Selective peripheral denervation for the treatment of intractable spasmodic torticollis: experience with 168 patients at the Mayo Clinic

2003 ◽  
Vol 98 (6) ◽  
pp. 1247-1254 ◽  
Author(s):  
Aaron A. Cohen-Gadol ◽  
J. Eric Ahlskog ◽  
Joseph Y. Matsumoto ◽  
Mary A. Swenson ◽  
Robyn L. McClelland ◽  
...  
Keyword(s):  
Cervical Dystonia ◽  
Mayo Clinic ◽  
Respiratory Arrest ◽  
Head Position ◽  
Spasmodic Torticollis ◽  
Symptom Duration ◽  
Content Type ◽  
Excellent Improvement ◽  
Fine Print

Object. Selective peripheral denervation is currently the primary surgical treatment for intractable cervical dystonia. The authors assessed preoperative factors to determine which, if any, correlated with outcomes in patients with torticollis who had undergone this procedure. Methods. The records of 168 consecutive patients who had undergone selective peripheral denervation for cervical dystonia between 1988 and 1996 at the Mayo Clinic were reviewed. There were 89 women (53%) and 79 men (47%) with a mean age of 53.4 years. Selection of muscles for denervation was based on the patient's clinical presentation and electromyography mapping results. The most common torticollis vectors were rotational in 141 patients (84%) and laterocollis in 59 (35%). Seventy patients (42%) presented with combined vectors. The technique used to remedy both conditions involved denervation of the ipsilateral posterior cervical paraspinal and splenius capitis muscles. Denervation of the sternocleidomastoid muscle was performed on the contralateral side for rotational torticollis and on the ipsilateral side for laterocollis. A rigorous physical therapy program followed surgery. At the 3-month postoperative evaluation, 125 patients (77%) of the 162 who were available for follow up had moderate to excellent improvement in their head position, and pain was moderately to markedly improved in 131 patients (81%). The long-term follow up lasted a mean of 3.4 years and was undertaken in 130 patients. The original level of moderate to excellent improvement in head position and pain was retained in at least 71 patients (70%). Outcome was not predicted by preoperative head position, severity of abnormal posture of head, symptom duration, presence of tremor or phasic dystonic movements, or failure to respond to botulinum toxin treatment. Five patients recovered from postoperative complications including one myocardial infarction, one pulmonary embolism, and three respiratory failures. Three patients suffered from persistent C-2 distribution dysesthesias and three from slight shoulder weakness; one had a wound infection, and one died of respiratory arrest. Conclusions. Selective peripheral denervation is an effective method of achieving lasting improvement of dystonia in most patients with intractable torticollis.

Cervicothoracic radiculopathy treated using posterior cervical foraminotomy/discectomy

2003 ◽  
Vol 98 (2) ◽  
pp. 131-136 ◽  
Author(s):  
James S. Harrop ◽  
Marco T. Silva ◽  
Ashwini D. Sharan ◽  
Steven J. Dante ◽  
Frederick A. Simeone
Keyword(s):  
Morbidity Rate ◽  
Symptom Duration ◽  
Specific Information ◽  
Disc Disease ◽  
Content Type ◽  
Included Patient ◽  
Posterior Cervical Foraminotomy ◽  
Disc Herniations ◽  
Fine Print

Object. The authors conducted a study to identify the effectiveness and morbidity rate associated with treating cervicothoracic disc disease (radiculopathy) via a posterior approach. Methods. Nineteen patients underwent posterior cervicothoracic laminoforaminotomy during a 5.6-year period. Medical records, imaging studies, office charts, hospital records, and phone interview data were reviewed. Specific information analyzed included patient demographics, side of lesion, and conservative treatment, symptoms, and pre- and postoperative pain levels. Pain was rated using a visual analog scale and classified into a radicular and neck component. Data in 19 patients (seven women and 12 men) who underwent 20 procedures (one patient underwent separate bilateral foraminotomies) were analyzed. The mean patient age was 54.8 years (range 38–73 years), and the follow-up period ranged from 23 to 62 months. Symptom duration ranged from 1 to 14 months (mean 3.4 months) and consisted of weakness, numbness, and painful radiculopathies in 11, 16, and 20 cases, respectively. Motor weakness was identified in 11 of 19 patients (mean grade of 4.35), and postoperatively strength normalized in eight of 11 (mean grade of 4.79). The improvement in motor scores was significant (p = 0.007). Pain was the most common presenting symptom. Preoperative radiculopathies were rated between 0 and 10 (mean 7.45), and postoperatively scores were reduced to 0 to 3 (mean 0.2) which was significant (p < 0.0001). Preoperative neck pain was rated between 0 and 8 (mean 2.55), and on follow up ranged from 0 to 2 (mean 0.5), which was also significant (p = 0.001). Conclusions. Posterior cervicothoracic foraminotomy was a safe and effective procedure in the treatment of patients with laterally located disc herniations.

Stereotactic ventrolateralis thalamotomy for medically refractory tremor in post-levodopa era Parkinson's disease patients

1991 ◽  
Vol 75 (5) ◽  
pp. 723-730 ◽  
Author(s):  
Mark W. Fox ◽  
J. Eric Ahlskog ◽  
Patrick J. Kelly
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Mayo Clinic ◽  
Microelectrode Recording ◽  
Stereotactic Techniques ◽  
Content Type ◽  
Resting Tremor ◽  
Fine Print

✓ Thirty-six patients with Parkinson's disease and medically refractory tremor underwent stereotactic ventrolateralis thalamotomy at the Mayo Clinic between 1984 and 1989. All patients had been or were being treated with carbidopa/levodopa but with unsatisfactory tremor control. Modern stereotactic techniques, including microelectrode recording, were used to treat 36 patients, of whom 31 (86%) had complete abolition of tremor and three patients (5%) had significant improvement. Tremor recurred in two patients within 3 months of surgery; however, the remaining patients suffered no recurrence of tremor during follow-up periods ranging from 14 to 68 months (mean 33 months). Persistent complications (arm dyspraxia, dysarthria, dysphasia, or abulia) were noted in five patients but were a source of disability in only two. It is concluded that thalamotomy in carefully selected patients is a beneficial operation for the control of medically refractory parkinsonian resting tremor.

Surgical treatment of jugular foramen schwannomas

1995 ◽  
Vol 82 (6) ◽  
pp. 924-932 ◽  
Author(s):  
Madjid Samii ◽  
Ramesh P. Babu ◽  
Marcos Tatagiba ◽  
Abolghassem Sepehrnia
Keyword(s):  
Mr Imaging ◽  
Type A ◽  
Jugular Foramen ◽  
Intracranial Extension ◽  
Cerebrospinal Fluid Leakage ◽  
Symptom Duration ◽  
Content Type ◽  
Type D ◽  
Fine Print

✓ Sixteen patients with schwannomas of the jugular foramen were operated on in the Department of Neurosurgery of the Nordstadt Hospital in Hannover, Germany, between 1986 and 1992. Patients with neurofibromatosis were excluded. The records of the 16 patients were retrospectively reviewed. There were five women and 11 men (mean age 43 years) with a symptom duration ranging from 6 months to 20 years (mean 5 years). The predominant symptoms were hearing loss, hoarseness, and cerebellar symptoms. Computerized tomography (CT), magnetic resonance (MR) imaging, and angiography were performed in all 16 patients. Depending on the radiological and surgical features, the tumors were classified into four types: Type A, a tumor primarily at the cerebellopontine angle with minimal enlargement of the jugular foramen (eight cases); Type B, a tumor primarily at the jugular foramen with intracranial extension (two cases); Type C, a primarily extracranial tumor with extension into the jugular foramen (one case); and Type D, a dumbbell-shaped tumor with both intra- and extracranial components (five cases). A retromastoid suboccipital craniectomy was performed for Type A tumors, and a combined cervical-mastoidectomy for Types B, C, and D. Total tumor removal was achieved in all cases. There was no operative mortality. Postoperative complications were cerebrospinal fluid leakage in one patient and mastoiditis in two patients. The follow-up period ranged from 12 to 42 months (mean 22 months). All patients were alive at the last follow-up review, and CT and/or MR imaging showed no tumor recurrence.

Spinal meningiomas in patients younger than 50 years of age: a 21-year experience

2003 ◽  
Vol 98 (3) ◽  
pp. 258-263 ◽  
Author(s):  
Aaron A. Cohen-Gadol ◽  
Ofer M. Zikel ◽  
Cody A. Koch ◽  
Bernd W. Scheithauer ◽  
William E. Krauss
Keyword(s):  
Mayo Clinic ◽  
Older Patients ◽  
Control Group ◽  
Younger Patients ◽  
Content Type ◽  
Spinal Meningiomas ◽  
The Mean ◽  
Worse Prognosis ◽  
Fine Print

Object. Spinal meningiomas occur most frequently in older patients. They are well-circumscribed and slow-growing tumors that are associated with good patient outcomes following surgery. Spinal meningiomas occurring in younger patients may be more aggressive, with a worse prognosis. The authors present their 21-year experience with spinal meningiomas in patients younger than 50 years of age. Methods. The authors reviewed data obtained in 40 patients (age < 50 years) treated at the Mayo Clinic, Rochester, during the past 21 years; in all cases the lesions were histologically confirmed spinal meningiomas. Five men (12.5%) and 35 women (87.5%) (mean age 34.5 ± 10.9 years) underwent 52 operations for 41 tumors. The mean follow-up duration was 82 ± 93 months (range 0–445 months). The data obtained in these patients were compared with those derived from a random control cohort of 40 patients older than age 50 years in whom spinal meningiomas were resected at the Mayo Clinic during a similar period. In this cohort, there were 33 women and seven men whose mean age was 67.1 ± 9.5 years. The mean follow-up duration for the older group was 88 ± 72.3 months (range 18–309 months). Compared with the random cohort of older patients, younger patients there tended to have more tumors located in the cervical spine (39%) as well as a greater number of predisposing factors such as neurofibromatosis Type 2, radiation exposure, or trauma. Nine (22%) of the patients younger than 50 years of age required reoperation for residual or recurrent tumor compared with two (5%) in the older patient control group. The overall mortality rate at the completion of the study for the younger patients was 10%. Conclusions. Spinal meningiomas in younger patients have a worse prognosis than similar tumors in older patients.

A new denervation procedure for idiopathic cervical dystonia

2002 ◽  
Vol 97 (2) ◽  
pp. 201-206 ◽  
Author(s):  
Takaomi Taira ◽  
Tomonori Kobayashi ◽  
Kenji Takahashi ◽  
Tomokatsu Hori
Keyword(s):  
Blood Loss ◽  
Cervical Dystonia ◽  
Symptomatic Improvement ◽  
Sensory Loss ◽  
Intraoperative Blood Loss ◽  
Content Type ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. The Bertrand selective peripheral denervation for cervical dystonia (CD) has been well described, and its effectiveness and safety are established. It is, however, always accompanied by postoperative sensory loss in the C-2 region. Intraoperative bleeding from epidural venous plexuses may also be problematic. The authors developed a new denervation procedure with which to avoid such complications and compared the surgery-related results with those of the traditional Bertrand operation. Methods. The new procedure consists of intradural rhizotomy of the anterior C-1 and C-2 nerve roots, extradural peripheral ramisectomy from C-3 to C-6, and selective section of peripheral branches of the accessory nerve to the sternocleidomastoid muscle. This procedure was performed in 30 patients (Group A). The results of this procedure were compared with those obtained in a matched group of 31 patients in the authors' series who underwent Bertrand denervation (Group B). Changes of CD rating score at 6-month follow up did not differ between the two groups. In one patient in Group A a C-2 sensory deficit was found, whereas C-2 sensory deficits were demonstrated in all the patients in Group B. No patients in Group A and four patients in Group B experienced occipital neuralgia. The operative time was significantly shorter in Group A. The mean intraoperative blood loss was 115 ± 30 ml (± standard deviation) in Group A and 233 ± 65 ml in Group B (p < 0.005). Conclusions. Although symptomatic improvement is the same after the Bertrand operation, the authors' new procedure for CD was associated with a lower incidence of complications and significant decrease of intraoperative blood loss.

Evaluation of gamma thalamotomy for parkinsonian and other tremors: survival of neurons adjacent to the thalamic lesion after gamma thalamotomy

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 120-127 ◽  
Author(s):  
Chihiro Ohye ◽  
Tohru Shibazaki ◽  
Junji Ishihara ◽  
Jie Zhang
Keyword(s):  
Tissue Reaction ◽  
Vascular Lesions ◽  
Thalamic Lesion ◽  
Mr Images ◽  
Unsatisfactory Result ◽  
Content Type ◽  
Rhythmic Discharge ◽  
Latent Interval ◽  
Fine Print

Object. The effects of gamma thalamotomy for parkinsonian and other kinds of tremor were evaluated. Methods. Thirty-six thalamotomies were performed in 31 patients by using a 4-mm collimator. The maximum dose was 150 Gy in the initial six cases, which was reduced to 130 Gy thereafter. The longest follow-up period was 6 years. The target was determined on T2-weighted and proton magnetic resonance (MR) images. The point chosen was in the lateral-most part of the thalamic ventralis intermedius nucleus. This is in keeping with open thalamotomy as practiced at the authors' institution. In 15 cases, gamma thalamotomy was the first surgical procedure. In other cases, previous therapeutic or vascular lesions were visible to facilitate targeting. Two types of tissue reaction were onserved on MR imaging: a simple oval shape and a complex irregular shape. Neither of these changes affected the clinical course. In the majority of cases, the tremor subsided after a latent interval of approximately 1 year after irradiation. The earliest response was demonstrated at 3 months. In five cases the tremor remained. In four of these cases, a second radiation session was administered. One of these four patients as well as another patient with an unsatisfactory result underwent open thalamotomy with microrecording. In both cases, depth recording adjacent to the necrotic area revealed normal neuronal activity, including the rhythmic discharge of tremor. Minor coagulation was performed and resulted in immediate and complete arrest of the remaining tremor. Conclusions. Gamma thalamotomy for Parkinson's disease seems to be an alternative useful method in selected cases.

Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 113-119 ◽  
Author(s):  
D. Hung-Chi Pan ◽  
Wan-Yuo Guo ◽  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Yue-Cune Chang ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Treatment ◽  
Gamma Knife Radiosurgery ◽  
Consecutive Series ◽  
Content Type ◽  
Obliteration Rate ◽  
Complete Obliteration ◽  
Fine Print

Object. A consecutive series of 240 patients with arteriovenous malformations (AVMs) treated by gamma knife radiosurgery (GKS) between March 1993 and March 1999 was evaluated to assess the efficacy and safety of radiosurgery for cerebral AVMs larger than 10 cm3 in volume. Methods. Seventy-six patients (32%) had AVM nidus volumes of more than 10 cm3. During radiosurgery, targeting and delineation of AVM nidi were based on integrated stereotactic magnetic resonance (MR) imaging and x-ray angiography. The radiation treatment was performed using multiple small isocenters to improve conformity of the treatment volume. The mean dose inside the nidus was kept between 20 Gy and 24 Gy. The margin dose ranged between 15 to 18 Gy placed at the 55 to 60% isodose centers. Follow up ranged from 12 to 73 months. There was complete obliteration in 24 patients with an AVM volume of more than 10 cm3 and in 91 patients with an AVM volume of less than 10 cm3. The latency for complete obliteration in larger-volume AVMs was significantly longer. In Kaplan—Meier analysis, the complete obliteration rate in 40 months was 77% in AVMs with volumes between 10 to 15 cm3, as compared with 25% for AVMs with a volume of more than 15 cm3. In the latter, the obliteration rate had increased to 58% at 50 months. The follow-up MR images revealed that large-volume AVMs had higher incidences of postradiosurgical edema, petechiae, and hemorrhage. The bleeding rate before cure was 9.2% (seven of 76) for AVMs with a volume exceeding 10 cm3, and 1.8% (three of 164) for AVMs with a volume less than 10 cm3. Although focal edema was more frequently found in large AVMs, most of the cases were reversible. Permanent neurological complications were found in 3.9% (three of 76) of the patients with an AVM volume of more than 10 cm3, 3.8% (three of 80) of those with AVM volume of 3 to 10 cm3, and 2.4% (two of 84) of those with an AVM volume less than 3 cm3. These differences in complications rate were not significant. Conclusions. Recent improvement of radiosurgery in conjunction with stereotactic MR targeting and multiplanar dose planning has permitted the treatment of larger AVMs. It is suggested that gamma knife radiosurgery is effective for treating AVMs as large as 30 cm3 in volume with an acceptable risk.

Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 96-101 ◽  
Author(s):  
Jong Hee Chang ◽  
Jin Woo Chang ◽  
Yong Gou Park ◽  
Sang Sup Chung
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Maximum Diameter ◽  
Content Type ◽  
Complete Occlusion ◽  
Factors Associated ◽  
Martin Grade ◽  
Fine Print

Object. The authors sought to evaluate the effects of gamma knife radiosurgery (GKS) on cerebral arteriovenous malformations (AVMs) and the factors associated with complete occlusion. Methods. A total of 301 radiosurgical procedures for 277 cerebral AVMs were performed between December 1988 and December 1999. Two hundred seventy-eight lesions in 254 patients who were treated with GKS from May 1992 to December 1999 were analyzed. Several clinical and radiological parameters were evaluated. Conclusions. The total obliteration rate for the cases with an adequate radiological follow up of more than 2 years was 78.9%. In multivariate analysis, maximum diameter, angiographically delineated shape of the AVM nidus, and the number of draining veins significantly influenced the result of radiosurgery. In addition, margin radiation dose, Spetzler—Martin grade, and the flow pattern of the AVM nidus also had some influence on the outcome. In addition to the size, topography, and radiosurgical parameters of AVMs, it would seem to be necessary to consider the angioarchitectural and hemodynamic aspects to select proper candidates for radiosurgery.

Gamma knife surgery for vestibular schwannoma: 10-year experience of 195 cases

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 87-97 ◽  
Author(s):  
Wen-Yuh Chung ◽  
Kang-Du Liu ◽  
Cheng-Ying Shiau ◽  
Hsiu-Mei Wu ◽  
Ling-Wei Wang ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Gamma Knife ◽  
Vestibular Schwannoma ◽  
Tumor Volume ◽  
Radiation Effect ◽  
Gamma Knife Surgery ◽  
Homogeneous Distribution ◽  
Content Type ◽  
Fine Print

Object. The authors conducted a study to determine the optimal radiation dose for vestibular schwannoma (VS) and to examine the histopathology in cases of treatment failure for better understanding of the effects of irradiation. Methods. A retrospective study was performed of 195 patients with VS; there were 113 female and 82 male patients whose mean age was 51 years (range 11–82 years). Seventy-two patients (37%) had undergone partial or total excision of their tumor prior to gamma knife surgery (GKS). The mean tumor volume was 4.1 cm3 (range 0.04–23.1 cm3). Multiisocenter dose planning placed a prescription dose of 11 to 18.2 Gy on the 50 to 94% isodose located at the tumor margin. Clinical and magnetic resonance (MR) imaging follow-up evaluations were performed every 6 months. A loss of central enhancement was demonstrated on MR imaging in 69.5% of the patients. At the latest MR imaging assessment decreased or stable tumor volume was demonstrated in 93.6% of the patients. During a median follow-up period of 31 months resection was avoided in 96.8% of cases. Uncontrolled tumor swelling was noted in five patients at 3.5, 17, 24, 33, and 62 months after GKS, respectively. Twelve of 20 patients retained serviceable hearing. Two patients experienced a temporary facial palsy. Two patients developed a new trigeminal neuralgia. There was no treatment-related death. Histopathological examination of specimens in three cases (one at 62 months after GKS) revealed a long-lasting radiation effect on vessels inside the tumor. Conclusions. Radiosurgery had a long-term radiation effect on VSs for up to 5 years. A margin 12-Gy dose with homogeneous distribution is effective in preventing tumor progression, while posing no serious threat to normal cranial nerve function.

Stereotactic radiotherapy for the treatment of acoustic neuromas

2004 ◽  
Vol 101 (Supplement3) ◽  
pp. 362-372 ◽  
Author(s):  
Michael T. Selch ◽  
Alessandro Pedroso ◽  
Steve P. Lee ◽  
Timothy D. Solberg ◽  
Nzhde Agazaryan ◽  
...  
Keyword(s):  
Stereotactic Radiotherapy ◽  
Tumor Size ◽  
Cranial Nerve ◽  
Target Volume ◽  
Tumor Control ◽  
Content Type ◽  
Seventh Cranial Nerve ◽  
Acoustic Neuromas ◽  
Fine Print

Object. The authors sought to assess the safety and efficacy of stereotactic radiotherapy when using a linear accelerator equipped with a micromultileaf collimator for the treatment of patients with acoustic neuromas. Methods. Fifty patients harboring acoustic neuromas were treated with stereotactic radiotherapy between September 1997 and June 2003. Two patients were lost to follow-up review. Patient age ranged from 20 to 76 years (median 59 years), and none had neurofibromatosis. Forty-two patients had useful hearing prior to stereotactic radiotherapy. The fifth and seventh cranial nerve functions were normal in 44 and 46 patients, respectively. Tumor volume ranged from 0.3 to 19.25 ml (median 2.51 ml). The largest tumor dimension varied from 0.6 to 4 cm (median 2.2 cm). Treatment planning in all patients included computerized tomography and magnetic resonance image fusion and beam shaping by using a micromultileaf collimator. The planning target volume included the contrast-enhancing tumor mass and a margin of normal tissue varying from 1 to 3 mm (median 2 mm). All tumors were treated with 6-MV photons and received 54 Gy prescribed at the 90% isodose line encompassing the planning target volume. A sustained increase greater than 2 mm in any tumor dimension was defined as local relapse. The follow-up duration varied from 6 to 74 months (median 36 months). The local tumor control rate in the 48 patients available for follow up was 100%. Central tumor hypodensity occurred in 32 patients (67%) at a median of 6 months following stereotactic radiotherapy. In 12 patients (25%), tumor size increased 1 to 2 mm at a median of 6 months following stereotactic radiotherapy. Increased tumor size in six of these patients was transient. In 13 patients (27%), tumor size decreased 1 to 14 mm at a median of 6 months after treatment. Useful hearing was preserved in 39 patients (93%). New facial numbness occurred in one patient (2.2%) with normal fifth cranial nerve function prior to stereotactic radiotherapy. New facial palsy occurred in one patient (2.1%) with normal seventh cranial nerve function prior to treatment. No patient's pretreatment dysfunction of the fifth or seventh cranial nerve worsened after stereotactic radiotherapy. Tinnitus improved in six patients and worsened in two. Conclusions. Stereotactic radiotherapy using field shaping for the treatment of acoustic neuromas achieves high rates of tumor control and preservation of useful hearing. The technique produces low rates of damage to the fifth and seventh cranial nerves. Long-term follow-up studies are necessary to confirm these findings.

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