Neurosurg Focus
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Since its introduction in the late 1980s, intrathecal baclofen (ITB) therapy has become the standard treatment for severe generalized spasticity and dystonia in children. Treatment with ITB decreases spasticity in the upper and lower extremities and has been associated with improved function and decreased musculoskeletal contractures. ⋯ Although ITB therapy is frequently associated with complications such as infections, catheter malfunctions, and cerebrospinal fluid leaks, the benefits of therapy appear to outweigh the risks. Additional investigation is needed to determine the effects of ITB on other movement disorders such as athetosis and chorea.
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The authors provide an overview of the minimally invasive transforaminal lumbar interbody fusion (TLIF) procedure including indications, technique, and complications. This novel technique is a method of achieving circumferential lumbar fusion using a unilateral dorsal approach. ⋯ This procedure is ideal for refractory mechanical low-back and radicular pain associated with spondylolisthesis, degenerative disc disease, and recurrent disc herniation. The authors' clinical experience and review of the medical literature indicate that TLIF can be effectively and safely performed in a minimally invasive fashion.
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Spinal nerve root stimulation is a recently developed form of neuromodulation used for the treatment of chronic pain conditions. Unlike spinal cord stimulation, in which electrical impulses are directed at the dorsal columns, spinal nerve root stimulation guides electrical current directly to one or more nerve roots. There are a variety of techniques by which this can be accomplished, yet no consistent terminology to describe these variations exists. In this review, the authors group the various techniques according to anatomical approach, define each category, describe and illustrate each of the techniques, review the available reports on their uses, and discuss the advantages and disadvantages of each one.
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In an effort to help clarify the current state of medical therapy for cerebral vasospasm, the authors reviewed the relevant literature on the established medical therapies used for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH), and they discuss burgeoning areas of investigation. Despite advances in the treatment of aneurysmal SAH, cerebral vasospasm remains a common complication and has been correlated with a 1.5- to threefold increase in death during the first 2 weeks after hemorrhage. ⋯ Although much has been elucidated regarding its pathophysiology, the treatment of cerebral vasospasm remains a dilemma. Although a poor understanding of SAH-induced cerebral vasospasm pathophysiology has, to date, hampered the development of therapeutic interventions, current research efforts promise the eventual production of new medical therapies.
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Since its introduction in 1967 by Shealy and colleagues, spinal cord stimulation (SCS) therapy has become an accepted approach to the treatment of certain types of chronic pain. Significant advances have been made in surgical technique, hardware technology, and the variety of disorders for which SCS has proven to be potentially beneficial. Despite these advancements, 25 to 50% of patients in whom a preimplantation trial screening yields successful results report loss of analgesia within 12 to 24 months of implantation, even in the presence of a functioning device. ⋯ Although few definitive conclusions can be drawn, the cumulative existing experience does lend itself to some reasonable recommendations. As with all therapies for chronic pain, invasive or noninvasive, the criteria for success and an acceptable level of failure need to be established, but remain elusive. The emphasis herein is to try to take what works and make it work better.