Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Jan 2014
ReviewNeuromodulation for depression: invasive and noninvasive (deep brain stimulation, transcranial magnetic stimulation, trigeminal nerve stimulation).
Major depressive disorder is among the most disabling illnesses and, despite best practices with medication and psychotherapy, many patients remain ill even after several treatment trials. For many of these patients with treatment-resistant or pharmacoresistant depression, treatment with neuromodulation offers an alternative. ⋯ This review surveys recent literature to update readers on 3 particular interventions: deep brain stimulation, transcranial magnetic stimulation, and trigeminal nerve stimulation. Additional comparative research is needed to delineate the relative advantages of these treatments, and how best to match individual patients to neuromodulation intervention.
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Chronic neuropathic pain affects 8.2% of adults, extrapolated to roughly 18 million people every year in the United States. Patients who have pain that cannot be controlled with pharmacologic management or less invasive techniques can be considered for deep brain stimulation or motor cortex stimulation. These techniques are not currently approved by the Food and Drug Administration for chronic pain and are, thus, considered off-label use of medical devices for this patient population. Conclusive effectiveness studies are still needed to demonstrate the best targets as well as the reliability of the results with these approaches.
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Peripheral nerve stimulation and peripheral nerve field stimulation are emerging as a viable neuromodulatory therapy in the treatment of refractory pain. Although the technology of percutaneous stimulation has been available for decades, recent advancements have broadened the number of indications. ⋯ Most results to date have come from case reports and retrospective studies. However, given the promising outcomes in reducing otherwise medically refractory pain, future randomized controlled studies are needed to assess this emerging technology.
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Advances in deep brain stimulation (DBS) surgery have been achieved through the use of stereotactic targeting of key tracks in patients undergoing awake surgery. Intraoperative detection of track location has been useful in interpreting physiologic results, has limited the number of brain penetrations, and has decreased the incidence of reoperations. Alternatively, some centers are gaining experience with placement of the lead under general anesthesia using a purely anatomic approach, for which both computed tomography and magnetic resonance imaging have proved useful. In this article, the use of image guidance with both the anatomic and physiologic approaches is described.
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Neurosurg. Clin. N. Am. · Jan 2014
ReviewPeripheral neuromodulation for treatment of chronic migraine headache.
Chronic migraines (CM) affect approximately 2% of the population, resulting in significant disability, economic burden, and impairments in quality of life. Historical neurosurgical procedures, such as lesioning of the trigeminal dorsal root entry zone or neurolysis of the occipital nerve, have not gained favor because of procedural morbidity and poor durability, respectively. Occipital nerve stimulation is emerging as a potentially promising modality for the treatment of CM, with greater than 50% pain reduction in approximately 80% of patients in open-label trials and ∼40% of patients in randomized controlled trials. Mechanisms of neuromodulation remain unclear.