Paddle-Lead Spinal-Cord Stimulation Surgeries for Chronic Neuropathic Pain: A Single Surgeon Case-Series Outcome Analysis in Indian Population.

Background Spinal-cord stimulation (SCS) for relief of chronic neuropathic pain is well established. Objective The inherent limitations with conventional percutaneous lead SCS are lead migration, positional variations in stimulation, as well as possible nonreplication of benefits after permanent SCS implantation, which were experienced during a positive trial period. To circumvent these limitations, we analyzed five consecutive cases of chronic intractable neuropathic pain who underwent direct SCS paddle lead placement during the trial period for pain relief. In addition, during the process of placing a permanent paddle lead, the impediment created by prior epidural scarring in such chronic patients can be obviated mechanically thereby increasing the efficacy of the procedure. Material and Methods The demographic details, diagnosis, preoperative visual analogue scale score (VAS), and follow-up VAS were recorded. Surgical procedure consisted of a standard dorsal laminotomy followed by placement of permanent paddle leads. Results All patients reported significant improvement in their VAS scores. Mean duration of follow-up was 23.6 months (9-35 months). Mean preoperative VAS was 9.4 and 1.4 at the last follow-up. No major complications were found. Conclusion With careful patient selection and appropriate surgical strategy, it was possible to implant permanent paddle leads during SCS trial itself in our five patients thereby replicating and sustaining the trial period pain relief. We argue that this can be a new cost-effective and reliable technique for the placement of SCS leads achieving excellent and sustained pain relief.

The Changing Nature of Epilepsy Surgery: A Retrospective Review of Practice Profiles.

OBJECTIVES: Recent literature documents a trend of gradual decline in temporal lobe (resective) epilepsy surgery over the past decade. Amongst these, a large scale, comprehensive survey done in selected European, Australian and American centres documents trends of resective temporal epilepsy surgery across two decades. Montreal Neurological Institute has been the leading epilepsy surgery centre for more than 50 years now. It has been at the forefront of investigating and managing epilepsy in Canada. We have looked into the trends of epilepsy surgery in our institute in the past 44 years. METHODS: The records of all adult epilepsy surgery procedures (excluding reoperations) performed by the senior authors were analysed from 1971 to 2015. Data retrieved for analysis included type of surgery (intracranial recording, resective, and neuromodulatory) and the specific surgical target for resection. Procedures were grouped into temporal resective, extratemporal (ET) resective and placement of intracranial electrodes (stereotactic electroencephalogram (SEEG)). RESULTS: A total of 2,078 new procedures were performed from 1971 to 2015 at the Montreal Neurological Institute. Temporal procedures constituted the bulk of the proportion of all procedures each year and the entire study period. SEEG group shows linear increase in the number of cases over the years catching up with the total number of temporal procedures. CONCLUSIONS: Our study involving a homogenous dataset spanning nearly 50 years shows a decline in temporal lobe surgeries and an increase in intracranial investigations despite the class I evidence of its effectiveness. This corroborates the trends in epilepsy surgery practice profiles in tertiary centres of developed countries.

DREZotomy in the management of post brachial plexus root avulsion neuropathic pain: fMRI correlates for pain relief.

BACKGROUND: Deafferentiation pain following brachial plexus root avulsion has been documented to be severe enough to affect activities of daily living in patients. Microsurgical DREZotomy is known to alleviate the symptoms by decreasing the afferent signals transmitted from the spinal cord to sensory cortex. OBJECTIVES: To document and analyse the effectiveness of DREZotomy and to evaluate the role of 'sensory cortex' in the cause and relief of dysesthetic pain, using fMRI. MATERIALS AND METHODS: This was a prospective study conducted between 2010 and 2016 and included all patients who underwent DREZotomy for dysesthetic pain following traumatic brachial plexus injury (TBPI). Patients were evaluated both preoperatively and postoperatively with Visual Analogue Scale(VAS), Hospital Anxiety and Depression score (HADS) and SF36 questionnaire and effectiveness of surgery was assessed. Functional magnetic resonance imaging (fMRI) of the brain in resting state was performed before and after surgery and was also compared with controls. Patients underwent standard microsurgical DREZotomy from C5 to D1. Postoperative assessment was done at 6 weeks and 6 months following surgery. RESULTS: Our series had 18 patients aged between 22 and 63 years. RTA was the most common cause of injury. There was significant decrease in pain at 6 months follow up compared to pre-operative values as assessed by VAS, HADS, SF36 questionnaire. fMRI analysis revealed cluster activations in the sensory, motor cortex and in the right cingulate gyrus in the preoperative group which was higher than in normal controls. In the postoperative group, the size of the resting state activation was significantly reduced. CONCLUSION: DREZotomy is an effective procedure for TBPI patients. We hypothesize that these fMRI findings reflect the cortical reorganization that occurs not only after injury but also following successful surgery which explains the cause and relief of dyesthetic pain.

Dengue Fever Presenting with Cervicodorsal Acute Spinal Spontaneous Subdural Hematoma-Case Report and Review of Literature.

BACKGROUND: Neurologic complications are increasingly being reported in dengue epidemics. Intraspinal hematomas are rare, and those associated with dengue fever are still rarer with only 1 being reported in the literature. CASE DESCRIPTION: We report a case of dengue fever presenting with acute-onset quadriparesis (upper limbs Medical Research Council [MRC] 4/5 and lower limbs 0/5) and urinary incontinence. The patient was radiologically diagnosed with cervicodorsal acute to subacute anterior epidural hematoma. On the basis of clinical and radiologic evaluations, the patient underwent an anterior cervical approach via a split-manubriotomy, C6-D4 right anterolateral partial oblique corpectomies for evacuation of the hematoma. Intraoperatively, however, there was no evidence of anterior epidural collection and the dura revealed a bluish hue. A durotomy revealed a subdural hematoma. After evacuation of the hematoma, the patient remained paraplegic and her upper limb power worsened by MRC 1 grade. Postoperative magnetic resonance imaging revealed good evacuation and no new bleed; however, the intramedullary T2-weighted signal hyperintensities extending up to C2 persisted. She was on ventilatory support for almost 5 months. For diaphragmatic incapacity she underwent bilateral cervical phrenic nerve stimulation (diaphragmatic pacing). Despite initial improvement, she succumbed to multiple underlying comorbidities. CONCLUSIONS: Acute spontaneous spinal subdural hematoma (SSDH) is extremely rare but should be kept in mind in patients with dengue hemorrhagic fever. The radiologic findings could be deceptive and plain computed tomography and magnetic resonance imaging should be used as complementary studies to establish the diagnosis of acute spontaneous SSDH. The outcomes of SSDH are guarded, and elaborate patient counseling should be done preoperatively, keeping these in perspective.

Demonstration of autonomic dysfunction in traumatic brachial plexus injury using quantitative sudomotor axon reflex test: Preliminary results.

OBJECTIVE: To objectively document autonomic dysfunction in the affected arm with traumatic brachial plexus injury (TBPI) using quantitative sudomotor axon reflex test (QSART). MATERIALS AND METHODS: Patients with TBPI presenting to the neurosurgical outpatient department from August 2013 to November 2014 were included in the study. The QSART was administered to each patient with prior informed consent detailing the procedure. A total of 20 patients with TBPI were included in the study. The age, sex, mode of injury, date of injury, side of injury, and type of injury (pan brachial plexus vs preserved distal function) were recorded. The presence of any pain was also recorded. The injuries were also grouped as preganglionic and postganglionic injuries based on clinical, electroneuromyography (ENMG) and magnetic resonance imaging (MRI) findings. The results of the test for the affected and normal limb were recorded and analyzed with appropriate statistical tests to determine any significant differences. RESULTS: The study included 20 patients, with their age ranging from 15 to 50 years. Out of the 20 patients, one was female and the rest 19 were males. Seven (35%) of the injuries were complete (pan brachial plexus) and 13 (65%) were incomplete (preserved distal function). All patients had preganglionic TBPI. There was no evidence of any statistically significant difference between the affected and normal arm for total sweat volume (P = 0.20) and latency period (P = 0.42). However, the average mean values for the same were lower in the affected arm as compared to the normal. The baseline sweat output (P = 0.010), however, was significantly lower in the affected arm as compared to the normal arm. CONCLUSION: QSART has demonstrated reduced baseline sweat output in the affected arm in patients with TBPI. This indicates the presence of autonomic dysfunction in the injured arm.

Eosinophilic Granuloma of Skull with Fluid Level and Epidural Hematoma: A Case Report and Review of the Literature.

Intracranial Langerhans cell histiocytosis commonly presents as skull lesions in children. An intratumoral cyst with fluid level and epidural hematoma occurring with eosinophilic granuloma is very rare. We report a 15-year-old boy who presented with a spontaneous epidural hematoma which was the result of a temporal eosinophilic granuloma. Multiple explanations for epidural hematoma in such cases have been discussed. Intratumoral hemorrhage followed by cyst formation and rupture may explain the pathophysiology of epidural hemorrhage formation.