Category: Pain

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Invasive Motor Cortex Stimulation for Trigeminal Facial Neuropathic Pain Syndromes

clinical_significance_of_invasive_motor_cortex

Neurosurgery 79:655–666, 2016

Invasive neuromodulation of the cortical surface for various chronic pain syndromes has been performed for .20 years. The significance of motor cortex stimulation (MCS) in chronic trigeminal neuropathic pain (TNP) syndromes remains unclear. Different techniques are performed worldwide in regard to operative procedure, stimulation parameters, test trials, and implanted materials.

OBJECTIVE: To present the clinical experiences of a single center with MCS, surgical approach, complications, and follow-up as a prospective, noncontrolled clinical trial.

METHODS: The implantation of epidural leads over the motor cortex was performed via a burr hole technique with neuronavigation and intraoperative neurostimulation. Special focus was placed on a standardized test trial with an external stimulation device and the implementation of a double-blinded or placebo test phase to identify falsepositive responders.

RESULTS: A total of 36 patients with TNP were operated on, and MCS was performed. In 26 of the 36 patients (72%), a significant pain reduction from a mean of 8.11 to 4.58 (on the visual analog scale) during the test trial was achieved (P , .05). Six patients were identified as false-positive responders (17%). At the last available follow-up of 26 patients (mean, 5.6 years), active MCS led to a significant pain reduction compared with the preoperative pain ratings (mean visual analog scale score, 5.01; P , .05).

CONCLUSION: MCS is an additional therapeutic option for patients with refractory chronic TNP, and significant long-term pain suppression can be achieved. Placebo or double-blinded testing is mandatory.

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Long-term outcomes of intradural cervical dorsal root rhizotomy for refractory occipital neuralgia

ON

J Neurosurg 125:102–110, 2016

Occipital neuralgia (ON) causes chronic pain in the cutaneous distribution of the greater and lesser occipital nerves. The long-term efficacy of cervical dorsal root rhizotomy (CDR) in the management of ON has not been well described. The authors reviewed their 14-year experience with CDR to assess pain relief and functional outcomes in patients with medically refractory ON.

Methods A retrospective chart review of 75 ON patients who underwent cervical dorsal root rhizotomy, from 1998 to 2012, was performed. Fifty-five patients were included because they met the International Headache Society’s (IHS) diagnostic criteria for ON, responded to CT-guided nerve blocks at the C-2 dorsal nerve root, and had at least one follow-up visit. Telephone interviews were additionally used to obtain data on patient satisfaction.

Results Forty-two patients (76%) were female, and the average age at surgery was 46 years (range 16–80). Average follow up was 67 months (range 5–150). Etiologies of ON included the following: idiopathic (44%), posttraumatic (27%), postsurgical (22%), post–cerebrovascular accident (4%), postherpetic (2%), and postviral (2%). At last follow-up, 35 patients (64%) reported full pain relief, 11 (20%) partial relief, and 7 (16%) no pain relief. The extent of pain relief after CDR was not significantly associated with ON etiology (p = 0.43). Of 37 patients whose satisfaction-related data were obtained, 25 (68%) reported willingness to undergo repeat surgery for similar pain relief, while 11 (30%) reported no such willingness; a single patient (2%) did not answer this question. Twenty-one individuals (57%) reported that their activity level/functional state improved after surgery, 5 (13%) reported a decline, and 11 (30%) reported no difference. The most common acute postoperative complications were infections in 9% (n = 5) and CSF leaks in 5% (n = 3); chronic complications included neck pain/stiffness in 16% (n = 9) and upper-extremity symptoms in 5% (n = 3) such as trapezius weakness, shoulder pain, and arm paresthesias.

Conclusions Cervical dorsal root rhizotomy provides an efficacious means for pain relief in patients with medically refractory ON. In the appropriately selected patient, it may lead to optimal outcomes with a relatively low risk of complications.

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Neurosurgical treatment of glossopharyngeal neuralgia: analysis of 103 cases

GP neuralgia

J Neurosurg 124:1088–1092, 2016

The object of this study was to investigate the immediate and long-term follow-up results of glossopharyngeal nerve rhizotomy (GPNR) with or without partial vagus nerve rhizotomy (VNR) for treating glossopharyngeal neuralgia (GPN).

Methods A retrospective review of the case notes of patients who had undergone surgery for GPN in the authors’ department between 2008 and 2013 was performed to investigate baseline characteristics and immediate outcomes during the hospitalization. For the long-term results, a telephone survey was performed, and information on pain recurrence and permanent complications was collected. Pain relief meant no pain or medication, any pain persisting after surgery was considered to be treatment failure, and any pain returning during the follow-up period was considered to be pain recurrence. For comparative study, the patients were divided into 2 cohorts, that is, patients treated with GPNR alone and those treated with GPNR+VNR.

Results One hundred three procedures, consisting of GPNR alone in 38 cases and GPNR+VNR in 65 cases, were performed in 103 consecutive patients with GPN. Seventy-nine of the 103 patients could be contacted for the follow-up study, with a mean follow-up duration of 2.73 years (range 1 month–5.75 years). While there were similar results (GPNR vs GPNR+VNR) in immediate pain relief rates (94.7% vs 93.8%), immediate complication rates (7.9% vs 4.6%), and longterm pain relief rates (92.3% vs 94.3%) between the 2 cohorts, a great difference was seen in long-term complications (3.8% vs 35.8%). The long-term complication rate for the combined GPNR+VNR cohort was 9.4 times higher than that in the GPNR cohort. There was no operative or perioperative mortality. Immediate complications occurred in 6 cases, consisting of poor wound healing in 3 cases, and CSF leakage, hoarseness, and dystaxia in 1 case each. Permanent complications occurred in 20 patients (25.3%) and included cough while drinking in 10 patients, pharyngeal discomfort in 8 patients, and hoarseness and dysphagia in 1 case each.

Conclusions In general, this study indicates that GPNR alone or in combination with VNR is a safe, simple, and effective treatment option for GPN. It may be especially valuable for patients who are not suitable for the microvascular decompression (MVD) procedure and for surgeons who have little experience with MVD. Of note, this study renews the significance of GPNR alone, which, the authors believe, is at least valuable for a subgroup of GPN patients, with significantly fewer long-term complications than those for rhizotomy for both glossopharyngeal nerve and rootlets of the vagus nerve.

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Trigeminal and sphenopalatine ganglion stimulation for intractable craniofacial pain

Trigeminal and sphenopalatine ganglion stimulation for intractable craniofacial pain

Acta Neurochir (2016) 158:513–520

Facial pain is often debilitating and can be characterized by a sharp, stabbing, burning, aching, and dysesthetic sensation. Specifically, trigeminal neuropathic pain (TNP), anesthesia dolorosa, and persistent idiopathic facial pain (PIFP) are difficult diseases to treat, can be quite debilitating and an effective, enduring treatment remains elusive.

Methods We retrospectively reviewed our early experience with stimulation involving the trigeminal and sphenopalatine ganglion stimulation for TNP, anesthesia dolorosa, and PIFP between 2010–2014 to assess the feasibility of implanting at these ganglionic sites. Seven patients received either trigeminal and/or sphenopalatine ganglion stimulation with or without peripheral nerve stimulation, having failed multiple alternative modalities of treatment. The treatments were tailored on the physical location of pain to ensure regional coverage with the stimulation.

Results Fluoroscopy or frameless stereotaxy was utilized to place the sphenopalatine and/or trigeminal ganglion stimulator. All patients were initially trialed before implantation. Trial leads implanted in the pterygopalatine fossa near the sphenopalatine ganglion were implanted via transpterygoid (lateral-medial, infrazygomatic) approach. Trial leads were implanted in the trigeminal ganglion via percutaneous Hartel approach, all of which resulted in masseter contraction. Patients who developed clinically significant pain improvement underwent implantation. The trigeminal ganglion stimulation permanent implants involved placing a grid electrode over Meckel’s cave via subtemporal craniotomy, which offered a greater ability to stimulate subdivisions of the trigeminal nerve, without muscular (V3) side effects. Two of the seven overall patients did not respond well to the trial and were not implanted. Five patients reported pain relief with up to 24- month follow-up. Several of the sphenopalatine ganglion stimulation patients had pain relief without any paresthesias. There were no electrode migrations or post-surgical complications.

Conclusions Refractory facial pain may respond positively to ganglionic forms of stimulation. It appears safe and durable to implant electrodes in the pterygopalatine fossa via a lateral transpterygoid approach. Also, implantation of an electrode grid overlying Meckel’s cave appears to be a feasible alternative to the Hartel approach. Further investigation is needed to evaluate the usefulness of these approaches for various facial pain conditions.

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Motor cortex stimulation and neuropathic pain: how does motor cortex stimulation affect pain-signaling pathways?

Motor cortex stimulation and neuropathic pain- how does motor cortex stimulation affect pain-signaling pathways?

J Neurosurg 124:866–876, 2016

Neuropathic pain is often severe. Motor cortex stimulation (MCS) is used for alleviating neuropathic pain, but the mechanism of action is still unclear. This study aimed to understand the mechanism of action of MCS by investigating pain-signaling pathways, with the expectation that MCS would regulate both descending and ascending pathways.

Methods Neuropathic pain was induced in Sprague-Dawley rats. Surface electrodes for MCS were implanted in the rats. Tactile allodynia was measured by behavioral testing to determine the effect of MCS. For the pathway study, immunohistochemistry was performed to investigate changes in c-fos and serotonin expression; micro–positron emission tomography (mPET) scanning was performed to investigate changes of glucose uptake; and extracellular electrophysiological recordings were performed to demonstrate brain activity.

Results MCS was found to modulate c-fos and serotonin expression. In the mPET study, altered brain activity was observed in the striatum, thalamic area, and cerebellum. In the electrophysiological study, neuronal activity was increased by mechanical stimulation and suppressed by MCS. After elimination of artifacts, neuronal activity was demonstrated in the ventral posterolateral nucleus (VPL) during electrical stimulation. This neuronal activity was effectively suppressed by MCS.

Conclusions This study demonstrated that MCS effectively attenuated neuropathic pain. MCS modulated ascending and descending pain pathways. It regulated neuropathic pain by affecting the striatum, periaqueductal gray, cerebellum, and thalamic area, which are thought to regulate the descending pathway. MCS also appeared to suppress activation of the VPL, which is part of the ascending pathway.

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Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia

A Review of Percutaneous Treatments for Trigeminal Neuralgia

Neurosurgery 78:421–428, 2016

Despite >30 years of clinical use, the literature is still sparse when it comes to comparisons between percutaneous balloon compression (PBC) and percutaneous retrogasserian glycerol rhizolysis (PRGR) as treatments for trigeminal neuralgia.

OBJECTIVE: To perform a retrospective cohort comparison between PBC and PRGR with regard to therapeutic effect, side effects, and complications.

METHODS: Medical records and follow-up data from 124 primary PRGRs performed from 1986 to 2000 and 82 primary PBCs performed from 2000 to 2013 were reviewed. All patients had undergone clinical sensory testing and assessment of sensory thresholds. Analyses were performed to compare duration of pain relief, frequency of sensory disturbances, and side effects.

RESULTS: Median duration of pain relief was 21 months after PRGR and 20 months after PBC. Both methods carried a high risk of hypesthesia/hypalgesia (P < .001) that was partly reversed with time. Decreased corneal sensibility was common after PRGR (P < .001) but not after PBC. Dysesthesia was more common after PRGR (23%) compared after PBC (4%; P < .001). Other side effects were noted but uncommon.

CONCLUSION: PBC and PRGR are both effective as primary surgical treatment of trigeminal neuralgia. Both carry a risk of postoperative hypesthesia, but in this series, the side effect profile favored PBC. Furthermore, PBC is technically less challenging, whereas PRGR requires fewer resources. Between these 2 techniques, we propose PBC as the primary surgical technique for percutaneous treatment of trigeminal neuralgia on the basis of its lower incidence of dysesthesia, corneal hypesthesia, and technical failures.

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Degree of distal trigeminal nerve atrophy predicts outcome after microvascular decompression for Type 1a trigeminal neuralgia

Trigeminal neuralgia due to neurovascular conflicts from venous origin- an anatomical-surgical study-1

J Neurosurg 123:1512–1518, 2015

Trigeminal neuralgia is often associated with nerve atrophy, in addition to vascular compression. The authors evaluated whether cross-sectional areas of different portions of the trigeminal nerve on preoperative imaging could be used to predict outcome after microvascular decompression (MVD).

Methods A total of 26 consecutive patients with unilateral Type 1a trigeminal neuralgia underwent high-resolution fast-field echo MRI of the cerebellopontine angle followed by MVD. Preoperative images were reconstructed and reviewed by 2 examiners blinded to the side of symptoms and clinical outcome. For each nerve, a computerized automatic segmentation algorithm was used to calculate the coronal cross-sectional area at the proximal nerve near the root entry zone and the distal nerve at the exit from the porus trigeminus. Findings were correlated with outcome at 12 months.

Results After MVD, 17 patients were pain free and not taking medications compared with 9 with residual pain. Across all cases, the coronal cross-sectional area of the symptomatic trigeminal nerve was significantly smaller than the asymptomatic side in the proximal part of the nerve, which was correlated with degree of compression at surgery. Atrophy of the distal trigeminal nerve was more pronounced in patients who had residual pain than in those with excellent outcome. Among the 7 patients who had greater than 20% loss of nerve volume in the distal nerve, only 2 were pain free and not taking medications at long-term follow-up.

Conclusions Trigeminal neuralgia is associated with atrophy of the root entry zone of the affected nerve compared with the asymptomatic side, but volume loss in different segments of the nerve has very different prognostic implications. Proximal atrophy is associated with vascular compression and correlates with improved outcome following MVD. However, distal atrophy is associated with a significantly worse outcome after MVD.

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A single thalamic target for deep brain stimulation to treat hemi-body pain syndrome

A single thalamic target

Acta Neurochir (2015) 157:1519–1523

Patients experiencing hemi-body pain represent a difficult problem when using the thalamus as a DBS target given its anatomical topology.
Methods A 50-year-old HIV positive male underwent a right unilateral thalamic DBS to treat his severe left hemi-body central post-stroke pain following years of unsuccessful medication therapy.
Results The final active contact of the electrode corresponded to stimulation of the nucleus ventrocaudalis parvocellularis internis, which has provided prolonged pain relief.
Conclusion To our knowledge this was the first time this pattern of pain was treated by a single thalamic DBS electrode, suggesting stimulation in this region may be a feasible target for achieving relief from chronic severe hemi-body pain.

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Occipital Nerve Stimulation for the Treatment of Patients With Medically Refractory Occipital Neuralgia

Occipital Nerve Stimulation for the Treatment of Patients With Medically Refractory Occipital Neuralgia

Neurosurgery 77:332–341, 2015

Occipital neuralgia (ON) is a disorder characterized by sharp, electrical, paroxysmal pain, originating from the occiput and extending along the posterior scalp, in the distribution of the greater, lesser, and/or third occipital nerve. Occipital nerve stimulation (ONS) constitutes a promising therapy for medically refractory ON because it is reversible with minimal side effects and has shown continued efficacy with long-term follow-up.

OBJECTIVE: To conduct a systematic literature review and provide treatment recommendations for the use of ONS for the treatment of patients with medically refractory ON.

METHODS: A systematic literature search was conducted using the PubMed database and the Cochrane Library to locate articles published between 1966 and April 2014 using MeSH headings and keywords relevant to ONS as a means to treat ON. A second literature search was conducted using the PubMed database and the Cochrane Library to locate articles published between 1966 and June 2014 using MeSH headings and keywords relevant to interventions that predict response to ONS in ON. The strength of evidence of each article that underwent full text review and the resulting strength of recommendation were graded according to the guidelines development methodology of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Guidelines Committee.

RESULTS: Nine studies met the criteria for inclusion in this guideline. All articles provided Class III Level evidence.

CONCLUSION: Based on the data derived from this systematic literature review, the following Level III recommendation can be made: the use of ONS is a treatment option for patients with medically refractory ON.

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Decreased Probability of Initial Pain Cessation in Classic Trigeminal Neuralgia Treated With Gamma Knife Surgery in Case of Previous Microvascular Decompression

TN and radiosurgery

Neurosurgery 77:87–95, 2015

Microvascular decompression (MVD) is the reference technique for pharmacoresistant trigeminal neuralgia (TN).

OBJECTIVE: To establish whether the safety and efficacy of Gamma Knife surgery for recurrent TN are influenced by prior MVD.

METHODS: Between July 1992 and November 2010, 54 of 737 patients (45 of 497 with .1 year of follow-up) had a history of MVD (approximately half also with previous ablative procedure) and were operated on with Gamma Knife surgery for TN in the Timone University Hospital. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range, 3.9-11.9 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range, 70-90 Gy) was delivered.

RESULTS: The median follow-up time was 39.5 months (range, 14.1-144.6 months). Thirty-five patients (77.8%) were initially pain free in a median time of 14 days (range, 0- 180 days), much lower compared with our global population of classic TN (P = .01). Their actuarial probabilities of remaining pain-free without medication at 3, 5, 7, and 10 years were 66.5%, 59.1%, 59.1%, and 44.3%. The hypoesthesia actuarial rate at 1 year was 9.1% and remained stable until 12 years (median, 8 months).

CONCLUSION: Patients with previous MVD showed a significantly lower probability of initial pain cessation compared with our global population with classic TN (P = .01). The toxicity was low (only 9.1% hypoesthesia); furthermore, no patient reported bothersome hypoesthesia. However, the probability of maintaining pain relief without medication was 44.3% at 10 years, similar to our global series of classic TN (P = .85).

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Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach

Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach

J Neurosurg 122:1429–1432, 2015

Microvascular decompression (MVD) via lateral suboccipital craniotomy is the standard surgical intervention for trigeminal neuralgia (TN). For recurrent TN, difficulties are sometimes encountered when performing reoperation via the same approach because of adhesions and prosthetic materials used in the previous surgery.

In the present case report the authors describe the efficacy of the subtemporal transtentorial approach for use in recurrent TN after MVD via the lateral suboccipital approach. An 86-year-old woman, in whom an MVD via a lateral suboccipital craniotomy had previously been performed for TN, underwent surgery for recurrent TN via the subtemporal transtentorial approach, which provided excellent visualization of the neurovascular relationships and the trigeminal nerve without adhesions due to the previous surgery. Her TN disappeared after the MVD.

The present approach is ideal for visualizing the trigeminal root entry zone, and the neurovascular complex can be easily dissected using a new surgical trajectory. This approach could be another surgical option for reoperation when the previous MVD had been performed via the suboccipital approach

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Epidural spinal cord stimulation for neuropathic pain

Spinal_Cord_Stimulation_Devices_clip_image010

Acta Neurochir (2015) 157:739–741

Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neuropathic pain refractory to any conservative treatment. The aim of this data collection is to enforce evidence of SCS effectiveness on neuropathic chronic pain reported in the literature and to speculate on the usefulness of the trial period in determining the long–term efficacy. Moreover, the very low percentage of undesired side effects and complications reported in our case series suggests that all implants should be performed by similarly well-trained and experienced professionals.

Method A multicentric data collection on a common database from 11 Italian neurosurgical departments started 3years ago. Two different types of electrodes (paddle or percutaneous leads) were used. Of 122 patients, 73 % (N=89) were submitted to a trial period, while the remaining patients underwent the immediate permanent implant (N=33). Statistical comparisons of continuous variables between groups were performed.

Results Most of the patients (80 %) had predominant pain to their lower limbs, while only 17 % of patients had prevalent axial pain. Significant reduction in pain, as measured by variation in visual analogue scale (VAS) score, was observed at least 1 year after implantation in 63.8%of the cases, 59.5%of patients who underwent a test trial and 71.4% of patients who underwent permanent implant at once. No statistical differences were found between the lower-limb pain group and the axial pain group.

Conclusions No relevant differences in long-term outcomes were observed in previously tested patients compared with patients implanted at once. Through this analysis we hope to recruit new centres, to give more scientific value to our results.

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Frameless Stereotactic Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy to Perform Bilateral Anterior Cingulotomy for Intractable Pain

Frameless Stereotactic Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy to Perform Bilateral Anterior Cingulotomy for Intractable Pain

Operative Neurosurgery 11:17–25, 2015

Bilateral anterior cingulotomy is well described for certain pain and psychiatric disorders. Typically, stereotactic frame-based radiofrequency ablation is used. We report the feasibility of a frameless approach using magnetic resonance imaging-guided laser induced thermal therapy (MRgLITT).

OBJECTIVE: To report experience and outcomes for MRgLITT in bilateral anterior cingulotomy.

METHODS: Three patients with chronic refractory cancer-related pain underwent bilateral anterior cingulotomy. The Brief Pain Inventory (Short Form) was used for pain evaluation. Frameless stereotaxy using the Medtronic S7 Navigation system was used for laser catheter placement. Patients were followed for evaluation of pain control outcomes.

RESULTS: Four MRgLITT bilateral cingulotomy procedures were performed in 3 patients. Two patients had a single MRgLITT procedure while the third had repeat ablation after pain recurrence. First time ablation coordinates were (medians): x = 7.9 mm (range, 6.9-8.6); y = 20.5 mm(range, 20-22); z = 6.9 mm(range, 2.9-7.0) above the lateral ventricle roof. Median trajectory length was 85.5 mm (range, 80-90). Median ablation volume was 1.5 cm3 (range, 0.6-1.2). Median ablation time was 257 seconds (range, 136-338) per cingulum and power was 10.0 Watts (range, 10-11). Median preoperative pain severity (PSS) and interference scores (PIS) were 7.7 (range, 7.5-9.3) and 9.9 (range, 9.7-10.0), respectively. Median postoperative PSS and PIS scores were 1.6 (range, 1.0-2.8) and 2.0 (range, 0.3-2.6), respectively.

CONCLUSION: MRgLITT cingulotomy is well tolerated for treatment of cancer pain and can be easily performed framelessly for appropriate candidates.

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Vago-glossopharyngeal neuralgia

Vago-glossopharyngeal neuralgiaActa Neurochir (2015) 157:311–321

Glossopharyngeal neuralgia (GPN), or better named vago-glossopharyngeal neuralgia (VGPN), is a rare disorder amounting to 1 % of the incidence of trigeminal neuralgia (TN). Pain is paroxysmal, of the electrical shooting type, and mainly provoked by stimulation of the pharynx or deep throat, especially during swallowing. Due to its rarity, VGPN is often misdiagnosed. The front line of medical treatment is based on anticonvulsants. Surgery should be considered when the pain is refractory to medications. In most patients, the cause is neurovascular conflict on root entry zone (REZ) or midcistern portion, of the IXth and/or Xth cranial nerves. Compressive vessels can be evidenced by means of a high sensibility and a high specificity resolution MR imaging in most centers.

Present consensus is that the first option of neurosurgical treatment be microvascular decompression. In patients with precarious general conditions, stereotactic radiosurgery may be considered. Also, thermo-rhizotomy at the pars nervosa of foramen jugularis or tractotomy-nucleotomy at brainstem may be alternatives, but these methods entail a significant risk of deficits.

In this article, the authors reviewed the main literature series on neurosurgical treatments of this disease.

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Long-term outcome and prognostic factors after C2 ganglion decompression in 68 consecutive patients with intractable occipital neuralgia

Long-term outcome and prognostic factors after C2 ganglion decompression in 68 consecutive patients with intractable occipital neuralgia

Acta Neurochir (2015) 157:85–92

Occipital neuralgia is a rare cause of severe headache characterized by paroxysmal shooting or stabbing pain in the distribution of the greater occipital or lesser occipital nerve. In cases of intractable occipital neuralgia, a definite cause has not been uncovered, so various types of treatment have been applied. The aim of this study is to evaluate the prognostic factors, safety, and long-term clinical efficacy of second cervical (C2) ganglion decompression for intractable occipital neuralgia.

Methods Retrospective analysis was performed in 68 patients with medically refractory occipital neuralgia who underwent C2 ganglion decompression. Factors based on patients’ demography, pre- and postoperative headache severity/characteristics, medication use, and postoperative complications were investigated. Therapeutic success was defined as pain relief by at least 50 % without ongoing medication.

Results The visual analog scale (VAS) score was significantly reduced between the preoperative and most recent follow-up period. One year later, excellent or good results were achieved in 57 patients (83.9 %), but poor in 11 patients (16.1 %). The long-term outcome after 5 years was only slightly less than the 1-year outcome; 47 of the 68 patients (69.1 %) obtained therapeutic success. Longer duration of headache (over 13 years; p=0.029) and presence of retro-orbital/frontal radiation (p=0.040) were significantly associated with poor prognosis.

Conclusions In the current study, C2 ganglion decompression provided durable, adequate pain relief with minimal complications in patients suffering from intractable occipital neuralgia. Due to the minimally invasive and nondestructive nature of this surgical procedure, C2 ganglion decompression is recommended as an initial surgical treatment option for intractable occipital neuralgia before attempting occipital nerve stimulation. However, further study is required to manage the pain recurrence associated with longstanding nerve injury.

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Subdural motor cortex stimulation

Subdural motor cortex stimulation

Acta Neurochir (2014) 156:2289–2294

Motor cortex stimulation (MCS) is considered to be an effective treatment in some types of chronic refractory neuropathic pain. The aim of this study is to evaluate and confirm the feasibility, efficacy and security of our surgical technique for subdural motor cortex stimulation (SDMCS) on 18 consecutive cases with follow-up of at least 3 years.

Methods Our population consists of 18 consecutive patients (12male) between 2000 and 2010,with a mean age of 63 years (11–91). The mean follow-up was 86 months (20–140 months). We identified the central sulcus by using classical anatomic landmarks and neuronavigation (BrainLab system; BrainLAB, Inc., Redwood City, CA). An elongated craniotomy (3 cm in length, 1 cm in width)was performed followed by linear opening of the dura mater. An eight-polar plate electrode (Specify Lead, 3998;Medtronic,Minneapolis,MN) was then slipped smoothly through this linear opening. In patients with interhemispheric electrodes (patients 2 and 17), we performed a parasagittal craniotomy of 4 cm length and 2 cm width.

Results At last follow-up assessment, 14 patients had a favourable outcome (77.7 %): 10 patients with excellent relief of pain (>80 %), 1 with good relief of pain (60–80 %) and 3 with satisfactory relief of pain (50–60 %). Four patients showed bad results (<50 %). We did not observe any late complications specific to SD MCS.

Conclusion We report an efficacy at least as good as ED MCS, with no complications specific to SD MCS, even with prolonged follow-up. The data are insufficient to actually prove a lower energy use in SD MCS.

Keywords Neuropathic pain , Neurostimulation , Motor cortex stimulation, Subdural

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Surgical Management of Trigeminal Neuralgia: Use and Cost-Effectiveness From an Analysis of the Medicare Claims Database

SnapShotPNGOID_38_20121112T070408_110023

Neurosurgery 75:220–226, 2014

Trigeminal neuralgia is a relatively common neurosurgical pathology with multiple management options. Microvascular decompression (MVD) is nonablative and is considered the gold standard. However, stereotaxic radiosurgery (SRS) and percutaneous stereotaxic rhizotomy (PSR) are 2 noninvasive but ablative options that have rapidly gained support.

OBJECTIVE: To use Medicare claims data in conjunction with a literature review to assess the usage, effectiveness, and cost-effectiveness of the 3 different invasive treatments for trigeminal neuralgia.

METHODS: All of the claims of trigeminal neuralgia treatment were extracted from the 2011 5% Inpatient and Outpatient Limited Data Set. Current Procedural Terminology, 4th Edition/International Classification of Diseases, Ninth Revision codes for the 3 different surgical treatment modalities were used to further classify these claims. Kaplan-Meier survival curves in key articles were used to calculate quality-adjusted life years and costeffectiveness for each procedure.

RESULTS: A total of 1582 claims of trigeminal neuralgia were collected. Ninety-four (6%) patients underwent surgical intervention. Forty-eight (51.1%) surgical patients underwent MVD, 39 (41.5%) underwent SRS, and 7 (7.4%) underwent PSR. The average weighted costs for MVD, SRS, and PSR were $40 434.95, $38 062.27, and $3910.64, respectively. The qualityadjusted life yearswere 8.2 forMVD, 4.9 for SRS, and 6.5 for PSR. The cost per quality-adjusted life year was calculated as $4931.1, $7767.8, and $601.64 for MVD, SRS, and PSR, respectively.

CONCLUSION: This study shows that the most frequently used surgical management of trigeminal neuralgia is MVD, followed closely by SRS. PSR, despite being the most cost-effective, is by far the least utilized treatment modality.

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Retrogasserian balloon compression for treatment of trigeminal neuralgia. Series of 901 patients

RGBC

Surgical Neurology International 2014, 5:118

The aim of our study was to describe the retrogasserian balloon compression (RGBC) procedure with some personal tricks and to assess the long‑term results.

Methods: Between 1985 and 2012, 901 patients, suffering from refractory trigeminal neuralgia (TN), underwent RGBC procedure in our department. Concerning the surgical technique, the introducer was in close contact with the posterior extremity of the horizontal plate of the palatine bone and had the direction of the bisector of the angle clivus‑superior edge of the petrous bone on an X‑rays sagittal view. No metallic material was inserted intracranially. The balloon was inflated with 0.7 cc of contrast medium for 6 min.

Results: At 1 month follow up, appreciable pain relief was obtained in 835 patients (92.7%). At 1 year, results were excellent in 605 patients (67.1%), satisfactory in 109 patients (12.1%), poor in 57 patients (6.3%), fair in 66 patients (7.3%), whereas recurrences were observed in the remaining 64 patients (7.2%). At mean follow up of 16,5 years, 559 (62%) patients remained pain free. Twenty six patients (2,8%) continued to experience severe pain. Recurrences occurred in two hundred and fifty patients (27,8%). Fifty two of them were operated on a third time and 22 underwent four procedures.

Conclusion: RGBC is an appropriate and effective procedure for treatment of refractory TN, ensuring a long lasting pain relief predicted on three factors: pear shape of the balloon, its volume, and duration as mentioned earlier.

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Repeat microvascular decompression for recurrent idiopathic trigeminal neuralgia

TN

DOI: 10.3171/2014.7.JNS132667

Microvascular decompression (MVD) is considered the method of choice to treat idiopathic trigeminal neuralgia (TN) refractory to medical treatment. However, repeat MVD for recurrent TN is not well established. In this paper, the authors describe a large case series in which patients underwent repeat MVD for recurrent TN, focusing on outcome, risk factors, and complication rates.

Methods. Between 1990 and 2012, a total of 33 consecutive patients underwent repeat MVD for recurrent TN at the University Medical Center Groningen. The authors performed a retrospective chart review and telephone interviews. Risk factors were analyzed by binary logistic regression analysis.

Results. After 12 months of follow-up, 22 (67%) operations were successful, of which 19 patients were completely free of pain without medication. With multivariate analysis significant risk factors for success were older age (OR 1.11, p < 0.01) and direct absence of pain after repeat MVD (OR 25.2, p < 0.01). Previous neurodestructive procedures did not influence success rates. Facial numbness occurred in 9 patients (27%), while other morbidity was minimal. There was no mortality.

Conclusions. This study demonstrates that repeat MVD is a feasible therapeutic option with good chances of success, even in patients who have undergone neurodestructive procedures. Complication rates, particularly facial numbness, can be avoided if only a limited neurolysis is performed.

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Deep Brain Stimulation of the Anterior Cingulate Cortex

Anterior cingulate DBS

Neurosurgery 74:628–637, 2014

Deep brain stimulation (DBS) has shown considerable promise for relieving nociceptive and neuropathic symptoms of refractory chronic pain. Nevertheless, for some patients, standard DBS for pain remains poorly efficacious. Pain is a multidimensional experience with an affective component: the unpleasantness. The anterior cingulate cortex (ACC) is a structure involved in this affective component, and targeting it may relieve patients’ pain.

OBJECTIVE: To describe the first case series of ACC DBS to relieve the affective component of chronic neuropathic pain.

METHODS: Sixteen patients (13 male and 3 female patients) with neuropathic pain underwent bilateral ACC DBS. The mean age at surgery was 48.7 years (range, 33-63 years). Patient-reported outcome measures were collected before and after surgery using a Visual Analog Scale, SF-36 quality of life survey, McGill Pain Questionnaire, and EQ-5D (EQ-5D and EQ-5D Health State) questionnaires.

RESULTS: Fifteen patients (93.3%) transitioned from externalized to fully internalized systems. Eleven patients had data to be analyzed with a mean follow-up of 13.2 months. Post-surgery, the Visual Analog Scale score dropped below 4 for 5 of the patients, with 1 patient free of pain. Highly significant improvement on the EQ-5D was observed (mean, 120.3%; range, 10%-183%; P = .008). Moreover, statistically significant improvements were observed for the physical functioning and bodily pain domains of the SF-36 qualityof- life survey: mean, 164.7% (range, 28.9%-1276%; P = .015) and mean 139.0% (range, 233.8%-1159%; P = .050), respectively.

CONCLUSION: Affective ACC DBS can relieve chronic neuropathic pain refractory to pharmacotherapy and restore quality of life.

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