Neurosurgery
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Failed Back Surgery Syndrome (FBSS) is notoriously refractory to treatment resulting in high health care utilization and high health care costs. Given the recent emphasis of cost-conscious care in the United States, we examined the trends in imaging use in FBSS over the past decade. Furthermore, the role of different types of imaging modalities MRI vs non-MRI is of interest when considering potential therapeutic interventions, including spinal cord stimulation (SCS), a common therapy for treating neuropathic pain in the FBSS population. ⋯ We found a trend for increased imaging use between 2000 and 2009 in FBSS patients, a population with already immense health care utilization and health care costs. Rates of both MRI and non-MRI imaging increased by 35% to 40% in a period of 10 years. The role of frequency and type of imaging modality utilized in evaluating FBSS patients will have a significant impact on overall health care expenses and therapeutic options, including SCS, going forward.
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124 Endoscopic Trigeminal Nucleus Caudalis Doral Root Entry Zone Lesioning for Atypical Facial Pain.
While many chronic pain conditions are challenging to treat, atypical facial pain including conditions such as anesthesia dolorosa and trigeminal deafferentation are among the most difficult. Patients experience numbness in facial areas that also have constant severe, burning pain. The condition results from traumatic or surgical deafferentation injuries of the first-order trigeminal nerve. Anesthesia dolorosa occurs in up to 4% of patients who have undergone prior trigeminal procedures. Deafferentation releases second-order neurons along the trigeminal pain pathway to generate spontaneous pain signals, without a nociceptive stimulus. Medications used for neuropathic pain are first-line but often ineffective. ⋯ Endoscopic NC DREZ lesioning is a safe, effective, and minimally invasive approach for reducing neural hyper-excitability in second order neurons in patients with intractable atypical facial pain. Longer-term studies and follow-up are needed for these challenging types of craniofacial pain.
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Quality improvement projects have begun to standardize surgical work flow as a component to optimize operative room (OR) efficiency. Removing special cause variability resulting from nonsurgical waste is an obvious target; however, surgical resident education must be maintained even in the setting of process improvement. There are no published data describing the impact on operative time of resident-identified risky or uncomfortable procedural steps during posterior instrumented fusion (PIF). Self-identification of risk or discomfort in surgical steps may allow for shorter OR time and reduced cost, without sacrificing resident education. ⋯ Resident perception of surgical complexity can be evaluated for procedural steps using a risk matrix survey. For PIF, residents assign more risk and are less comfortable performing steps in a training-dependent manner. Identification of particular high-risk steps, which are uncomfortable, should prompt strict faculty oversight to improve patient safety, monitor resident education, and reduce operative time.
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Cell therapies represent a promising alternative treatment for neurodegenerative diseases of the spinal cord, and traumatic spinal cord injury. Cell survival, migration, proliferation and differentiation are intrinsic factors that greatly influence the therapeutic potential of cell therapies. Other factors like local inflammatory and immune response also play an important role. This study analyzed the migration patterns of fetal-derived neural precursors (NPCs) transplanted to the spinal cord of healthy Gottingen minipigs. ⋯ Understanding the migration patterns and other dynamics of different cell lines will allow neurosurgeons to ensure accurate delivery and maximize effectiveness of cell therapeutics in the spinal cord.
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Cerebral arteries innervated by several systems contribute to the control of cerebral blood flow. Subarachnoid hemorrhage causes acutely developed vasospasm by various mechanical and neurochemical mechanisms, cranial parasympathetic nerve ischemia, and related stellate ganglion overdischarges. Dilatatory sensory fibers of cranial parasympathetic nerves and vasospastic fibers of stellate ganglions have a vasoregulatory effect on the cerebral arteries The aim of this study is to investigate the effect of sympathectomy on vasospasm of the middle cerebral artery. ⋯ Sympathetic blockage may be a useful effect in the prevention of cerebral vasospasm and other complications of SAH.