Long-term seizure and psychosocial outcomes of vagus nerve stimulation for intractable epilepsy

Vagus nerve stimulation (VNS) is a widely used adjunctive treatment option for intractable epilepsy. Most studies have demonstrated short-term seizure outcomes, usually for up to 5 years, and thus far, none have reported psychosocial outcomes in adults. We aimed to assess long-term seizure and psychosocial outcomes in patients with intractable epilepsy on VNS therapy for more than 15 years. We identified patients who had VNS implantation for treatment of intractable epilepsy from 1997 to 2013 at our Comprehensive Epilepsy Program and gathered demographics including age at epilepsy onset and VNS implantation, epilepsy type, number of antiepilepsy drugs (AEDs) and seizure frequency before VNS implantation and at the last clinic visit, and the most recent stimulation parameters from electronic medical records (EMR). Phone surveys were conducted by research assistants from May to November 2014 to determine patients\u27 current seizure frequency and psychosocial metrics, including driving, employment status, and use of antidepressants. Seizure outcomes were based on modified Engel classification (I: seizure-free/rare simple partial seizures; II: \u3e90% seizure reduction (SR), III: 50-90% SR, IV:50% SR)=favorable outcome). A total of 207 patients underwent VNS implantation, 15 of whom were deceased at the time of the phone survey, and 40 had incomplete data for medical abstraction. Of the remaining 152, 90 (59%) were contacted and completed the survey. Of these, 51% were male, with the mean age at epilepsy onset of 9.4 years (range: birth to 60 years). There were 35 (39%) patients with extratemporal epilepsy, 19 (21%) with temporal, 18 (20%) with symptomatic generalized, 5 (6%) with idiopathic generalized, and 13 (14%) with multiple types. Final VNS settings showed 16 (18%) patients with an output current \u3e2 mA and 14 (16%) with rapid cycling. Of the 80 patients with seizure frequency information, 16 (20%) had a modified Engel class I outcome, 14 (18%) had class II, 24 (30%) had class III, and 26 (33%) had class IV. Eighty percent said having VNS was worthwhile. Among the 90 patients, 43 patients were ≥ 18 years old without developmental delay in whom psychosocial outcomes were further analyzed. There was a decrease in the number of patients driving (31% vs 14%, p=0.052) and working (44% vs 35%, p=0.285) and an increase in the number of patients using antidepressant medication (14% vs 28%, p=0.057) at the time of survey compared to before VNS. In this subset, patients with \u3e50% SR (60%) were taking significantly fewer AEDs at the time of survey compared to patients with unfavorable outcomes (median: 3 vs 4, p=0.045). The associations of \u3e50% SR with the psychosocial outcomes of driving, employment, and antidepressant use were not significant, although 77% of this subset said VNS was worthwhile. This is the first study that assesses both seizure and psychosocial outcomes, and demonstrates favorable seizure outcomes of \u3e50% SR in 68% of patients and seizure freedom in 20% of patients. A large majority of patients (80%) considered VNS therapy worthwhile regardless of epilepsy type and psychosocial outcomes

Patient navigation in epilepsy care

The concept of patient navigation was first introduced in 1989 by the American Cancer Society and was first implemented in 1990 by Dr. Harold Freeman in Harlem, NY. The role of a patient navigator (PN) is to coordinate care between the care team, the patient, and their family while also providing social support. In the last 30 years, patient navigation in oncological care has expanded internationally and has been shown to significantly improve patient care experience, especially in the United States cancer care system. Like oncology care, patients who require epilepsy care face socioeconomic and healthcare system barriers and are at significant risk of morbidity and mortality if their care needs are not met. Although shortcomings in epilepsy care are longstanding, the COVID-19 pandemic has exacerbated these issues as both patients and providers have reported significant delays in care secondary to the pandemic. Prior to the pandemic, preliminary studies had shown the potential efficacy of patient navigation in improving epilepsy care. Considering the evidence that such programs are helpful for severely disadvantaged cancer patients and in enhancing epilepsy care, we believe that professional societies should support and encourage PN programs for coordinated and comprehensive care for patients with epilepsy

Magnetic resonance-guided focused ultrasound treatment for essential tremor shows sustained efficacy: a meta-analysis

Although magnetic resonance-guided focused ultrasound (MRgFUS) is a viable treatment option for essential tremor, some studies note a diminished treatment benefit over time. A PubMed search was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if hand tremor scores (HTS), total Clinical Rating Scale for Tremor (CRST) scores, or Quality of Life in Essential Tremor Questionnaire (QUEST) scores at regular intervals following MRgFUS treatment for essential tremor were documented. Data analyses included a random effects model of meta-analysis and mixed-effects model of meta-regression. Twenty-one articles reporting HTS for 395 patients were included. Mean pre-operative HTS was 19.2 ± 5.0. Mean HTS at 3 months post-treatment was 7.4 ± 5.0 (61.5% improvement, p \u3c 0.001). Treatment effect was mildly decreased at 36 months at 9.1 ± 5.4 (8.8% reduction). Meta-regression of time since treatment as a modifier of HTS revealed a downward trend in effect size, though this was not statistically significant (p = 0.208). Only 4 studies included follow-up ≥ 24 months. Thirteen included articles reported total CRST scores with standardized follow-up for 250 patients. Mean pre-operative total CRST score decreased by 46.2% at 3 months post-treatment (p \u3c 0.001). Additionally, mean QUEST scores at 3 months post-treatment significantly improved compared to baseline (p \u3c 0.001). HTS is significantly improved from baseline ≥ 24 months post-treatment and possibly ≥ 48 months post-treatment. There is a current paucity of long-term CRST and QUEST score reporting in the literature

Data mining MR image features of select structures for lateralization of mesial temporal lobe epilepsy

PURPOSE: This study systematically investigates the predictive power of volumetric imaging feature sets extracted from select neuroanatomical sites in lateralizing the epileptogenic focus in mesial temporal lobe epilepsy (mTLE) patients. METHODS: A cohort of 68 unilateral mTLE patients who had achieved an Engel class I outcome postsurgically was studied retrospectively. The volumes of multiple brain structures were extracted from preoperative magnetic resonance (MR) images in each. The MR image data set consisted of 54 patients with imaging evidence for hippocampal sclerosis (HS-P) and 14 patients without (HS-N). Data mining techniques (i.e., feature extraction, feature selection, machine learning classifiers) were applied to provide measures of the relative contributions of structures and their correlations with one another. After removing redundant correlated structures, a minimum set of structures was determined as a marker for mTLE lateralization. RESULTS: Using a logistic regression classifier, the volumes of both hippocampus and amygdala showed correct lateralization rates of 94.1%. This reflected about 11.7% improvement in accuracy relative to using hippocampal volume alone. The addition of thalamic volume increased the lateralization rate to 98.5%. This ternary-structural marker provided a 100% and 92.9% mTLE lateralization accuracy, respectively, for the HS-P and HS-N groups. CONCLUSIONS: The proposed tristructural MR imaging biomarker provides greater lateralization accuracy relative to single- and double-structural biomarkers and thus, may play a more effective role in the surgical decision-making process. Also, lateralization of the patients with insignificant atrophy of hippocampus by the proposed method supports the notion of associated structural changes involving the amygdala and thalamus

Adjuvant medical therapy in cervical dystonia after deep brain stimulation: A retrospective analysis

Background: There is limited information on optimization of symptomatic management of cervical dystonia (CD) after implantation of pallidal deep brain stimulation (DBS). Objectives: To describe the long-term, real-world management of CD patients after DBS implantation and the role of reintroduction of pharmacologic and botulinum toxin (BoNT) therapy. Methods: A retrospective analysis of patients with focal cervical or segmental craniocervical dystonia implanted with DBS was conducted. Results: Nine patients were identified with a mean follow-up of 41.7 ± 15.7 months. All patients continued adjuvant oral medication(s) to optimize symptom control post-operatively. Three stopped BoNT and four reduced BoNT dose by an average of 22%. All patients remained on at least one medication used to treat dystonia post-operatively. Conclusion: Optimal symptom control was achieved with DBS combined with either BoNT and/or medication. We suggest utilization of adjuvant therapies such as BoNT and/or medications if DBS monotherapy does not achieve optimal symptom control

Multimodal Imaging in a Patient with Hemidystonia Responsive to GPi Deep Brain Stimulation

BACKGROUND: Dystonia is a syndrome with varied phenomenology but our understanding of its mechanisms is deficient. With neuroimaging techniques, such as fiber tractography (FT) and magnetoencephalography (MEG), pathway connectivity can be studied to that end. We present a hemidystonia patient treated with deep brain stimulation (DBS). METHODS: After 10 years of left axial hemidystonia, a 45-year-old male underwent unilateral right globus pallidus internus (GPi) DBS. Whole brain MEG before and after anticholinergic medication was performed prior to surgery. 26-direction diffusion tensor imaging (DTI) was obtained in a 3 T MRI machine along with FT. The patient was assessed before and one year after surgery by using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). RESULTS: In the eyes-closed MEG study there was an increase in brain coherence in the gamma band after medication in the middle and inferior frontal region. FT demonstrated over 50% more intense ipsilateral connectivity in the right hemisphere compared to the left. After DBS, BFMDRS motor and disability scores both dropped by 71%. CONCLUSION: Multimodal neuroimaging techniques can offer insights into the pathophysiology of dystonia and can direct choices for developing therapeutics. Unilateral pallidal DBS can provide significant symptom control in axial hemidystonia poorly responsive to medication

Kyphoplasty vs Vertebroplasty: A Systematic Review of Height Restoration in Osteoporotic Vertebral Compression Fractures

Background: Back pain is a leading cause of morbidity in older US adults, especially those with osteoporosis. Osteoporotic vertebral compression fractures (OVCF) commonly occur in people with osteoporosis. ~1/3 of OVCF are symptomatic with acute or chronic low back pain. Annual US cases of osteoporosis with OVCF are ~700,000/year. OVCF and osteoporosis cause high levels of morbidity, decreased functional independence, and chronic pain. Conservative treatment for OVCF is often insufficient for many patients. Insufficient vertebral height caused by OVCF can lead to spinal deformities, reduced pulmonary function, depression, reduced mobility, and lower quality of life. Surgical correction is a viable option for increasing vertebral height in patients with OVCF. Kyphoplasty and vertebroplasty are vertebral augmentation therapies that can restore bone height for the alleviation of OVCF. Both procedures involve injection of a polymer cement into sites of fracture. Only kyphoplasty involves using an inflatable balloon to first make space for polymer injection. These minimally invasive procedures are recommended for patients who have OVCF but are refractory to conventional therapies. Also, patients with benign bone tumors or traumatic acute vertebral compression fractures with a local kyphotic angle greater than 15 degrees can benefit from these procedures. The aim of our systematic review was to identify the overall effectiveness of kyphoplasty and vertebroplasty. Height restoration after treatment was used as the key indicator of therapeutic success. Restoration of function and pain relief were also assessed. Purpose: To critically investigate whether vertebral body height restoration correlates with pain relief after kyphoplasty and vertebroplasty. Primary Outcome: height restoration. Secondary Outcomes: pain relief, functionality, cement leakage, Cobb’s Angle, wedge angle restoration, kyphosis angle restoration, and Gardner’s angle. We assessed only randomized controlled trials (RCTs) to generate a more robust and clinically applicable. We also provide an update on the literature comparing kyphoplasty versus vertebroplasty for height restoration, pain relief, and function restoration. We searched 6 databases to ensure that the review was comprehensive. Methods: We performed a systematic review per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. Level II randomized controlled trials assessing kyphoplasty and/or vertebroplasty were included. Study selection inclusion criteria: patients \u3e 18 years, in English, study of OVCF, active comparator vs placebo, outcome measure of height restoration, with pain relief and functionality as secondary outcomes. Of 4147 individual articles, 238 articles were screened, and 33 were analyzed. Of the 33 analyzed studies, 6 compared kyphoplasty to vertebroplasty. Results: Vertebral Height Restoration 7 studies of vertobroplasty 2 showed height loss 1 showed height restoration 2 showed absolute height gain 20 studies of kyphoplasty None showed height loss 8 showed height restoration 8 showed absolute height gain 6 head-to-head comparisons 3 showed correlation of cement injection volume with improved height 5 favored kyphoplasty for height restoration Alleviation of Pain: Assessed by visual analogue scale (VAS)score 6 of 6 vertebroplasty studies showed reduced postop pain 6 of 18 kyphoplasty studies showed sustained reduced pain at 12 months 6 studies compared kyphoplasty & vertebroplasty and none saw a difference between the 2 for reducing postop pain Restoration of Function Assessed by Oswestry disability index (ODI) 3 studies showed improved ODI after vertebroplasty at 18 to 36 months postop 4 studies showed improved ODI at 12 months after kyphoplasty 3 studies compared kyphoplasty & vertebroplasty and all showed lower postop ODI Conclusions: Both kyphoplasty and vertebroplasty are effective treatments for OVCF and are viable options for OVCF patients. Both treatments restored some vertebral body height, reduced kyphosis angle, improved Cobbs angle, and improved wedge angle. Both treatments showed similar benefits of pain reduction and improved functionality. It was unclear whether fracture type or age of fracture influence procedure outcomes. Kyphoplasty has the possibility of cement leakage, which can lead to negative outcomes. It was not possible to conclude whether one approach was superior.https://scholarlycommons.henryford.com/sarcd2021/1006/thumbnail.jp

Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs

BACKGROUND: Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE: To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS: A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS: A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P \u3c .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105). CONCLUSION: A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns

A Matched Cohort Analysis of Drain Usage in Elective Anterior Cervical Discectomy and Fusion: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study

STUDY DESIGN: This is a retrospective, cohort analysis of multi-institutional database. OBJECTIVE: This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. SUMMARY OF BACKGROUND DATA: After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. RESULTS: We identified 7943 patients during the study period. Propensity-score matching yielded 3206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of postoperative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs. 6.3%; P = 0.003) and had longer hospital stay (P \u3c 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (relative risk 1.23, 95% confidence interval [CI] 1.13-1.34; P \u3c 0.001). There were no significant differences in other outcomes measured. CONCLUSION: Our analysis demonstrated that drain use is associated with significant longer hospital stay.Level of Evidence: 3