Neurosurgery
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It is estimated that 40% to 60% of patients with obsessive-compulsive disorder (OCD) continue to experience symptoms despite adequate medical management. For this population of treatment-refractory patients, promising results have been reported with the use of deep brain stimulation (DBS). ⋯ Based on the data published in the literature, the following recommendations can be made: (1) There is Level I evidence, based on a single class I study, for the use of bilateral subthalamic nucleus DBS for the treatment of medically refractory OCD. (2) There is Level II evidence, based on a single class II study, for the use of bilateral nucleus accumbens DBS for the treatment of medically refractory OCD. (3) There is insufficient evidence to make a recommendation for the use of unilateral DBS for the treatment of medically refractory OCD.
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Randomized Controlled Trial Multicenter Study
Cervical spondylotic myelopathy surgical trial: randomized, controlled trial design and rationale.
Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the world. There are significant practice variation and uncertainty as to the optimal surgical approach for treating CSM. ⋯ A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014.
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Sports-related concussions, which have become more prevalent in the past decade, are an extremely common phenomenon in organized athletics and create a substantial economic burden on the health care system. Furthermore, they can have devastating impacts on the athletic careers and long-term health of athletes. However, concussion evaluation remains a controversy with respect to diagnosis, management, and return-to-play guidelines for sports-related concussions. ⋯ Considerable effort has been directed toward developing reliable and valid sidelines assessment modalities for concussion evaluation with a goal of accurately determining whether an athlete requires rapid removal from or is able to return to competition. This paper discusses the role of the concussion specialist on the sidelines during athletic competition and examines the current tools and resources available for the sidelines assessment of concussion. Additionally, new technologies, including electronic applications for Smartphones and tablets, as well as future directions in sidelines assessment of concussion are examined.
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Since the original descriptions of postconcussive pathophysiology, there has been a significant increase in interest and ongoing research to study the biological underpinnings of concussion. The initial ionic flux and glutamate release result in significant energy demands and a period of metabolic crisis for the injured brain. These physiological perturbations can now be linked to clinical characteristics of concussion, including migrainous symptoms, vulnerability to repeat injury, and cognitive impairment. ⋯ Critical studies are underway to better link the acute pathobiology of concussion with potential mechanisms of chronic cell death, dysfunction, and neurodegeneration. This "new and improved" article summarizes in a translational fashion and updates what is known about the acute neurometabolic changes after concussive brain injury. Furthermore, new connections are proposed between this neurobiology and early clinical symptoms as well as to cellular processes that may underlie long-term impairment.
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Review Historical Article
The history of neurosurgical treatment of sports concussion.
Concussion has a long and interesting history spanning at least the 5 millennia of written medical record and closely mirrors the development of surgery and neurosurgery. Not surprisingly, much of the past and present experimental head injury and concussion work has been performed within neurosurgically driven laboratories or by several surgically oriented neurologists. This historical review chronicles the key aspects of neurosurgical involvement in sports concussion as related to the diagnosis, treatment, mitigation, and prevention of injury using the example of American football. In addition, we briefly trace the developments that led to our current understanding of the biomechanical and neurophysiological basis of concussion.