Pudendal neuralgia due to solitary neurofibroma

Object. Each year a greater number of patients with trigeminal neuralgia (TN) undergo radiosurgery, including a large number of patients who are candidates for microvascular decompression (MVD). Methods. The case characteristics and outcomes of 117 consecutive patients who underwent radiosurgery were retrieved from a prospectively maintained database. The mean patient age was 67.8 years; and the majority (58%) of patients had undergone surgery previously. The dependent variable for all analyses of facial pain was complete pain relief without medication (excellent outcome). Median follow-up duration was 26 months (range 1–48 months). The actuarial rate of achieving and maintaining an excellent outcome was 57% and 55% at 1 and 3 years, respectively, after radiosurgery. A greater percentage of patients who had not previously undergone surgery achieved and maintained excellent outcomes (67% at 1 and 3 years) than that of patients who had undergone prior surgery (51% and 47% at 1 and 3 years, respectively; relative risk [RR] = 1.77, 95% confidence interval [CI] 1.01–3.13, p = 0.04). New persistent trigeminal dysfunction was noted in 43 patients (37%). Tolerable numbness or paresthesias occurred in 29 patients (25%), whereas bothersome dysesthesias developed in 14 patients (12%). Only a radiation dose of 90 Gy correlated with new trigeminal deficits or dysesthesias (RR = 3.10, 95% CI 1.64–5.81, p < 0.001). Excellent outcomes in patients with new trigeminal dysfunction were achieved and maintained at rates of 76% and 74% at 1 and 3 years, respectively, after radiosurgery, compared with respective rates of 46% and 42% in patients who did not experience postradiosurgery trigeminal dysfunction (RR = 4.53, 95% CI 2.03–9.95, p < 0.01). Conclusions. Radiosurgical treatment provides complete pain relief for the majority of patients with idiopathic TN. There is a strong correlation between the development of new facial sensory loss and achievement and maintenance of pain relief after this procedure. Because the long-term results of radiosurgery still remain unknown, MVD should continue to be the primary operation for medically fit patients with TN.

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Safety and efficacy of stereotactic radiosurgery for tumors of the spine

Journal of Neurosurgery ◽

10.3171/jns.2004.101.supplement_3.0413 ◽

2004 ◽

pp. 413-418 ◽

Cited By ~ 14

Author(s):

Deborah L. Benzil ◽

Mehran Saboori ◽

Alon Y. Mogilner ◽

Ronald Rocchio ◽

Chitti R. Moorthy

Keyword(s):

Spinal Cord ◽

Single Dose ◽

Pain Relief ◽

Total Dose ◽

Stereotactic Radiosurgery ◽

Medical Center ◽

Primary Tumors ◽

Content Type ◽

Increased Risk ◽

Fine Print

Object. The extension of stereotactic radiosurgery treatment of tumors of the spine has the potential to benefit many patients. As in the early days of cranial stereotactic radiosurgery, however, dose-related efficacy and toxicity are not well understood. The authors report their initial experience with stereotactic radiosurgery of the spine with attention to dose, efficacy, and toxicity. Methods. All patients who underwent stereotactic radiosurgery of the spine were treated using the Novalis unit at Westchester Medical Center between December 2001 and January 2004 are included in a database consisting of demographics on disease, dose, outcome, and complications. A total of 31 patients (12 men, 19 women; mean age 61 years, median age 63 years) received treatment for 35 tumors. Tumor types included 26 metastases (12 lung, nine breast, five other) and nine primary tumors (four intradural, five extradural). Thoracic tumors were most common (17 metastases and four primary) followed by lumbar tumors (four metastases and four primary). Lesions were treated to the 85 to 90% isodose line with spinal cord doses being less than 50%. The dose per fraction and total dose were selected on the basis of previous treatment (particularly radiation exposure), size of lesion, and proximity to critical structures. Conclusions. Rapid and significant pain relief was achieved after stereotactic radiosurgery in 32 of 34 treated tumors. In patients treated for metastases, pain was relieved within 72 hours and remained reduced 3 months later. Pain relief was achieved with a single dose as low as 500 cGy. Spinal cord isodoses were less than 50% in all patients except those with intradural tumors (mean single dose to spinal cord 268 cGy and mean total dose to spinal cord 689 cGy). Two patients experienced transient radiculitis (both with a biological equivalent dose (BED) > 60 Gy). One patient who suffered multiple recurrences of a conus ependymoma had permanent neurological deterioration after initial improvement. Pathological evaluation of this lesion at surgery revealed radiation necrosis with some residual/recurrent tumor. No patient experienced other organ toxicity. Stereotactic radiosurgery of the spine is safe at the doses used and provides effective pain relief. In this study, BEDs greater than 60 Gy were associated with an increased risk of radiculitis.

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Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures

Journal of Neurosurgery Spine ◽

10.3171/spi.2002.96.1.0056 ◽

2002 ◽

Vol 96 (1) ◽

pp. 56-61 ◽

Cited By ~ 39

Author(s):

Kyung Sik Ryu ◽

Chun Kun Park ◽

Moon Chan Kim ◽

Joon Ki Kang

Keyword(s):

Pain Relief ◽

Epidural Space ◽

Percutaneous Vertebroplasty ◽

Vertebral Compression Fractures ◽

Osteoporotic Vertebral Compression Fractures ◽

Content Type ◽

Compression Fractures ◽

Dose Dependent ◽

Pmma Cement ◽

Fine Print

Object. The use of polymethylmethacrylate (PMMA) cement by percutaneous injection in cases requiring vertebroplasty provides pain relief in the treatment of osteoporotic vertebral compression fractures. A retrospective study was performed to assess what caused PMMA cement to leak into the epidural space and to determine if this leakage caused any changes in its therapeutic benefits. Methods. Polymethylmethacrylate was injected into 347 vertebral compression fractures in 159 patients. The cement leaked into the epidural space in 92 (26.5%) of 347 treated vertebrae in 64 (40.3%) of the 159 patients, as demonstrated on postoperative computerized tomography scanning. Epidural leakage of PMMA cement occurred more often when injected above the level of T-7 (p = 0.001) than below. The larger the volume of PMMA injected the higher the incidence of epidural leakage (p = 0.03). Using an injector also increased epidural leakage (p = 0.045). The position of the needle tip within the vertebral body and the pattern of venous drainage did not affect epidural leakage of the cement. Leakage of PMMA into the epidural space reduced the pain relief expected after vertebroplasty. The immediate postoperative visual analog scale scores were higher (and therefore reflective of less pain relief) in patients in whom epidural PMMA leakage occurred (p = 0.009). Three months postoperatively, the authors found the highest number of patients presenting with pain relief, including those in the group with epidural leakage, and at this follow-up stage there were no significant differences between the two groups. Conclusions. The authors found that epidural leakage of PMMA after percutaneous vertebroplasty was dose dependent. The larger amount of injected PMMA, the higher the incidence of leakage. Injecting vertebral levels above T-7 also increased the incidence of epidural leakage. Epidural leakage of PMMA may attenuate only the immediate therapeutic effects of vertebroplasty.

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Circumferential fracture of the skull base causing craniocervical dislocation

Journal of Neurosurgery Spine ◽

10.3171/spi.2002.97.1.0118 ◽

2002 ◽

Vol 97 (1) ◽

pp. 118-122 ◽

Cited By ~ 1

Author(s):

Ganesh Rao ◽

Adam S. Arthur ◽

Ronald I. Apfelbaum

Keyword(s):

High Speed ◽

Unusual Case ◽

Motor Vehicle ◽

Neurological Impairment ◽

Craniocervical Junction ◽

Motor Vehicle Accidents ◽

Review Of The Literature ◽

Content Type ◽

Vehicle Accidents ◽

Fine Print

✓ Fractures of the craniocervical junction are common in victims of high-speed motor vehicle accidents; indeed, injury to this area is often fatal. The authors present the unusual case of a young woman who sustained a circumferential fracture of the craniocervical junction. Despite significant trauma to this area, she suffered remarkably minor neurological impairment and made an excellent recovery. Her injuries, treatment, and outcome, as well as a review of the literature with regard to injuries at the craniocervical junction, are discussed.

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Activation of the anterior cingulate cortex by thalamic stimulation in patients with chronic pain: a positron emission tomography study

Journal of Neurosurgery ◽

10.3171/jns.2000.92.1.0064 ◽

2000 ◽

Vol 92 (1) ◽

pp. 64-69 ◽

Cited By ~ 76

Author(s):

Karen D. Davis ◽

Ethan Taub ◽

Frank Duffner ◽

Andres M. Lozano ◽

Ronald R. Tasker ◽

...

Keyword(s):

Positron Emission Tomography ◽

Chronic Pain ◽

Pain Relief ◽

Anterior Cingulate Cortex ◽

Analgesic Effect ◽

Anterior Cingulate ◽

Emission Tomography ◽

Content Type ◽

Positron Emission ◽

Fine Print

Object. Deep brain stimulation (DBS) of the sensory thalamus has been used to treat chronic, intractable pain. The goal of this study was to investigate the thalamocortical pathways activated during thalamic DBS.Methods. The authors compared positron emission tomography (PET) images obtained before, during, and after DBS in five patients with chronic pain. Two of the five patients reported significant DBS-induced pain relief during PET scanning, and the remaining three patients did not report any analgesic effect of DBS during scanning. The most robust effect associated with DBS was activation of the anterior cingulate cortex (ACC). An anterior ACC activation was sustained throughout the 40 minutes of DBS, whereas a more posteriorly located ACC activation occurred at a delay after onset of DBS, although these activations were not dependent on the degree of pain relief reported during DBS. However, implications specific to the analgesic effect of DBS require further study of a larger, more homogeneous patient population. Additional effects of thalamic DBS were detected in motor-related regions (the globus pallidus, cortical area 4, and the cerebellum) and visual and association cortical areas.Conclusions. The authors demonstrate that the ACC is activated during thalamic DBS in patients with chronic pain.

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Gamma knife surgery with a dose of 75 to 76.8 Gray for trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns.2004.100.5.0848 ◽

2004 ◽

Vol 100 (5) ◽

pp. 848-854 ◽

Cited By ~ 74

Author(s):

Ronald Brisman

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Surgery ◽

Recurrent Pain ◽

Content Type ◽

Kaplan Meier ◽

Uniform Manner ◽

Second Procedure ◽

Fine Print

Object. The author presents a large series of patients with idiopathic trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS), at a maximum dose of 75 to 76.8 Gy, and followed up in a nearly uniform manner for up to 4.6 years. Methods. Two hundred ninety-three patients were treated and followed up for at least 6 months (range 0.4–4.6 years, median 1.9 years). At the final follow-up review, there was complete (100%) pain relief without medicines in 64 patients (21.8%), 90% or greater relief with or without small doses of medicines in 86 (29.4%), between 75 and 89% relief in 31 (10.6%), between 50 and 74% relief in 19 (6.5%), and less than 50% relief in 23 patients (7.8%). Recurrent pain requiring a second procedure occurred in 70 patients (23.9%). Kaplan—Meier analysis showed that 100%, 90% or greater, and 50% or greater pain relief was obtained and maintained for 3.5 to 4.1 years in 5.6 , 23.7, and 50.4% patients, respectively. Of 31 patients who described pain relief ranging from 75 to 89%, 80% of patients described it as good and 10% as excellent; of 17 patients who reported between 50 and 74% pain relief, 53% described it as good and none as excellent (p = 0.014). Dysesthesia scores greater than 5 (scale of 0–10, in which a score of 10 represents excruciating pain) occurred in four (3.2%) of 126 patients who had not undergone prior surgery; all these patients obtained either good or excellent relief from TN pain. There were 36 patients in whom the TN had atypical features; these patients were less likely to attain at least 50% or at least 90% pain relief compared with those without atypical TN features (p = 0.001). Conclusions. Gamma knife surgery is a safe and effective way to relieve TN. Patients who attain between 75 and 89% pain relief are much more likely to describe this outcome as good or excellent than those who attain between 50 and 74% pain relief.

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Spinal intradural schwannoma without attachment to a nerve root

Journal of Neurosurgery ◽

10.3171/jns.1982.57.5.0701 ◽

1982 ◽

Vol 57 (5) ◽

pp. 701-702 ◽

Cited By ~ 6

Author(s):

Angelo Bollati ◽

Giuseppe Galli ◽

Massimo Gandolfini ◽

Giovanni Marini ◽

Gabriele Pizzoli

Keyword(s):

Nerve Root ◽

Unusual Case ◽

Content Type ◽

Fine Print ◽

Root Connection

✓ The authors report an unusual case of intradural schwannoma, without demonstrable nerve root connection. An original explanation is given.

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Safety and efficacy of stereotactic radiosurgery for tumors of the spine

Journal of Neurosurgery ◽

10.3171/sup.2004.101.supplement3.0413 ◽

2004 ◽

Vol 101 (Supplement3) ◽

pp. 413-418 ◽

Cited By ~ 108

Author(s):

Deborah L. Benzil ◽

Mehran Saboori ◽

Alon Y. Mogilner ◽

Ronald Rocchio ◽

Chitti R. Moorthy

Keyword(s):

Spinal Cord ◽

Single Dose ◽

Pain Relief ◽

Total Dose ◽

Stereotactic Radiosurgery ◽

Medical Center ◽

Primary Tumors ◽

Content Type ◽

Increased Risk ◽

Fine Print

Object. The extension of stereotactic radiosurgery treatment of tumors of the spine has the potential to benefit many patients. As in the early days of cranial stereotactic radiosurgery, however, dose-related efficacy and toxicity are not well understood. The authors report their initial experience with stereotactic radiosurgery of the spine with attention to dose, efficacy, and toxicity. Methods. All patients who underwent stereotactic radiosurgery of the spine were treated using the Novalis unit at Westchester Medical Center between December 2001 and January 2004 are included in a database consisting of demographics on disease, dose, outcome, and complications. A total of 31 patients (12 men, 19 women; mean age 61 years, median age 63 years) received treatment for 35 tumors. Tumor types included 26 metastases (12 lung, nine breast, five other) and nine primary tumors (four intradural, five extradural). Thoracic tumors were most common (17 metastases and four primary) followed by lumbar tumors (four metastases and four primary). Lesions were treated to the 85 to 90% isodose line with spinal cord doses being less than 50%. The dose per fraction and total dose were selected on the basis of previous treatment (particularly radiation exposure), size of lesion, and proximity to critical structures. Conclusions. Rapid and significant pain relief was achieved after stereotactic radiosurgery in 32 of 34 treated tumors. In patients treated for metastases, pain was relieved within 72 hours and remained reduced 3 months later. Pain relief was achieved with a single dose as low as 500 cGy. Spinal cord isodoses were less than 50% in all patients except those with intradural tumors (mean single dose to spinal cord 268 cGy and mean total dose to spinal cord 689 cGy). Two patients experienced transient radiculitis (both with a biological equivalent dose (BED) > 60 Gy). One patient who suffered multiple recurrences of a conus ependymoma had permanent neurological deterioration after initial improvement. Pathological evaluation of this lesion at surgery revealed radiation necrosis with some residual/recurrent tumor. No patient experienced other organ toxicity. Stereotactic radiosurgery of the spine is safe at the doses used and provides effective pain relief. In this study, BEDs greater than 60 Gy were associated with an increased risk of radiculitis.

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False cerebral aneurysm associated with metastatic carcinoma of the brain

Journal of Neurosurgery ◽

10.3171/jns.1974.41.3.0380 ◽

1974 ◽

Vol 41 (3) ◽

pp. 380-382 ◽

Cited By ~ 11

Author(s):

Abdon Reina ◽

Robert B. Seal

Keyword(s):

Cerebral Aneurysm ◽

Clinical History ◽

Metastatic Carcinoma ◽

Malignant Cells ◽

Carotid Angiography ◽

Left Frontal Lobe ◽

Content Type ◽

Aneurysm Wall ◽

The Brain ◽

Fine Print

✓In a patient with metastatic carcinoma of the left frontal lobe, carotid angiography revealed a false cerebral aneurysm arising from the middle cerebral vessels. At craniotomy the aneurysm was found to be surrounded by tumor and cortex. Since the clinical history excluded trauma, it was inferred that the histologically-proven invasion of the aneurysm wall by malignant cells was responsible for the formation of a false cerebral aneurysm.

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Aberrant vertebral artery course in a case of Chiari malformation and occipitoatlantal assimilation

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.3.3.0246 ◽

2005 ◽

Vol 3 (3) ◽

pp. 246-248 ◽

Cited By ~ 7

Author(s):

Shinji Hotta ◽

Akio Morita ◽

Atsushi Seichi ◽

Takaaki Kirino

Keyword(s):

Vertebral Artery ◽

Chiari Malformation ◽

Unusual Case ◽

Content Type ◽

Fine Print

✓ The authors report an unusual case of a patient with combined vertebral artery and Chiari malformation anomalies. Unless such anomalies are properly recognized prior to decompression and fusion, this condition can have grave surgical consequences. The diagnostic and surgery-related implications of such anomalous codiseases are discussed.

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