Journal of neurosurgery
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Journal of neurosurgery · Jan 2011
Case ReportsBifocal cortical electrical stimulation for pain by interdural implantation of the electrodes.
Chronic electrical cortical stimulation (ECS) is an evolving therapy for alleviating treatment-refractory chronic pain syndromes. In this report, the authors describe a modified technique of ECS that involves resection of dural strips and interdural placement of the electrodes as a patch, and bifocal stimulation by implanting 2 electrode strips, that is, one over the motor and one over the sensory cortices. The technique was used in 4 patients with treatment-refractory pain syndromes: a 76-year-old woman with poststroke central pain, 2 women, (71 and 73 years old) with trigeminal pain, and a 44-year-old man with phantom limb pain. ⋯ The factors affecting the efficacy of ECS are discussed. In the authors' opinion, interdural implantation of the electrodes holds the promise to improve the efficacy and consistency of ECS compared with the standard epidural or subdural implantation without increasing the risk of the procedure. The technical considerations and the potential therapeutic advantages of the interdural bifocal approach are discussed.
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The mechanism responsible for exceptional examples of intraneural ganglia with extensive longitudinal involvement has not been understood. Such cases of intraneural cysts, seemingly remote from a joint, have been thought not to have articular connections. Decompression and attempted resection of the cyst has led to intraneural recurrence and poor neurological recovery. The purpose of this report is not only to clarify the pathogenesis of these cysts, but also to discuss their treatment based on modern concepts of intraneural ganglia. ⋯ This paper demonstrates that extreme intraneural cysts are not clinical outliers but represent extreme examples of other more typical intraneural cysts. They logically obey the same principles, previously described in the unified articular (synovial) theory. The degree of longitudinal extension is probably due to high intraarticular pressures within the degenerative joint of origin. The generalizability of the mechanistic principles is highlighted by the fact that these 2 cases, involving the tibial and the peroneal nerve respectively, both extended well distant (that is, to the buttock) from the STFJ via their respective articular branch of origin. These extensive intraneural cysts can be treated successfully by disconnecting the affected articular branch and by resection of the joint of origin, rather than by a more aggressive operation resecting the cyst and cyst wall.
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This study was designed to investigate the efficacy of delayed thymosin β(4) (Tβ(4)) treatment of traumatic brain injury (TBI) in rats. ⋯ These data for the first time demonstrate that delayed administration of Tβ(4) significantly improves histological and functional outcomes in rats with TBI, indicating that Tβ(4) has considerable therapeutic potential for patients with TBI.
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Journal of neurosurgery · Jan 2011
Case ReportsOnyx embolization of a carotid cavernous fistula via direct transorbital puncture.
The treatment of indirect carotid cavernous fistulas (CCFs) is challenging and primarily accomplished by endovascular means utilizing a variety of embolic agents. Transvenous access to the cavernous sinus is the preferred method of embolizaiton of indirect CCFs as they are frequently associated with numerous small-caliber meningeal branches. Although the inferior petrosal sinus is the simplest, shortest, and most commonly used venous route to the cavernous sinus, the superior ophthalmic vein, superior petrosal sinus, basilar plexus, and pterygoid plexus present other endovenous options. ⋯ The cavernous sinus was cannulated directly via a transorbital approach using fluoroscopic guidance with a 3D skull reconstruction overlay. The fistula was subsequently obliterated using ethylene vinyl alcohol copolymer (Onyx). The technique and advantages of both 3D osseous reconstruction as well as Onyx embolization are discussed.
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Medical student exposure to neurosurgery is limited. To improve the educational interactions between neurosurgeons and medical students as well as neurosurgical medical student rotations or clerkships (NSCs) we must first understand the current status. ⋯ There is significant room for improvement in the neurosurgeon-to-medical student interactions in both the NSCs and during the didactic years of medical school.