paper is to determine the incidence of PP in isolated cadaveric vertebrae in the Brazilian population. The cervical vertebrae C1 from thirty not identified adult cadavers were examined at the Laboratory of Anatomy of the Federal University of Sergipe, Brazil. PP was present in 40 percent of evaluated C1 and it involved a complete bony arch in 42 percent of the cases. In 58 percent of the cases, PP was observed bilaterally. In the cases where the presence of PP was unilateral, this structure was situated exclusively on the right, even though a bigger incidence on the left side has been described for the majority of right-handed people. PP was a frequent finding in our study and its presence always must be suspected while setting the diagnosis of cervicogenic chronic headache and cervical pain without radiation to upper limbs.

Congenital inclusion dermoid cyst of the posterior fontanel: a case report

Background: Dermoid cysts are rare and benign tumors originating from failure of the normal embryologic development. Congenital inclusion dermoid cysts are usually located over the anterior fontanel. Surgical treatment is curative and provides good aesthetic results. The authors present a rare case of congenital inclusion dermoid cyst over the posterior fontanel and discuss the location, differential diagnosis, treatment and prognosis of this unusual pathological entity. Case description: A two-year old boy presented with a lesion on the posterior aspect of the head which had dated since birth. Imaging studies revealed an extracranial lesion over the posterior fontanel without intracranial extension. Surgical removal was performed and the histopathological examination confirmed the diagnosis of a dermoid cyst. The patient was discharged free of any medical complications. Conclusion: Although congenital inclusion dermoid cysts are more common over the anterior fontanel, they can occur over the posterior fontanel as well. Surgical treatment is curative in both locations with favorable aesthetic results.

Chronic subdural hematomas and the elderly: Surgical results from a series of 125 cases: Old "horses" are not to be shot!

BACKGROUND: To present the accumulated experience from treating chronic subdural hematomas (CSDH) in a local hospital of a third world country. METHODS: One hundred and twenty-five consecutive patients with CSDH who were surgically treated in the Neurosurgical Department of the Hospital da Restauração, Recife-PE, Brazil, between January 2006 and May 2008, were retrospectively studied. Glasgow Outcome Scale (GOS) was employed to define outcome at 6 months as good (GOS 4 and 5) or poor (GOS ≤ 3). Age, admission Glasgow Coma Scale (GCS), location of hematomas (unilateral/bilateral), drainage system placement and recurrence were all analyzed for potential impact on final outcome. RESULTS: The median age was 69 years, with a male/female ratio of 102/23. History of trauma was present in 60.8% of the patients. The median GCS on admission was 14. In 64 patients, the hematoma was on the left side, while in 42 patients it was on the right side. Bilateral hematomas were present in 19 cases (15.2%). Drainage systems were used in 93.6% of the cases. Recurrence occurred in 8.8% of the patients. One hundred and three patients obtained a good outcome at 6 months. The mortality rate was 11.2%. Patients with GCS ≥9 on admission presented better outcome (P < 0.05). Recurrent cases presented a poor outcome (P < 0.05). CONCLUSIONS: This study suggests that the main factors associated with outcome in patients harboring CSDH are the admission GCS score and the recurrence status. Advanced age is not a contraindication for surgical treatment. This study, solely focused on the Brazilian population, is the first of its kind in the English literature, and it could serve as a useful introduction to a more complex, multivariate, debate.

Ocular melanoma: Keep your eyes open for late brain metastases.

BACKGROUND: The most frequent intraocular malignant tumor is choroidal melanoma (CM). Although brain metastasis is a common feature of other types of cancers, metastasis of CM to the brain is a rare entity. CASE DESCRIPTION: The authors report a case of a 28-year-old woman presenting with a single brain metastasis, 10 years after the treatment of a CM. She underwent a total en-bloc resection of the lesion, and the diagnosis was confirmed histopathologically. The patient concomitantly received whole-brain irradiation therapy combined with chemotherapy, with a survival period of 24 months. CONCLUSION: The present case report draws attention to the necessity of a close and lifelong follow-up of patients treated for this malignancy. The international literature is also reviewed.

Intraventricular trigonal meningioma: Neuronavigation? No, thanks!

BACKGROUND: Most of the time meningiomas are benign brain tumors and surgical removal ensures cure in the vast majority of the cases. Thus, whenever possible, complete surgical resection should be the goal of the treatment. METHODS: This is a report of our surgical technique for the operative resection of a trigonal meningioma in a resource-limited setting. The necessity of accurate and deep knowledge of the regional anatomy is outlined. RESULTS: A 44-year-old male presented to our outpatient clinic complaining of cephalalgia increasing in frequency and intensity over the last month. His neurological exam was normal, yet a brain computed tomography scan revealed a lesion in the right trigone of the ventricular system. The diagnosis of possible meningioma was set. After thoroughly informing the patient, tumor resection was decided. An intraparietal sulcus approach was favored without the use of any modern technological aids such as intraoperative magnetic resonance imaging or neuronavigation. The postoperative course was uneventful and a postoperative computed tomography scan demonstrated the complete resection of the tumor. The patient was discharged two days later with no neurological deficits. In a two-year-follow-up he remains recurrence-free. CONCLUSION: In the current cost-effective era it is still possible to safely remove an intraventricular trigonal meningioma without the convenience of neuronavigation. Since the best neuronavigator is the profound neuroanatomical knowledge, no technological advancement could replace a well-educated and trained neurosurgeon.

Spinal metastasis of glioblastoma multiforme: an uncommon suspect?

STUDY DESIGN: Case report. OBJECTIVE: To report a case and review the literature on glioblastoma multiforme (GBM) with drop-like metastasis to the spine. SUMMARY OF BACKGROUND DATA: GBM constitutes the most common adult malignant brain tumor with poor prognosis. Spinal metastases of this malignancy are quite rare and dissemination usually occurs late in the course of the disease. However, recent advances in cancer treatment prolongate survival and provide adequate time for these metastases to give clinical symptoms. METHODS: We hereby present a case of a 57-year-old woman with a history of pineal GBM treated by stereotactic biopsy, chemotherapy, and radiotherapy, readmitted 38 months later due to gait disturbance, spastic paraparesis, edema of lower limbs, bilateral positive Babinski response, and loss of bladder control. A contrast-enhanced magnetic resonance imaging demonstrated an intramedullary lesion extending from C7 to T3 level. A T1 and T2 laminectomy was undertaken followed by extensive biopsy. RESULTS: Histologic examination was consistent with GBM. No further treatment was given, and the patient died 2 months after the diagnosis of the spinal metastasis. CONCLUSION: Spinal metastases should be commonly suspected in patients with a history of intracranial GBM who complain about symptoms not explained by the primary lesion.Glioblastoma multiforme (GBM) was first described by Rudolph Virchow in 1863 and represents the most common and most malignant tumor of the cerebral hemispheres, usually arising between the ages of 40 and 60 years. The incidence in Europe and North America is 2 to 3 cases/100,000 per year, and 75% of the patients die within 18 months after diagnosis. It is an infiltrating malignancy that recurs locally and it may spread along compact fiber pathways such as corpus callosum, optic irradiation, anterior commisure, and fornix or via cerebrospinal fluid (CSF) pathways. However, when GBM is under apparent control, spinal metastases are clinically rarely detected. Although involvement of the spinal cord (SC) has been noted with increasing frequency in recent years, literature provides only a few well documented cases.

Patient satisfaction questionnaire and quality achievement in hospital care: the case of a Greek public university hospital.

The scope of this research has been to investigate the satisfaction of Greek patients hospitalized in a tertiary care university public hospital in Alexandroupolis, Greece, in order to improve medical, nursing and organizational/administrative services. It is a cross-sectional study involving 200 patients hospitalized for at least 24 h. We administered a satisfaction questionnaire previously approved by the Greek Health Ministry. Four aspects of satisfaction were employed (medical, hotel facilities/organizational, nursing, global). Using principal component analysis, summated scales were formed and tested for internal consistency with the aid of Cronbach's alpha coefficient. The non-parametric Spearman rank correlation coefficient was also used. The results reveal a relatively high degree of global satisfaction (75.125%), yet satisfaction is higher for the medical (89.721%) and nursing (86.432%) services. Moreover, satisfaction derived from the hotel facilities and the general organization was found to be more limited (76.536%). Statistically significant differences in participant satisfaction were observed (depending on age, gender, citizenship, education, number of previous admissions and self-assessment of health status at the first and last day of patients' stay) for the medical, nursing and hotel facilities/organizational dimension, but not for global satisfaction. The present study confirms the results of previously published Greek surveys.