Neurosurgery
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Since its first application in 1967, the methodology and technology of spinal cord stimulation for the management of chronic, intractable pain have evolved continuously. Despite these developments and improved knowledge of the effects of spinal anatomy and epidural contact configuration on paresthesia coverage, the clinical results of spinal cord stimulation-particularly the long-term effects-are still unsatisfactory in many patients. This dissatisfaction has come primarily from the failure of single-electrode configurations to provide consistent paresthesia coverage of the entire painful area. ⋯ To target parts of the latter, different methods have been developed and tested using either two-dimensional contact configurations or electronic field steering. These developments hold promise for improving long-term outcomes as well as increasing the number of pain conditions that can be treated with neuromodulation therapy. In this review, the history, theoretical basis, and evolution of these methodologies, as well as the ways in which they represent new trends in neuromodulation, are discussed.
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Trochlear nerve neuromas are extremely rare. Seventeen surgical cases of this pathological condition have been reported in the English literature. The presented case is distinct from previous reports. ⋯ The facial pain resolved immediately after surgery. Although facial dysesthesias have been noted among patients with trochlear nerve neuromas, here the atypical facial pain was the only clinical manifestation. In all previously reported cases, neuromas originated from the cisternal segment of the trochlear nerve (always before the site of nerve entrance into the tentorial leaves) and expanded mainly into the prepontine and interpeduncular cisterns. Subtemporal and suboccipital approaches were used. In this case, the tumor arose from the short segment of the nerve running between the tentorial leaves. The tumor did not extend either into the ambient cistern or into the cavernous sinus but did involve the parasellar area. A pterional approach was appropriate for tumor removal. A trochlear nerve neuroma should be considered as a potential cause of atypical facial pain.
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Three-dimensional (3-D) ultrasound is an intraoperative imaging modality used in neuronavigation as an alternative to magnetic resonance imaging (MRI). This article summarizes 4 years of clinical experience in the use of intraoperative 3-D ultrasound integrated into neuronavigation for guidance in brain tumor resection. ⋯ Intraoperative 3-D ultrasound seems to provide a time- and cost-effective way to update high-quality 3-D maps used in neuronavigation.
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The concept of neurovascular decompression for the treatment of hemifacial spasm is now widely accepted. In this study, we report our long-term results for 145 cases treated with this procedure. ⋯ Deafness was the main postoperative complication (8.3%); most of those cases (66%) occurred before the routine use of intraoperative evoked potential monitoring. Analysis of our series demonstrates that this surgical procedure involves very low risk, is well tolerated by elderly patients, is associated with very low recurrence rates, and is a definitive treatment for more than 90% of cases.
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Abnormal serum sodium levels (hyponatremia and hypernatremia) are frequently observed during the acute period after aneurysmal subarachnoid hemorrhage (SAH) and may worsen cerebral edema and mass effect. We performed this study to determine the prognostic significance of serum sodium concentration abnormalities. ⋯ Hyponatremia seems to be more common than hypernatremia after SAH. However, hypernatremia after SAH is independently associated with poor outcomes, and this association is independent of previously identified outcome predictors, including age and admission Glasgow Coma Scale scores. Further studies are needed to define the underlying mechanism of this association.