Surgical Interventions Targeting the Nucleus Caudalis for Craniofacial Pain: A Systematic and Historical Review.

INTRODUCTION: Craniofacial pain is a prevalent group of conditions, and when refractory to conventional treatments, it poses a significant burden. The last decade has seen a renewed interest in the multimodal management of pain. Interventions targeting the nucleus caudalis (NC) of the trigeminocervical complex have been available as a treatment option since the 1930s, yet evidence for efficacy remains limited. MATERIALS AND METHODS: We present a systematic review of the literature providing a historical perspective on interventions targeting the NC leading up to the present. We examine the various intervention techniques, clinical indications, and procedural efficacy. A novel outcome-reporting scheme was devised to enable comparison among studies owing to historically variable reporting methods. RESULTS: A review of the literature revealed 33 retrospective studies published over the last 80 years, reporting on 827 patients. The most common technique was the open NC dorsal root entry zone nucleotomy/tractotomy; however, there has been an emergence of novel approaches such as endoscopic and spinal cord stimulation in the last ten years. Regardless of intervention technique or preoperative diagnosis, 87% of patients showed improvement with treatment. CONCLUSIONS: The literature surrounding NC intervention techniques is reviewed. Recent advancements and the wide range of craniofacial pain syndromes for which these interventions show potential efficacy are discussed. New and less invasive techniques continue to emerge as putative therapeutic options. However, prospective studies are lacking. Furthermore, the evidence supporting even well-established techniques remains of poor quality. Future work should be prospective, use standard outcome reporting, and address efficacy comparisons between intervention type and preoperative diagnosis.

High-fidelity, simulation-based microsurgical training for neurosurgical residents.

OBJECTIVE: Simulation is increasingly recognized as an important supplement to operative training. The live rat femoral artery model is a well-established model for microsurgical skills simulation. In this study, the authors present an 11-year experience incorporating a comprehensive, longitudinal microsurgical training curriculum into a Canadian neurosurgery program. The first goal was to evaluate training effectiveness, using a well-studied rating scale with strong validity. The second goal was to assess the impact of the curriculum on objective measures of subsequent operating room performance during postgraduate year (PGY)-5 and PGY-6 training. METHODS: PGY-2 neurosurgery residents completed a 1-year curriculum spanning 17 training sessions divided into 5 modules of increasing fidelity. Both perfused duck wing and live rat vessel training models were used. Three modules comprised live microvascular anastomosis. Trainee performance was video recorded and blindly graded using the Objective Structured Assessment of Technical Skills Global Rating Scale. Eleven participants who completed the training curriculum and 3 subjects who had not participated had their subsequent operative performances evaluated when they were at the PGY-5 and PGY-6 levels. RESULTS: Eighteen participants completed 106 microvascular anastomoses during the study. There was significant improvement in 6 measurable skills during the curriculum. The mean overall score was significantly higher on the fifth attempt compared with the first attempt for all 3 live anastomotic modules (p < 0.001). Each module had a different improvement profile across the skills assessed. Those who completed the microvascular skills curriculum demonstrated a greater number of independent evaluations during superficial surgical exposure, deep exposure, and primary maneuvers at the PGY-5 and PGY-6 levels. CONCLUSIONS: High-fidelity microsurgical simulation training leads to significant improvement in microneurosurgical skills. Transfer of acquired skills to the operative environment and durability for at least 3 to 4 years show encouraging preliminary results and are subject to ongoing investigation.

Effects of systemic corticosteroid treatment on pseudotumoral hemicerebellitis: a case report and literature review.

PURPOSE: Pseudotumoral hemicerebellitis is an acute, unilateral inflammation of the cerebellum that typically affects the pediatric population. The purpose of this paper is to review cases of pseudotumoral hemicerebellitis in the literature and evaluate if treatment with systemic corticosteroids reduces length of time to symptomatic recovery. METHODS: We present a case report of a 12-year-old male with pseudotumoral hemicerebellitis and unilateral cerebellar dysfunction. Additionally, we review the thirty-five reported cases of pseudotumoral hemicerebellitis with respect to length of time to symptomatic recovery with or without systemic corticosteroid treatment. RESULTS: Thirty cases reported length of time to symptomatic recovery. Including our case, the mean time to recovery for those treated with systemic corticosteroids (n = 20) was 48.05 days (SE = 16.3). The mean time to recovery for those treated without (n = 10) was 86.7 days (SE = 29.3). CONCLUSIONS: Treatment with systemic corticosteroids was associated with a faster time to symptomatic recovery compared to without. Regardless of etiology, reducing inflammation and mass effect involved in pseudotumoral hemicerebellitis may be integral to a more rapid return to neurological baseline.