Max Ward

Investigating Complications Associated With Occipital Nerve Stimulation: A MAUDE Study: COMPLICATIONS IN ONS

The objectives of this study are to utilize the MAUDE data base to enhance our understanding of the complication profile for Occipital Nerve Stimulation, a therapy for which the current level of evidence is limited. Additionally, it is our objective to describe a systematic approach to processing the MAUDE data, which addresses its flaws and enhances its utility.

Nasal Distortion in Short-Distance Photographs: The Selfie Effect

Nasal Distortion in Short-Distance Photographs: The Selfie Effect The selfie, or self-photograph, has rapidly become one of the major photographic modalities of our time; in 2014 alone, there were over 93 billion selfies taken on Android phones per day.1,2 Despite the ease with which selfies are taken, the short distance from the camera causes a distortion of the face owing to projection, most notably an increase in nasal dimensions. According to a poll by the American Academy of Facial Plastic and Reconstructive Surgeons, 42% of surgeons reported patients seeking cosmetic procedures for improved selfies and pictures on social media platforms.3 We present a mathematical model to describe the distortive effects, prove the increased perceived nasal size in selfies, and calculate the magnitude of this effect from different camera distances. No patient intervention or contact was made during this study and was therefore exempt from institutional review board review.

The 50 Most Cited Articles in Invasive Neuromodulation

OBJECTIVEnBibliometric analysis is a commonly used analytic tool for objective determination of the most influential and peer-recognized articles within a given field. This study is the first bibliometric analysis of the literature in the field of invasive neuromodulation, excluding deep brain stimulation. The objectives of this study are to identify the 50 most cited articles in invasive neuromodulation, provide an overview of the literature to assist in clinical education, and evaluate the effect of impact factor on manuscript recognition.nnnMETHODSnBibliometric analysis was performed using the Science Citation Index from the Institute for Scientific Information, accessed through the Web of Science. Search terms relevant to the field of invasive neuromodulation were used to identify the 50 most cited journal articles between 1900 andxa02016.nnnRESULTSnThe median number of citations was 236 (range, 173-578). The most common topics among the articles were vagus nerve stimulation (nxa0= 24), spinal cord stimulation (nxa0= 9), and motor cortex stimulation (nxa0= 6). Median journal impact factor was 5.57. Most of these articles (nxa0= 19) contained level I, II, or III evidence.nnnCONCLUSIONSnThis analysis provides a brief look into the most cited articles within the field, many of which evaluated innovated procedures and therapies that helped to drive surgical neuromodulation forward. These landmark articles contain vital clinical and educational information that remains relevant to clinicians and students within the field and provide insight into areas of expanding research. Journal impact factor may play a significant role in determining the literary relevance and general awareness of invasive neuromodulation studies.

Endoscopic Pericranial Flap Repair of Occipital-Frontal Electrode Erosion

INTRODUCTIONnOccipital-frontal nerve stimulation is an off-label therapy for treating chronic refractory migraine and orofacial pain. Though effective, patients experience a high rate of complications including lead migration and erosion through the overlying skin.nnnCASE DESCRIPTIONnWe present a case of frontal electrode erosion that was revised via pericranial flap repair. The patient presented with multiple lead migrations, necessitating multiple revision surgeries with eventual frontal wound dehiscence. The choice was made to wrap the electrode in a pericranial flap to prevent recurrent lead migration. Two weeks postoperatively, the wound was well healed and the patient reported that the midline electrode was functioning properly.nnnDISCUSSIONnPericranial flap revision confers little additional risk when compared with simple wound closure, and the surgeon can proceed without total electrode removal, additional incisions, or lead tunneling. The flap provides a highly vascular additional layer of stability to the electrode, reducing the likelihood of further lead exposure without compromising the efficacy of the device. These results suggest that endoscopic pericranial flap revision is a viable technique for the repair of occipital nerve stimulation lead erosions.

Novel Association Between Intrathecal Drug Administration and Arachnoiditis Ossificans

BACKGROUNDnWe present a case of delayed progression of adhesive arachnoiditis to arachnoiditis ossificans (AO) in a patient being treated with a high-dose polypharmaceutical intrathecal regimen.nnnCASE DESCRIPTIONnThe patient is a 39-year-old Caucasian male who was implanted with an intrathecal pump in 2006 to control severe low back pain and administered intrathecal pain medication for a period of 10 years. In 2016, he developed new-onset radicular pain and worsened sensation in his lower extremities. Computed tomography scan of the lumbar spine at that time demonstrated profound calcification of the arachnoid consistent with a diagnosis of AO. It was presumed that prolonged high-dose intrathecal medication precipitated this condition, and his intrathecal medications were titrated down with removal of the pump.nnnCONCLUSIONSnIt is unlikely that his condition occurred as a result of prior surgery, with the more likely cause being hyperplasia of the spinal arachnoid, leading to scarring and calcification, due to the high-dose intrathecal regimen. This case highlights the delayed progression from stable arachnoiditis to AO concurring with a regimen of high-dose intrathecal medications. Clinicians should closely monitor patients undergoing intrathecal drug administration, particularly at elevated doses, for indications of damage to the spinal arachnoid mater.

Minimally Invasive Trigeminal Ablation: Transoral Approach for Targeting V2

BACKGROUNDnTrigeminal neuralgia (TN) is a chronic orofacial pain syndrome, which manifests as severe pain in the distribution of any trigeminal nerve branch. Though traditionally responsive to anticonvulsant therapy, TN can become refractory to medications and require surgical intervention.nnnCASE DESCRIPTIONnWe present a case of V2 TN that was treated with minimally invasive trigeminal ablation. The patient presented with a 6-year history of type 1 TN and had failed the maximum tolerated doses of carbamazepine and gabapentin. There was no evidence of vascular compression on neuroimaging. After the patient refused stereotactic radiosurgery, she was offered minimally invasive trigeminal ablation. At 5 months postoperatively the patient reported complete alleviation of pain with tolerable sensorineural numbness.nnnCONCLUSIONSnThe endoscopic approach allows for precise targeting of V2, which is ideal in patients undergoing targeted neuroablation for pain. This is the first documented case of a transoral endoscopic approach toward ablative V2 TN management.

Minimally Invasive Trigeminal Ablation: Novel Transoral Technique for Targeted Treatment of V3

BACKGROUNDnTrigeminal neuralgia (TN) is a chronic orofacial pain syndrome that presents with debilitating shooting pains in the V3 nerve distribution. The condition is traditionally responsive to anticonvulsant therapy; however, cases that become refractory to medications often require surgical intervention.nnnCASE DESCRIPTIONnWe present a case of TN that was treated with minimally invasive trigeminal ablation. The patient presented with a 6-year history of TN that had been resistant to medical management. The patient opted for minimally invasive management, refused stereotactic radiosurgery, and was treated using the minimally invasive trigeminal ablation approach. At 16 weeks postoperatively, the patient reported complete alleviation of pain with minimal sensorineural numbness.nnnCONCLUSIONSnThe endoscopic approach allows for precise targeting through visual guidance, which is ideal in patients undergoing neuroablation for pain within specific nerve distributions. This is the first documented case of an endoscopic minimally invasive transoral approach toward ablative TN management.

Pituitary Apoplexy following Endoscopic Retrograde Cholangiopancreatography

BACKGROUNDnPituitary apoplexy is an uncommon neurosurgical emergency that may be the initial presentation of undiagnosed pituitary adenomas. Though the exact pathogenesis is unclear, there appears to be an association between pituitary apoplexy and medical interventions that disturb the blood supply and venous drainage of the abnormal sellar region. We present the first case of pituitary apoplexy occurring after an endoscopic retrograde cholangiopancreatography (ERCP).nnnCASE DESCRIPTIONnA 43-year-old male who was several hours status post ERCP presented with a severe headache, bilateral ptosis, and multidirectional ophthalmoplegia. Computed tomography scan and magnetic resonance imaging of the brain revealed a hemorrhagic and necrotic sellar mass with suprasellar extension compressing the optic chiasm and bilateral extension displacing the cavernous carotid arteries laterally. The patient underwent emergent endoscopic endonasal transsphenoidal resection of the underlying pituitary tumor apoplexy with eventual resolution of his cranial nerve palsies.nnnCONCLUSIONSnAlthough pituitary apoplexy has been recognized as a sequela of surgical and laparoscopic procedures, it should also be considered in less invasive gastrointestinal procedures which may alter the intraabdominal pressures, such as ERCP. Early detection of this unusual complication allows for rapid diagnosis and timely surgical intervention in select cases to prevent debilitating cranial nerve palsies, preserve visual function, and retain normal pituitary function.

Post-Traumatic Pituitary Tumor Apoplexy After Closed Head Injury: Case Report and Review of the Literature

BACKGROUNDnHead trauma is a rare inciting factor of pituitary apoplexy (PA); however, there is a clear temporal relationship between trauma and apoplexy, and this is the first reported case of PA after an assault.nnnCASE DESCRIPTIONnWe present a rare case of a 63-year-old man who developed PA after sustaining a closed head injury from assault with a metal pole. The patient had a known pituitary tumor for which he had previously declined surgical resection. On initial computed tomography scan, there was no traumatic intracerebral hemorrhage or subarachnoid hemorrhage. There was sellar expansion but no obvious sellar hemorrhage. Within 48 hours of admission, the patient was presumed septic after developing altered mental status, fevers, hypotension, and tachycardia. Magnetic resonance imaging of the brain with and without gadolinium revealed a poorly enhancing, necrotic, and hemorrhagic pituitary mass, consistent with pituitary tumor apoplexy. After administration of intravenous glucocorticoids, the patient underwent emergent endoscopic transsphenoidal resection of the pituitary tumor apoplexy. Postoperatively, the patient had neurologic improvement with stable vision.nnnCONCLUSIONSnEarly and accurate diagnosis is important to allow for timely neurosurgical intervention. Symptoms of fever, hypotension, and tachycardia in a patient with a known sellar mass should raise the suspicion of hypocortisolemia from pituitary tumor apoplexy.

Assessment of YouTube as an Informative Resource on Facial Plastic Surgery Procedures

Assessment of YouTube as an Informative Resource on Facial Plastic Surgery Procedures YouTube is a major modality for patient education. During the last decade, videos documenting facial plastic surgery procedures, patient experiences, and medical commentary have garnered hundreds of millions of views. The growing prevalence of YouTube as a primary source of medical information has prompted investigators to evaluate video quality and creator qualification.1,2 To date, the quality of facial plastic surgery content on YouTube has not been evaluated.