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Failed back surgery syndrome (FBSS) represents one main cause of chronic neuropathic or mixed pain, functional disability and reduced Health Related Quality of Life (HRQoL). Spinal Cord Stimulation (SCS) can be a value for money option to treat patients refractory to conventional medical management (CMM). We estimated from real-world data: 1) the amount of reduced levels of HRQoL of target patients compared to general population, 2) the relationship between pain intensity, functional disability, and overall HRQoL, and 3) the improvement of patients’ health from SCS intervention, and 4) we give some insights and make some suggestions on the selection of a battery of patients’ reported health instruments for use in routine clinical practice.BACKGROUNDFailed back surgery syndrome (FBSS) represents one main cause of chronic neuropathic or mixed pain, functional disability and reduced Health Related Quality of Life (HRQoL). Spinal Cord Stimulation (SCS) can be a value for money option to treat patients refractory to conventional medical management (CMM). We estimated from real-world data: 1) the amount of reduced levels of HRQoL of target patients compared to general population, 2) the relationship between pain intensity, functional disability, and overall HRQoL, and 3) the improvement of patients’ health from SCS intervention, and 4) we give some insights and make some suggestions on the selection of a battery of patients’ reported health instruments for use in routine clinical practice.At recruitment (before SCS) and every 6 months for 2 years after SCS a battery of questionnaires/tests were completed: the generic EQ-5D and SF-36 for HRQoL, the specific Numerical Rating Scale (NRS) to measure pain intensity, and Oswestry Disability Index (ODI) to measure functional disability. We conducted multilevel regression analyses to investigate the association of HRQoL with the NRS and ODI indexes; multiple regression analyses to compare EQ-5D data with those of the general population adjusted for age, sex and education, and statistical tests to compare the changes of HRQoL, NRS and ODI estimates at baseline with those measured during the follow-up.METHODSAt recruitment (before SCS) and every 6 months for 2 years after SCS a battery of questionnaires/tests were completed: the generic EQ-5D and SF-36 for HRQoL, the specific Numerical Rating Scale (NRS) to measure pain intensity, and Oswestry Disability Index (ODI) to measure functional disability. We conducted multilevel regression analyses to investigate the association of HRQoL with the NRS and ODI indexes; multiple regression analyses to compare EQ-5D data with those of the general population adjusted for age, sex and education, and statistical tests to compare the changes of HRQoL, NRS and ODI estimates at baseline with those measured during the follow-up.Eighty patients (40% male, mean age = 58 years) participated. HRQoL was significantly worse in the patients than in the corresponding general population. Pain, functional disability and HRQoL significantly related each other during follow-up, Significant improvements (p < 0.001) in pain intensity, functional capability and HRQoL were reached after 6 months from SCS and generally remained stable during follow-up. Specific instruments provided detailed information on disability and pain, while generic instruments assessed the overall HRQoL and allowed a comparison with the general population’s one.RESULTSEighty patients (40% male, mean age = 58 years) participated. HRQoL was significantly worse in the patients than in the corresponding general population. Pain, functional disability and HRQoL significantly related each other during follow-up, Significant improvements (p < 0.001) in pain intensity, functional capability and HRQoL were reached after 6 months from SCS and generally remained stable during follow-up. Specific instruments provided detailed information on disability and pain, while generic instruments assessed the overall HRQoL and allowed a comparison with the general population’s one.SCS + CMM treatment reaches a statistically significant and probably a clinically relevant improvement in pain perception, functional disability and HRQoL in patients with FBSS refractory to CMM. An appropriate selection of instruments for use in clinical practice is crucial for a routine assessment of health perception in patients, aimed to guide decisions for optimal treatment.CONCLUSIONSSCS + CMM treatment reaches a statistically significant and probably a clinically relevant improvement in pain perception, functional disability and HRQoL in patients with FBSS refractory to CMM. An appropriate selection of instruments for use in clinical practice is crucial for a routine assessment of health perception in patients, aimed to guide decisions for optimal treatment.

Various drugs and surgical procedures have been utilized for the treatment of trigeminal neuralgia (TN). Despite numerous available approaches, the results are not completely satisfying. The need for more contemporaneous drugs to control the pain attacks is a common experience. Moreover, a number of patients become drug resistant, needing a surgical procedure to treat the neuralgia. Nonetheless, pain recurrence after one or more surgical operations is also frequently seen. These facts reflect the lack of the precise understanding of the TN pathogenesis. Classically, it has been related to a neurovascular compression at the trigeminal nerve root entry-zone in the prepontine cistern. However, it has been evidenced that in the pain onset and recurrence, various neurophysiological mechanisms other than the neurovascular conflict are involved. Recently, the introduction of new magnetic resonance techniques, such as voxel-based morphometry, diffusion tensor imaging, three-dimensional time-of-flight magnetic resonance angiography, and fluid attenuated inversion recovery sequences, has provided new insight about the TN pathogenesis. Some of these new sequences have also been used to better preoperatively evidence the neurovascular conflict in the surgical planning of microvascular decompression. Moreover, the endoscopy (during microvascular decompression) and the intraoperative computed tomography with integrated neuronavigation (during percutaneous procedures) have been recently introduced in the challenging cases. In the last few years, efforts have been made in order to better define the optimal target when performing the gamma knife radiosurgery. Moreover, some authors have also evidenced that neurostimulation might represent an opportunity in TN refractory to other surgical treatments. The aim of this work was to review the recent literature about the pathogenesis, diagnosis, and medical and surgical treatments, and discuss the significant advances in all these fields.

ABSTRACT OBJECTIVE After randomizing 100 failed back surgery syndrome patients to receive spinal cord stimulation (SCS) plus conventional medical management (CMM) or CMM alone, the results of the 6-month Prospective Randomized Controlled Multicenter Trial of the Effectiveness of Spinal Cord Stimulation (i.e., PROCESS) showed that SCS offered superior pain relief, health-related quality of life, and functional capacity. Because the rate of crossover favoring SCS beyond 6 months would bias a long-term randomized group comparison, we present all outcomes in patients who continued SCS from randomization to 24 months and, for illustrative purposes, the primary outcome (>50% leg pain relief) per randomization and final treatment. METHODS Patients provided data on pain, quality of life, function, pain medication use, treatment satisfaction, and employment status. Investigators documented adverse events. Data analysis included inferential comparisons and multivariate regression analyses. RESULTS The 42 patients continuing SCS (of 52 randomized to SCS) reported significantly improved leg pain relief (P < 0.0001), quality of life (P ≤ 0.01), and functional capacity (P = 0.0002); and 13 patients (31%) required a device-related surgical revision. At 24 months, of 46 of 52 patients randomized to SCS and 41 of 48 randomized to CMM who were available, the primary outcome was achieved by 17 (37%) randomized to SCS versus 1 (2%) to CMM (P = 0.003) and by 34 (47%) of 72 patients who received SCS as final treatment versus 1 (7%) of 15 for CMM (P = 0.02). CONCLUSION At 24 months of SCS treatment, selected failed back surgery syndrome patients reported sustained pain relief, clinically important improvements in functional capacity and health-related quality of life, and satisfaction with treatment.

•Laminectomy was an independent prognostic factor for onset of spinal deformity.•Pre-operative spinal deformity was associated with worsening of spinal deformity.•No new-onset spinal deformities were observed after laminoplasty.•No CSF leak was recorded in the laminoplasty cohort of patients. Laminectomy has normally been used as a standard approach for intradural spinal tumors but this procedure is associated with spinal instability and deformity. Laminoplasty was developed to overcome these limitations. Controversies still exist regarding its actual role in preventing spinal deformity in adults. The aim of our study was to determine the impact of laminoplasty on the prevention of spinal deformity's onset or worsening in adult patients submitted to intradural spinal tumors resection. We retrospectively reviewed the data of 43 consecutive adult patients, who underwent either laminectomy or laminoplasty for spinal intradural tumor resection, between January 2006 and May 2011. We evaluated the role of sex, spinal segment (cervical, thoracic, lumbar), tumor location (intra- or extra-medullary), procedure (laminoplasty or laminectomy), number of treated levels (≤2 vs >2), presence of pre-operative deformity and pre-operative Modified McCormick Scale (≤2 vs >2) in the development or worsening of spinal deformity, using Fisher's exact test and multivariate logistic regression analysis. Nine patients developed deformity or experienced a worsening of pre-operative deformity at latest follow-up. Among the considered potential prognostic factors, laminectomy (p=0.03) and evidence of pre-operative spinal deformity (p=0.009) were significantly associated with new-onset or worsening of spinal deformity. At logistic regression analysis, only the performed surgical procedure emerged as independent prognostic factor (p=0.044). No CSF leak was recorded in the laminoplasty cohort. No new-onset spinal deformities, no CSF leaks and a lower rate of spinal deformity progression were observed after laminoplasty for intradural intra- or extra-medullary tumor resection.

Drug-resistant trigeminal neuralgia (TN) can complicate the clinical course of patients affected by multiple sclerosis (MS). Various surgical procedures have been reported for the treatment of this condition, but there is no agreement on the best management of these patients. To our knowledge, there is no critical literature analysis focusing on this particular topic. The aim of this study was to evaluate the clinical outcome of different surgical procedures utilized for drug-resistant TN in MS patients. We reviewed the literature about the studies reporting on surgical treatment of drug-resistant TN in MS patients. Case reports and case series less than 4 patients were excluded from the analysis. Nineteen studies were selected for the statistical analysis. To reduce the variability of the data, the selected studies were evaluated for the following outcome parameters: acute pain relief rate (APR), rate of recurrence (RR), pain free at follow-up rate (PF at FU) and complication rate (CR). For the statistical analysis, chi-square statistic, using the Fisher's exact test was utilized. There was no procedure statistically superior in terms of APR rate in MS patients following the surgical treatment of TN. The highest RR was observed for percutaneous balloon compression (PBC) (60.2±14.4%). This result was statistically significant when compared to gamma knife surgery (GKS) (p=0.0129) and microvascular decompression (MVD) (p=0.0281). MVD together with percutaneous radiofrequency rhizothomy (PRR) was associated with a statistically better PF at FU rate (56.5±16.8% and 73.5±14.2%, respectively). However PBC and MVD showed statistical significant minor CR compared to other techniques (no complications and 18.7±17.4%, respectively). Our study shows no differences in the short term results among different procedures for TN in MS patients. Each technique demonstrate advantages and limits in terms of long term pain, recurrence rate and complication rate. Each patient should be accurately informed on pros and cons of each procedure in order to be involved in the most appropriate choice.

Background The role of different procedures for the treatment of drug-resistant trigeminal neuralgia (TN) in patients affected by multiple sclerosis (MS) is under discussion and there are no clear indications in the literature. In particular, the role of percutaneous balloon compression (PBC) has been poorly addressed so far. Moreover, to the best of our knowledge, there are no reports analysing the factors potentially related to the prognosis in these patients. We examined the role of PBC for the treatment of TN in MS patients and investigated the role of some clinical and procedure-related factors in determining the prognosis of these patients. Method We retrospectively reviewed clinical and outcome data of 21 MS patients submitted to PBC (eight of them had already been treated with different procedures). We analysed the impact of the sex, number of affected trigeminal divisions, pre-operative deficit, previous operations, compression time and balloon shape at the operation, on acute pain relief (APR) by the chi-squared statistic and on pain-free survival (PFS) by the Kaplan-Meier method. Findings An excellent (BNI I-II)-good (BNI III) outcome was obtained in all patients with a single or repeated procedure. The presence of a single affected trigeminal division ( p  = 0.042), the absence of previous operations ( p  = 0.048), the compression time ≤5 min ( p  = 0.0067) and the pear-like shape of the balloon at the operation ( p  < 0.05) were associated to higher pain-free survival. Conclusions PBC is a safe and effective technique to treat drug-resistant TN in MS patients. Some clinical and procedure-related factors may play a role in the prognosis of these patients.

Abstract BACKGROUND Tentorial meningiomas are a broad and consistent category of tumors but their definition is still unclear and their classification uncertain. OBJECTIVE To report the clinical and surgical characteristics of tentorial hiatus meningiomas based on a revised classification of tentorial meningiomas. METHODS We reviewed the records of 14 patients who had undergone microsurgical removal of incisural tentorial meningioma. Two tumor subgroups, anterolateral (AL) and posteromedial (PM), were distinguished according to their site of attachment: the middle third and the posterior third of the tentorial free margin, respectively. Clinical presentation, radiological findings, surgical approaches, extent of resection, and outcome were compared. RESULTS The 2 subgroups differed by tumor size (larger in PM), incidence of the direction of growth (infratentorial in PM), and hydrocephalus (only in PM), as well as by some clinical aspects. Surgical approach depended on tumor location: lateral (pterional, subtemporal, and retromastoid) for AL lesions; medial (occipital or supracerebellar infratentorial) for PM lesions. Total removal (Simpson grade I-II) was performed in 64% of cases and complications occurred in 14%. Stereotactic radiosurgery was performed in cases of incomplete resection. At a mean follow-up of 104.5 mo, clinical improvement with low recurrence (9%) was achieved. CONCLUSION Reallocation of tentorial edge meningiomas is the premise to compare treatment and further improve the approach case-by-case. In spite of their deep site, good outcomes can be achieved in both AL and PM tentorial meningiomas. Also of note is the indolent behavior of residual tumor.

Background The results of vagus nerve stimulation (VNS) for the treatment of drug-resistant epilepsies are highly variable due to the lack of defined patient’s selection criteria and a follow-up of published studies being generally too short. Here we report the outcome of VNS in a series with long-term follow-up and try to identify subgroups of patients who could be better candidates for this procedure. Method We studied 53 patients (33 male, 20 female) with a prospectively recorded follow-up (mean, 55.96 ± 43.53 months). The monthly average seizure frequency for each patient at baseline, 3, 6, 12 months, and each year until the latest follow-up after implant was measured and the percentage of “responders” and response time (RT) were calculated. We investigated the following potential prognostic role of these factors: age of onset of epilepsy, pre-implant epilepsy duration, etiology, and age at implant. Results Globally, 40 % of patients responded to VNS (mean RT, 14.85 ± 16.85 months). Lesional etiology ( p  = 0.0179, logrank test), particularly ischemia ( p  = 0.011, Fisher exact test) and tuberous sclerosis ( p  = 0.0229, Fisher exact test), and age at implant <18 years ( p  = 0.0242, logrank test) were associated to better response to VNS. In the lesional subgroup the best results were observed in patients with a pre-implant epilepsy duration <15 years ( p  = 0.0204, logrank test) and an age at implant <18 years ( p  = 0.0187 logrank test). Conclusions The best candidate to VNS seems to be a patient with lesional etiology epilepsy (particularly post-ischemic and tuberous sclerosis) and a short duration of epilepsy who undergo VNS younger than 18 years.

Introduction Various cranial repairs have been described to limit the incidence of cerebrospinal fluid (CSF) leak, the rate of infections, postoperative headache and local discomfort in patients undergoing cerebello-pontine angle surgery. Materials and methods The aim of this study was to evaluate the impact of a feasible craniotomy procedure and cranial repair technique, which does not require bone replacers or filling materials, on postoperative outcome. We analysed postoperative results in a series of 34 patients undergoing cerebello-pontine angle surgery. Discussion and conclusions We observed a statistically significant reduced incidence of local discomfort, postoperative headache and CSF leak in patients who underwent such a reconstructive technique compared to those undergoing retrosigmoid craniectomy.

Abstract BACKGROUND: The primary motor cortex, which is part of the corticobasal ganglia loops, may be an alternative option for the surgical treatment of Parkinson disease. OBJECTIVE: To report on the 1-year safety and efficacy of unilateral extradural motor cortex stimulation in Parkinson disease. METHODS: A quadripolar electrode strip was extradurally implanted over the motor cortex. Stimulation was continuously delivered through the electrode paddle contralateral to the most affected clinical side. Subjects were prospectively evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS) and the Parkinson's Disease Quality of Life Questionnaire. In addition, an extensive cognitive and behavioral assessment and electroencephalogram recording were performed. RESULTS: Nine patients were included in this study. No surgical complications or adverse events occurred. Moreover, no cognitive or behavioral changes were observed. Under the off-medication condition, the UPDRS III at baseline was decreased by 14.1%, 23.3%, 19.9%, and 13.2%, at 1, 3, 6, and 12 months, respectively. The motor effects were bilateral, appeared after 3 to 4 weeks of stimulation, and outlasted the stimulation itself for 3 to 4 weeks in 1 case of stimulator accidental switching off. The UPDRS IV was decreased by 40.8%, 42.1%, and 35.5% at 1, 3, and 12 months, respectively. The scores on the Parkinson's Disease Quality of Life Questionnaire were increased at months 3, 6, and 12. CONCLUSION: Extradural motor cortex stimulation is a safe procedure. After 12 months, the patients demonstrated a moderate improvement of motor symptoms (particularly axial symptoms) and quality of life.