Combined occipital and supraorbital neurostimulation for the treatment of chronic migraine headaches: initial experience.

A novel approach to the treatment of chronic migraine headaches based on neurostimulation of both occipital and supraorbital nerves was developed and reduced to clinical practice in a series of patients with headaches unresponsive to currently available therapies. Following positive trials, seven patients with chronic migraine and refractory chronic migraine headaches had permanent combined occipital nerve-supraorbital nerve neurostimulation systems implanted. The relative responses to two stimulation programs were evaluated: one that stimulated only the occipital leads and one that stimulated both the occipital and supraorbital leads together. With follow-up ranging from 1 to 35 months all patients reported a full therapeutic response but only to combined supraorbital-occipital neurostimulation. Occipital nerve stimulation alone provided a markedly inferior and inadequate response. Combined occipital nerve-supraorbital nerve neurostimulation systems may provide effective treatment for patients with chronic migraine and refractory chronic migraine headaches. For patients with chronic migraine headaches the response to combined systems appears to be substantially better than occipital nerve stimulation alone.

Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries.

We report herein the results of operatively treating 44 consecutive acute fractures of the humeral shaft using plates for internal fixation. Ninety-seven percent (43 of 44) of the fractures healed after plate fixation at an average of 12 weeks. One short plate pulled out and required revision with a longer plate and bone grafting; this fracture also healed. Cancellous bone grafting successfully filled in cortical bone gaps. Range of motion of the shoulder and elbow were essentially normal. Plate size varied depending on the location of the fracture and bone size. Eight of nine fractures treated with 3.5-mm compression plates healed uneventfully. All 11 open fractures, eight from bullet wounds, healed uneventfully after early plating. Fifteen radial nerve injuries were associated with the fractures. Twelve anatomically intact radial nerve palsies recovered in 17 weeks on average after plate fixation. One lacerated nerve was sutured and recovered. One nerve with segmental loss associated with an open fracture was left unrepaired, as was an avulsed nerve associated with a closed fracture. The dissection required for plate fixation provides information that may be helpful in determining appropriate treatment of radial nerve injuries and the prognosis for spontaneous return of function.

Measurement of effective pedicle diameter in the human spine.

Effective pedicle diameter (EPD), the maximal cancellous diameter of the spinal pedicle, demonstrates the maximal diameter available for transpedicular screw placement. The pedicles of 16 spines from T6 to L5 were measured directly with a graduated mean increase in the EPD ranging from 4.8 mm at T6 to 5.9 mm at L5. This direct pedicle measurement was significantly smaller than that of previously reported studies, which directly and radiographically measured pedicle outside width rather than inner diameter. Three specimens had little, if any, pedicular medullary cavity on direct measurement, although radiographic appearance of a medullary cavity existed. If EPD is significantly smaller than radiographic pedicle width measurements, safe transpedicular screw fixation may not be achieved. Preoperative planning must account for this so that transpedicular screws of correct diameter may be used and the complications of pedicular blowout fracture and neurologic impairment may be avoided.