To be considered for a 2012-2013 CSNS/CNS Medical Student Summer Fellowship, applicants must apply by March 9, 2012.

The fellowship is open to all medical students in the United States and Canada. The fellow will spend 8 to 10 weeks conducting supervised research on a socioeconomic topic of importance to neurosurgery. Click here to apply.

Objective: To assess the effect of microdiscectomy on depression, somatization, and mental well-being in patients with herniated lumbar discs.

Methods: Patients undergoing surgical discectomy for single-level, herniated lumbar disc were prospectively evaluated preoperatively, and at 6 weeks and 3, 6, and 12 months postoperatively. Back and leg pain, depression, somatic perception, and mental well-being were assessed.

Results: One hundred patients were enrolled. All were available for 1-year follow-up. Preoperatively, the visual analog scale for low-back pain (BP-VAS), visual analog scale for leg pain (LP-VAS), Zung Self-Rating Depression Scale (ZUNG), Modified Somatic Perception Questionnaire (MSPQ), and Medical Outcomes Short Form-36 mental component summary scale (SF-36-MCS) were 6.3 ± 2.5, 6.3 ± 2.5, 19 ± 11, 9 ± 7, and 4 ± 14. BP-VAS and LP-VAS significantly improved by 6 weeks. Significant improvement in SF-36-MCS was observed by 6 weeks postoperatively, improvement in MSPQ score was observed 3 months postoperatively, and improvement in the ZUNG depression score was observed 12 months postoperatively. No statistical difference occurred during the remainder of follow-up for any outcome measured once improvement reached statistical significance. Eighteen patients were somatized preoperatively, 67% of which were nonsomatized 1 year postoperatively. Ten patients were clinically depressed preoperatively, 70% of which were nondepressed 1 year postoperatively. Improvement in SF-36-MCS, ZUNG, and MSPQ correlated (P < .001) with improvement in BP-VAS and LP-VAS.

Conclusion: The majority of patients somatized or depressed preoperatively returned to good mental well-being postoperatively. Improvement in pain and overall mental well-being was seen immediately after discectomy. Improvement in somatic anxiety and depression occurred months later. Microdiscectomy significantly improves pain-associated depression, somatic anxiety, and mental well-being in patients with herniated lumbar disc.

From: Microdiscectomy Improves Pain-Associated Depression, Somatic Anxiety, and Mental Well-Being in Patients With Herniated Lumbar Disc by Lebow et al

Full article access for Neurosurgery subscribers at Neurosurgery-Online.com.

Objective: To report our experience with focal epilepsy arising from the cingulate gyrus and surrounding structures and its surgical treatment.

Methods: 22 patients (mean age 36, range 12-63) with a mean seizure history of 23 years (range 2-52) were retrospectively analyzed. We report pre-surgical diagnostics, surgical strategy, and post-operative follow up concerning functional morbidity and seizures (mean follow-up 86 months, range 25-174).

Results: Nineteen patients showed potential epileptogenic lesions on preoperative MRI. All patients had non-invasive pre-surgical work-up; 15 (68%) underwent invasive Video-EEG-Monitoring. In 12 patients we performed extended lesionectomy according to MRI; an extension with regard to EEG-results was done in 6 patients. In 4 patients the resection was incomplete due to involvement of eloquent areas according to functional mapping results. Eight pure cingulate resections (36%, three in the posterior cingulate gyrus) and 14 extended supra-cingular frontal resections were performed. Nine patients suffered from temporary postoperative supplementary motor area (SMA) syndrome after resection in the superior frontal gyrus. Two patients retained a persistent mild hand or leg paresis, respectively. Post-operatively, 62% of patients were seizure-free (ILAE 1) and 76% had a satisfactory seizure outcome (ILAE 1-3).

Conclusion: Epilepsy surgery for lesions involving the cingulate gyrus represents a small fraction of all epilepsy surgery cases, with good seizure outcome and low rates of post-operative permanent deficits. In case of extended supra-cingular resection, SMA-syndrome should be considered.

From: Epilepsy Surgery of the Cingulate Gyrus and the Fronto-mesial Cortex by von Lehe et al

Full article access for Neurosurgery subscribers at Neurosurgery-Online.com.

Background

Objective: To assess the technical feasibility of using the Merci retriever system as an access adjunct in acute ischemic stroke and tortuous ophthalmic segment anatomy.

Methods: The acute ischemic stroke database was queried, and 3 patients presenting with acute ischemic stroke and tortuous proximal anatomy who were treated with mechanical thrombectomy and the Merci retriever as an access adjunct were identified. Patient charts and procedure reports were reviewed.

Results: In each of the patients, the ophthalmic segment of the internal carotid artery proved difficult to navigate. An appropriately sized Merci retriever was deployed in the M1 segment. Gentle tension on the retriever was applied, altering the angle at which the aspiration catheter navigated the ophthalmic segment, affording rapid access past the ophthalmic artery origin and into the target vessel. The 18 L microcatheter and retriever were withdrawn, followed by aspiration and clot maceration with the Penumbra aspiration system.

Conclusion: Tortuous proximal anatomy may impede access to an occluded vessel. Use of tension on a deployed Merci retriever straightens the course of the wire, changing the angle that the aspiration catheter makes with the vessel. In the setting of unfavorable anatomy, this technique may be used to advance an aspiration catheter to the target lesion.

From: Merci Retrievers as Access Adjuncts for Reperfusion Catheters: The Grappling Hook Technique by Hui et al

Free full text access.

Background

Objective: To solve the problems of: 1) facial nerve segmentation and 2) calculating a safety zone around the facial nerve in relation to drill tip tracking inaccuracies.

Methods: We developed a new algorithm, called NerveClick, for semi-automatic segmentation of the intra-temporal facial nerve centerline from temporal bone CT images. We evaluated NerveClick’s accuracy in an experimental setting on healthy, neuro-otologic and neurosurgical patients. Three neurosurgeons used it to segment 126 facial nerves, which were compared to the gold standard: manually segmented facial nerve centerlines. The centerlines are used as a central axis around which a tubular safety zone is built. The zone’s thickness incorporates the drill tip tracking errors. The system will warn when the tracked tip crosses the safety zone.

Results: Neurosurgeons using NerveClick could segment facial nerve centerlines with a maximum error of 0.44+/-0.23 mm (mean+/-standard deviation) on average compared to manual segmentations.

Conclusion: Neurosurgeons using our new NerveClick algorithm can robustly segment facial nerve centerlines to construct a facial nerve safety zone, which potentially allows timely audiovisual warnings during navigated temporal bone drilling despite tracking inaccuracies.

From: Determination of a Facial Nerve Safety Zone for Navigated Temporal Bone Surgery by Voormolen et al

Full article access for Neurosurgery subscribers at Neurosurgery-Online.com.

To the Editor:

Recently, I met the opportunity to read the recommendations from the Neurocritical Care Society’s multidisciplinary consensus conference concerning the management of patients following subarachnoid hemorrhage (SAH).¹ The recommendations formulate about the use of antifibrinolytics in preventing rebleeding be worth a comment. As cited in this article, recommendations of early, short course antifibrinolytic therapy exist, but are still weak. Indeed, only 3 studies have evaluated short-term administration of antifibrinolytic agents: a prospective trial,² a retrospective review of prospective recorded data,³ and 1 retrospective analysis.⁴ I could agree that reduction of rebleeding is described in these studies, but level of recommendation is really poor. Discussion exists in this field and even if Gaberel and Emery have tried to performed a meta-analysis,⁵ comparison of 2 studies which use different drug makes no sense. As written by Prof Vincent, the realization of randomized controlled trials (RCT) in the Intensive Care is not always easy and sometimes gives false negative results.⁶ However, good clinical practice and evidence-based medicine are necessary, especially if experts want to formulate guidelines. Antifibrinolytic agent administration is not without any consequences; cerebral ischemia, peripheral thrombosis, pulmonary embolisms, kidney injury and seizures have been described after administration of tranexamic acid and epsilon aminocaproic acid.⁷ The 3 cited studies were not designed to evaluate such complications and side effects are probably underestimated. Moreover, I really don’t understand how experts could recommend careful administration of antifibrinolytics, while literature is completely silent about pharmacokinetic/pharmacodynamic evaluation in the neurological population. Until now, recommendation about the best agent and ideal dose scheme cannot be formulated. I would also specify that treatment option of intracranial aneurysms has evolved during the last years with an increased experience in interventional neuroradiology and critical care management. First, interventional neuroradiology improves treatment success and decreases postoperative complication without an increase of re-exploration.^8,9 Secondly, the use of careful hemodynamic monitoring and pharmacological approach improves patient management and outcome.^10,11 In the 3 cited studies, the rate of rebleeding is compared while interventional and surgical treatment could lead to different rebleeding rate. According to the lack of evidence in the actual literature and the abundance of discussion published in this field, antifibrinolytics have to be used with caution until new well-designed, well-powered evaluation of effects and side effects will be published. Routine use of these agents could not be formulated and careful monitoring of complication has to be performed if clinicians venture to use antifibrinolytics. With this letter, I would like to invite the reader to interpret the recommendation of this expert consensus conference with caution.

Faraoni, David

Brussels, Belgium

REFERENCES

1. Diringer MN, Bleck TP, Claude Hemphill J III, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical care Society’s multidisciplinary consensus conference. Neurocrit Care. 2011;15(2):211–240

2. Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 2002;97(4):771–778

3. Starke RM, Kim GH, Fernandez A, et al. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008;39(9):2617–2621

4. Harrigan MR, Rajneesh KF, Ardelt AA, Fisher WS III. Short-term antifibrinolytic therapy before early aneurysm treatment in subarachnoid hemorrhage: effects on rehemorrhage, cerebral ischemia, and hydrocephalus. Neurosurgery. 2010;67(4):935–939 discussion 939-940

5. Gaberel T, Emery E. Antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage: time to reconsider the question? [published online ahead of print]. Neurosurgery. 2011 doi: 10.1227/NEU.0b013e31821ff91b

6. Vincent JL. We should abandon randomized controlled trials in the intensive care unit. Crit Care Med. 2010;38(10 suppl):S534–S538

7. Faraoni D. Safety of tranexamic acid in pediatric cardiac surgery: what we do not know [published online ahead of print]. Eur J Cardiothorac Surg. 2011 doi: 10.1016/j.ejcts.2011.03.009

8. Lubicz B, Lefranc F, Bruneau M, Baleriaux D, De Witte O. Balloon-assisted coiling of intracranial aneurysms is not associated with a higher complication rate. Neuroradiology. 2008;50(9):769–776

9. Bandeira A, Raphaeli G, Baleriaux D, Bruneau M, De Witte O, Lubicz B. Selective embolization of unruptured intracranial aneurysms is associated with low retreatment rate. Neuroradiology. 2010;52(2):141–146

10. Dankbaar JW, Slooter AJ, Rinkel GJ, Schaaf IC. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care. 2010;14(1):R23

11. Treggiari MM. Hemodynamic management of subarachnoid hemorrhage. Neurocrit Care. 2011;15(2):329–335

Objective: To evaluate the efficacy and active components of a previously described epidural analgesic paste in controlling postoperative pain and facilitating early discharge from hospital after lumbar decompressive surgery.

Methods: A randomized double-blind controlled trial was conducted. Two-hundred and one patients were randomized to 1 of 4 analgesic epidural pastes at the time of lumbar spinal surgery: combination paste (morphine + methylprednisolone), steroid paste (methylprednisolone alone), morphine paste (morphine alone), or placebo. The primary outcome measures used were analgesic consumption and the McGill Pain Questionnaire (MPQ). Secondary outcome measures were: modified American Spinal Cord Injury Association (ASIA) score, Short Form 36 General Health Survey (SF-36), Aberdeen Pain Index (ABPI), time to ambulation and time to discharge from hospital.

Results: Administration of combination and steroid paste, but not morphine paste, resulted in a statistically significant reduction in mean pain rating index (PRI) and present pain intensity (PPI) components of the MPQ in the first 3 days after surgery. Likewise, postoperative in-patient narcotic analgesic consumption was reduced in the combination paste and steroid paste group, but not in the morphine paste group. No difference in time to ambulation or discharge, SF-36 scores, ABPI scores, or neurologic recovery was observed.

Conclusion: An analgesic paste containing methylprednisolone acetate is effective at reducing postoperative pain after lumbar decompressive surgery. Mixing effective doses of morphine sulfate in the paste abrogates the expected analgesic effects of epidural morphine.

From: Evaluation of Epidural Analgesic Paste Components in Lumbar Decompressive Surgery: A Randomized Double-Blind Controlled Trial by Diaz et al

Full article access for Neurosurgery subscribers at Neurosurgery-Online.com.

Philadelphia, PA (January 19, 2012) – Anabolic steroids don’t appear to contribute to degenerative brain disease caused by repeated head trauma in athletes, according to a study in the January issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The experimental findings do not support the theory that steroid use by athletes plays a role in the long-term damaging effects of mild traumatic brain injury (MTBI).  The lead author was Dr. James D. Mills of West Virginia University, Morgantown.

No Difference in Effects of Brain Trauma with vs without Steroids
Dr. Mills and colleagues designed an experiment to determine whether treatment with anabolic steroids makes any difference in the effects of brain trauma in rats. It has been suggested that steroids may contribute to the abnormalities seen in chronic traumatic encephalopathy (CTE): a progressive neurodegenerative disease linked to concussions and other forms of MTBI. In recent years, a growing number of cases of CTE have been identified in athletes, especially football players.

Use of anabolic steroids has increased dramatically in recent decades, mainly among athletes seeking a competitive advantage. Because athletes are also at high risk of sustaining concussions or MTBI, it’s possible that steroid use could be a factor in the development CTE.

The researchers used a standard technique to induce traumatic brain injury in rats, some of which were treated with anabolic steroids before and after injury. Brainstem specimens were analyzed to compare levels of a protein called beta-amyloid precursor protein (APP): an indicator of brain cell damage caused by MTBI.

The results showed no difference in responses to brain injury between rats that were and were not treated with steroids. Both groups of animals had similar elevations in AAP level. In a comparison group of rats that were not subjected to brain injury, there was no difference in APP levels with versus without steroid treatment.

Typically occurring in former professional athletes years after retirement, CTE is associated with a wide range of mental, emotional, and physical problems. The brains of patients with CTE show a distinct pattern of abnormalities for which brain trauma is the only known cause.

The new results cast doubt on the theory that anabolic steroid use could be a cause or contributing factor to the development of CTE. While acknowledging the limitations of their animal experiments, Dr. Mills and coauthors write, “[W]e see no adverse effect or causative role of anabolic steroid administration on the brain following MTBI with the use of APP counts as a marker for anatomic injury.” Rather, they point to a growing body of clinical research strongly suggesting that CTE risk is “most likely related to exposure to repetitive MTBI with a tendency toward a genetic predisposition.”

###

About Neurosurgery
Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher for healthcare professionals and students with nearly 300 periodicals and 1,500 books in more than 100 disciplines publishing under the LWW brand, as well as content-based sites and online corporate and customer services.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of  ]]> http://neurosurgerycns.wordpress.com/2012/01/23/press-release-no-link-between-steroids-and-chronic-traumatic-encephalopathy-study-suggests/feed/ 0 Neurosurgery Editorial Staff http://neurosurgerycns.wordpress.com/2012/01/23/ahead-of-print-interest-of-the-ascent-balloon/ http://neurosurgerycns.wordpress.com/2012/01/23/ahead-of-print-interest-of-the-ascent-balloon/#comments Mon, 23 Jan 2012 13:08:04 +0000 NEUROSURGERY® Editorial Office http://neurosurgerycns.wordpress.com/?p=5776 ]]> Background and Importance: To present the feasibility of using the Ascent® balloon, a new double lumen remodeling balloon, for a new two-in-one technique allowing coiling through the lumen of the balloon and no use of an additional coiling microcatheter.

Clinical Presentation: A 55 year-old woman presented with a 7.7 mm x 4.5 mm incidental anterior communicating artery aneurysm. Only one A1 segment (left side) was patent on cerebral angiogram. A 6F Fargo Max guiding catheter was positioned in the left petrous internal carotid artery. The Ascent® balloon was placed in front of the neck of the aneurysm after navigation on a Traxcess .014 in guide wire. Coiling of the aneurysm sac was performed via one lumen of the device, under iterative inflations of the balloon through the second lumen.

Conclusion: This new two-in-one technique using a sole remodeling balloon without an additional coiling microcatheter is very promising, especially in cases of small calibre parent artery.

From: The Use of the Ascent® Balloon for a Two-in-one Remodeling Technique: Feasibility and Initial Experience by Clarençon et al