Progress in neurological surgery
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Peripheral nerve stimulation (PNS) is an established neuromodulation approach that has been successfully used for the treatment of various painful conditions since the early 1960s. This review provides a comprehensive summary of relevant publications on PNS dividing its history into three distinct periods. The milestones of the field are related to the development of procedures, equipment and indications. As the most rapidly growing segment of operative neuromodulation, PNS continues to evolve as current and emerging clinical indications become matched by basic and clinical research, technological developments and procedural refinements.
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Treatment of chronic back and leg pain in patients with failed back surgery syndrome (FBSS) remains problematic as none of the currently available approaches are universally successful in achieving lasting pain control. Spinal cord stimulation (SCS) is very effective for controlling radicular pain but rarely provides adequate control of pain in the lower back. ⋯ Because PNS does not control neuropathic pain due to lumbosacral radiculopathy involving the lower extremities, we developed a hybrid technique of SCS and PNS that offers potential control of both axial pain in the lumbar area and radicular pain to the lower extremities. This chapter presents our results and the possible mechanisms of action.
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The purpose of this study was to analyze tumor control and possible complications of gamma knife radiosurgery (GKRS) in patients with vestibular schwannomas using low marginal doses and conformal multiple shots to fit irregular tumor shapes. The authors evaluated 152 patients with more than 5 years of follow-up. Marginal doses were 9-15 Gy (median 12 Gy), with corresponding treatment volumes ranging from 0.1 to 18.7 cm3 (median 2.0 cm3). ⋯ Hydrocephalus was recognized in 5.3% of all patients, and tended to occur in cases with larger tumors (p = 0.0024). GKRS provides a safe and effective therapy for small to medium-sized tumors. However, indications for larger tumors must be carefully considered, as they are more difficult to control and liable to produce ataxia due to transient expansion.
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Gamma knife (GK) thalamotomy for functional disorders, primarily Parkinson disease and central pain, are described herein. The goal was to extend our present indications for selective thalamotomy. Our target for tremor surgery is about 45% of the thalamic length. ⋯ In most of our cases, the protocol was 130 Gy, delivered in one shot with a 4-mm collimator. The time courses of thalamic lesion changes and clinical improvement after irradiation were assessed. Thus, despite thalamic reaction changes being variable, we achieved a clinical success rate of approximately 80% with negligible complications.
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One of the earliest indications for Gamma Knife treatment, radiosurgery for cerebral arteriovenous malformations, has stood the test of time. While initially only the ideal cases (small, compact nidus in a non-eloquent site) were chosen, increasingly larger, more complex AVMs were treated. Combination treatment with embolisation and surgery enables most lesions to be treated with success and remarkably low complication rate. This paper is a brief overview of the experience gained in Sheffield.