Neurosurgery
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Randomized Controlled Trial Comparative Study
Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial.
We analyzed the cost-effectiveness and cost-utility of treating failed back-surgery syndrome using spinal cord stimulation (SCS) versus reoperation. ⋯ SCS was less expensive and more effective than reoperation in selected failed back-surgery syndrome patients, and should be the initial therapy of choice. SCS is most cost-effective when patients forego repeat operation. Should SCS fail, reoperation is unlikely to succeed.
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Multicenter Study Comparative Study
Sex differences in neuropsychological function and post-concussion symptoms of concussed collegiate athletes.
Our purpose was to determine whether sex differences exist with respect to post-concussion symptoms and neurocognitive function in concussed collegiate athletes. ⋯ College athletes exhibit differences on visual memory composite scores and symptoms post-concussion as a function of sex. These data support the importance of evaluating neuropsychological status and post-concussion symptoms in concussed athletes. In addition, these data illustrate the importance of analyzing an individual athlete's recovery pattern, because individual differences in recovery trajectories may be overshadowed by global norm-group comparisons.
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A new paradigm for the radiotherapeutic management of paraspinal tumors has emerged. Intensity-modulated radiotherapy (IMRT) has gained wide acceptance as a way of delivering highly conformal radiation to tumors. IMRT is capable of sparing sensitive structures such as the spinal cord of high-dose radiation even if only several millimeters away from the tumor. Image-guided treatment tools such as cone beam computed tomography coupled with IMRT have reduced treatment errors associated with traditional radiotherapy, making highly accurate and conformal treatment feasible. ⋯ IG IMRT represents a significant technological advance. Paraspinal IG IMRT is proof of principle, making it possible to give very-high-dose radiation within close proximity to the spinal cord. By reducing treatment-related uncertainties, margins around tumors can be shortened, thereby reducing the volume of normal tissue that must be irradiated to tumoricidal doses, reducing the likelihood of toxicity. Similarly, higher doses of radiation can be administered safely, improving the likelihood of eradication. Dose escalation can be done to increase the likelihood of tumor cell kill without increasing the dose given to nearby sensitive structures.
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Studies have documented an inflammatory response in the circulating plasma and cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage (aSAH). In particular, early upregulation of several complement proteins, including C3a, C4a, and C5b-9, has been demonstrated after the initial hemorrhagic insult. The inflammatory actions of the complement cascade are largely mediated through the anaphylatoxins, C3a and C5a. Recent investigations have established a critical role for C3a in the pathogenesis of cerebral ischemia. We attempt to confirm that plasma C3a and C5a values are elevated in patients with aSAH and to determine whether or not these levels are reliable independent predictors of functional outcome irrespective of clinical presentation. ⋯ These results demonstrate an association between early complement C3a levels and outcome after aSAH that seems to be independent of the initial hemorrhage. The findings suggest that inflammatory processes involving C3a may contribute to delayed morbidity and mortality after aneurysmal rupture.
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Clinical Trial
Exhaustive, one-year follow-up of subthalamic nucleus deep brain stimulation in a large, single-center cohort of parkinsonian patients.
To prospectively assess the impact of subthalamic nucleus (STN) deep brain stimulation (DBS) at 12 months after surgery in a series of 100 consecutive patients treated in a single center. The primary objective was to describe the clinical outcome in terms of efficacy and tolerance in STN-DBS patients. A secondary objective was to discuss presurgery clinical characteristics a posteriori as a function of outcome. ⋯ The efficacy and safety of STN-DBS in our center's large cohort of Parkinsonian patients are generally similar to the results obtained by other groups, albeit at the lower limit of the range of reported values. In contrast to efficacy, the occurrence of adverse events cannot be predicted. Younger patients with Parkinson's disease (i.e., those younger than 60 yr) often show an excellent response to levodopa. However, in view of our data on overall patient satisfaction and the occurrence of adverse events, we suggest that older patients (but not those older than 70 yr) and less dopa-sensitive patients (but not those with a response <50%) should still be offered the option of STN-DBS.