Marshall T. Holland

The Cost-Effectiveness of Surgery for Trigeminal Neuralgia in Surgically Naïve Patients: a Retrospective study.

OBJECTIVE For 75% of patients with trigeminal neuralgia (TN), the pain can be controlled with medication. For those who fail medication therapy, surgical options include microvascular decompression (MVD), percutaneous radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS). Few studies have explored the relative cost-effectiveness of these interventions, particularly in surgically naïve patients. METHODS A retrospective chart review performed between January 2003 and January 2013 identified a total of 89 patients who underwent surgical treatment for TN (MVD=27, RFR=23, SRS=39). Outcome measures included facial pain (excellent=no pain, no medications; good=no pain, medications required; fair=>50% decrease in pain; and poor=<50% decrease in pain/secondary surgery), numbness, cost, and the need for a subsequent procedure. RESULTS The average age of patients for each procedure was MVD=53.9±16, RFR=76.2±16, and SRS=74.5±12 (p<0.001 MVD vs. other modalities). Total charges for the procedures (US dollars) were MVD=50,100±9600, RFR=4700±2200, and SRS=39,300±6000 (p<0.001). Actual collections varied by insurance. Percentages of postoperative facial numbness were MVD=11%, RFR=52%, and SRS=28% (p<0.01). At two years, the rates of recurrence requiring a second procedure were MVD=22%, RFR=74%, and SRS=31% (p<0.01). Average times to secondary procedure in months were MVD=26±29, RFR=59±76, and SRS=35±25. Mean quality adjusted pain-free years were MVD=1.58, RFR=2.28, and SRS=0.99. Cost-effectiveness calculations in US dollars showed MVD=31,800, RFR=2100, and SRS=39,600 (p<0.001). CONCLUSION There are significant cost differences among the three most common surgical procedures for TN. MVD was the most expensive procedure, was more likely to be performed on younger patients, had the lowest rate of facial numbness, and had the lowest rate of recurrence requiring a secondary procedure. SRS was slightly less costly, more likely to be performed on an older population, and had a rate of recurrence similar to MVD. RFR was the least expensive procedure, provided immediate relief, but was associated with the highest rates of facial numbness and recurrence. Based on cost-effectiveness, considering both cost and outcome, RFR was the most cost-effective, followed by MVD, and finally SRS.

Options in Treating Trigeminal Neuralgia: Experience With 195 Patients.

OBJECTIVE For patients with medically unresponsive trigeminal neuralgia (TN), surgical options include microvascular decompression (MVD), radiofrequency rhizotomy (RF), and stereotactic radiosurgery (SRS). In an attempt to identify the risks and benefits and cost inherent with each of the three modalities, we performed a retrospective review of our experience with 195 cases of TN treated over the past 15 years. METHODS Since 2001, 195 patients with previously untreated TN were managed: with MVD in 79, RF in 36, and SRS in 80. All patients reported herein underwent preoperative MRI. Women outnumbered men 122/73 (p=0.045). Follow-up after surgery was 32±46months. RESULTS The patients qualifying for MVD were generally healthier and younger, with a mean age±SD of 57±14, compared to those undergoing RF (75±15) or SRS (73±13, p<0.0001). In case of relapse, medical treatment was always tried and failed prior to consideration of surgical intervention. A second surgical procedure was necessary in 2, 23, and 18 patients initially treated with MVD, RF, and SRS respectively (p<0.0001). In the patients treated with MVD, RF, and SRS, the average number of procedures per patient necessary to achieve pain control was 1.1, 2.0, and 1.3 respectively (p=0.001). There were 7 complications in the patients treated with MVD but no deaths. Numbness was present in 13, 18, and 29 patients treated with MVD, RF, and SRS respectively (p=0.008). CONCLUSION MVD for TN is the treatment least likely to fail or require additional treatment. Patients who underwent MVD were younger than those undergoing RF or SRS. The highest rate of recurrence of TN was encountered in patients undergoing RF (64%). Facial numbness was least likely to occur with MVD (16%) compared to RF and SRS (50% and 36% respectively).

A Unique Case of Primary Ewing’s Sarcoma of the Cervical Spine in a 53-Year-Old Male: A Case Report and Review of the Literature

Extraskeletal Ewings sarcoma (EES) is a rare presentation, representing only 15% of all primary Ewings sarcoma cases. Even more uncommon is EES presenting as a primary focus in the spinal canal. These rapidly growing tumors often present with focal neurological symptoms of myelopathy or radiculopathy. There are no classic characteristic imaging findings and thus the physician must keep a high index of clinical suspicion. Diagnosis can only be definitively made by histopathological studies. In this report, we discuss a primary cervical spine EES in a 53-year-old man who presented with a two-month history of left upper extremity pain and acute onset of weakness. Imaging revealed a cervical spinal canal mass. After undergoing cervical decompression, histopathological examination confirmed a diagnosis of Ewings sarcoma. A literature search revealed fewer than 25 reported cases of primary cervical spine EES published in the past 15 years and only one report demonstrating this pathology in a patient older than 30 years of age (age = 38). Given the low incidence of this pathology presenting in this age group and the lack of treatment guidelines, each patients plan should be considered on a case-by-case basis until further studies are performed to determine optimal evidence based treatment.

Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation

The intrathecal space remains underutilized for diagnostic testing, invasive monitoring or as a pipeline for the delivery of neurological therapeutic agents and devices. The latter including drug infusions, implants for electrical modulation, and a means for maintaining the physiologic pressure column. The reasons for this are many but include unfamiliarity with the central nervous system and the historical risks that continue to overshadow the low complication rates in modern clinical series.

Value of Targeted Epidural Blood Patch and Management of Subdural Hematoma in Spontaneous Intracranial Hypotension: Case Report and Review of the Literature

BACKGROUND Spontaneous intracranial hypotension (SIH) is a more common than previously noted condition (1-2.5 per 50,000 persons) typically caused by cerebrospinal fluid (CSF) leakage. Initial treatment involves conservative therapies, but the mainstay of treatment for patients who fail conservative management is the epidural blood patch (EBP). Subdural hematoma (SDH) is a common complication occurring with SIH, but its management remains controversial. METHODS In this report, we discuss a 62-year-old woman who presented with a 5-week history of orthostatic headaches associated with nausea, emesis, and neck pain. Despite initial imaging being negative, the patient later developed classic imaging evidence characteristic of SIH. Magnetic resonance imaging was unrevealing for the source of the CSF leak. Radionuclide cisternography showed possible CSF leak at the right-sided C7-T1 nerve root exit site. After failing a blind lumbar EBP, subsequent targeted EBP at C7-T1 improved the patients symptoms. Two days later she developed a new headache with imaging evidence of worsening SDH with midline shift requiring burr hole drainage. This yielded sustained symptomatic relief and resolution of previously abnormal imaging findings at 2-month follow-up. RESULTS A literature review revealed 174 cases of SIH complicated by SDH. This revealed conflicting opinions concerning the management of this condition. CONCLUSIONS Although blind lumbar EBP is often successful, targeted EBP has a lower rate of patients requiring a second EBP or other further treatment. On the other hand, targeted EBP has a larger risk profile. Depending on the clinic situation, treatment of the SDH via surgical evacuation may be necessary.

Epidural Spinal Cord Stimulation: A Novel Therapy in the Treatment of Restless Legs Syndrome

BACKGROUND We report a unique finding of a patient whose restless legs syndrome (RLS) symptoms abated after the placement of a spinal cord stimulator for chronic neuropathic pain. RLS is a common disorder, with many patients unable to find sufficient relief from their symptoms. CASE DESCRIPTION A patient diagnosed with neuropathic pain who also suffered from RLS symptoms despite medication therapy underwent implantation of a spinal cord stimulator after a successful trial. This patient was interviewed formally about his RLS symptoms immediately before his procedure and at 6 weeks, 6 months, and 2.5 years after the procedure. The patient also completed the International Restless Legs Syndrome Scale questionnaire to objectively quantify the severity of his symptoms. Finally, the patient kept a 5-day journal detailing when the stimulator was in use. The patient reported subjective symptomatic improvement in his RLS symptoms with improved sleep quality and quantity, in addition to improvement in his back pain. The patients score on the International Restless Legs Syndrome Scale improved after implantation from 33 to 0 on a 40-point scale. Moreover, when asked to keep a journal record of his stimulator use, the patient noted that he only used the stimulator before going to bed to help his RLS symptoms and no longer required any medication for his previous RLS symptoms. CONCLUSIONS Epidural stimulation may be an additional, alternative, or novel therapy in the treatment of RLS.

Infantile cranial fasciitis: case-based review and operative technique

BackgroundCranial fasciitis (CF) is an uncommon benign primary lesion of the skull that typically affects the pediatric age group. Due to the rarity of CF, no prospective studies exist. Earliest description of this condition dates to 1980. The limited scientific and clinical literature regarding CF is dominated by case reports. For these reasons, questions pertaining to the true incidence, genetic risk factors, prognosis, and long-term outcome remain unanswered.DiscussionClinically, CF presents as a firm, painless, growing scalp mass that is typically not considered in the differential diagnosis. Preoperative pathognomonic signs and symptoms are absent, and imaging features are often nonspecific. Treatment is typically through complete surgical resection, at which time histopathological examination confirms the diagnosis of CF. Reconstruction of the skull defect in the child is critical. Autograft techniques help maintain a rigid construct that integrates with the native skull while preserving its continued ability to grow. Generally, a good outcome is observed with complete resection.Exemplary caseWe report a case of CF in an infant with emphasis on operative nuances and early follow-up results.ConclusionCF is a rare fibroproliferative disease that has a poorly defined incidence and long-term follow-up. Due to its locally invasive nature and nonspecific presentation, CF is often difficult to differentiate from malignancies and infections. Complete surgical resection is the best approach for diagnosis and cure. Its occult clinical presentation often allows it to achieve considerable growth, leaving a sizeable skull defect following resection. Since CF presents in the pediatric population, allograft reconstruction is preferred over titanium mesh or other synthetic materials to allow osseous integration and continued uninterrupted skull growth.

John C. Vangilder (1935–2007): Neurosurgical Leader and Founder of the Department of Neurosurgery at the University of Iowa

John C. VanGilder, the former professor and chairman of neurosurgery at The University of Iowa died on August 27, 2007 after making a lasting impact to the field of neurosurgery both in the United States and abroad. In this manuscript, we review VanGilders life and achievements. VanGilder was born in 1935 in West Virginia and received his undergraduate education at West Virginia University in Morgantown. He studied medicine at the University of West Virginia, completing his final 2 years at the University of Pittsburgh, and after serving in the U.S. military, completed his neurosurgical training at Washington University in St. Louis. He was appointed to faculty positions first at Yale University and later at The University of Iowa, where he became professor and later chairman of the Division of Neurosurgery. VanGilder also served as president of the Society of Neurological Surgeons (1997-1998), president of the Neurosurgical Society of America (1998-1999), chairman of the American Board of Neurological Surgery (1997-1998), and vice president of the American Academy of Neurological Surgery. At The University of Iowa, VanGilder played a key role in the transition of the Division of Neurosurgery to a Department of Neurosurgery and mentored several neurosurgeons who would go on to become department chairmen or make other important neurosurgical contributions at other medical schools in the United States.

Spinal dura mater: biophysical characteristics relevant to medical device development

Abstract Understanding the relevant biophysical properties of the spinal dura mater is essential to the design of medical devices that will directly interact with this membrane or influence the contents of the intradural space. We searched the literature and reviewed the pertinent characteristics for the design, construction, testing, and imaging of novel devices intended to perforate, integrate, adhere or reside within or outside of the spinal dura mater. The spinal dura mater is a thin tubular membrane composed of collagen and elastin fibres that varies in circumference along its length. Its mechanical properties have been well-described, with the longitudinal tensile strength exceeding the transverse strength. Data on the bioelectric, biomagnetic, optical and thermal characteristics of the spinal dura are limited and sometimes taken to be similar to those of water. While various modalities are available to visualise the spinal dura, magnetic resonance remains the best modality to segment its structure. The reaction of the spinal dura to imposition of a foreign body or other manipulations of it may compromise its biomechanical and immune-protective benefits. Therefore, dural sealants and replacements are of particular clinical, research and commercial interest. In conclusion, existing devices that are in clinical use for spinal cord stimulation, intrathecal access or intradural implantation largely adhere to traditional designs and their attendant limitations. However, if future devices are built with an understanding of the dura’s properties incorporated more fully into the designs, there is potential for improved performance.

Successful deep brain stimulation for central post-stroke pain and dystonia in a single operation

BACKGROUND Central post-stroke pain is known to be refractory to medications and difficult to manage. We present a case of central post-stroke pain associated with dystonia. Both conditions were successfully treated with a single deep brain stimulation (DBS) operation. CASE DESCRIPTION A 60-year-old female suffered a right posterior cerebral artery stroke following emergent clipping of a ruptured posterior cerebral artery aneurysm resulting in central post-stroke pain. This manifested as delayed left face and hemibody allodynia and hyperesthesia. The patient also developed marked left-sided dystonia. These progressive symptoms were disabling and refractory to conservative management. The patient underwent a single-stage DBS surgery with stereotactic targeting and implantation of two leads. One lead was placed in the right-sided ventral capsule/ventral striatum for treatment of pain and a second lead in the right-sided globus pallidus interna for treatment of dystonia. The surgical implantation proceeded without complication. The patients dystonia markedly improved following surgery. While her pain improved, she required multiple, meticulous programing sessions to achieve significant pain relief and decrease in pain medication use. Overall, the patient was satisfied with the results of her intervention. She did, however, have occasional intermittent spells of severe pain on top of her residual discomfort throughout her treatment course. Unfortunately, she died from small cell lung carcinoma a year after her DBS surgery. CONCLUSIONS Deep brain stimulation targeting multiple brain networks in one operation is feasible and safe. Deep brain stimulation may be considered in some refractory cases of central post-stroke pain; however, it requires meticulous programming.