Stereotactic radiofrequency ventral posterolateral thalamotomy for cancer pain

Palliative neuroablative procedures are often performed for medication-refractory cancer pain. A 57-year-old female with lung carcinoma and metastases to the brachial plexus and cervical spine with severe neuropathic pain affecting the right upper limb was referred to the authors’ functional neurosurgery service. This video shows her treatment with an awake stereotactic radiofrequency thalamotomy targeting the left ventral posterolateral nucleus. Postoperatively, she experienced immediate and complete resolution of the pain. Palliative radiofrequency thalamotomy can be a viable and effective procedure for somatotopically distributed regional cancer pain. The video can be found here: https://youtu.be/jykYWXTP3c

Consent: an event or a memory in lumbar spinal surgery? A multi-centre, multi-specialty prospective study of documentation and patient recall of consent content.

STUDY DESIGN: Prospective, multi-centre, multi-specialty medical notes review and patient interview. PURPOSE: The consenting process is an important communication tool which also carries medico-legal implications. While written consent is a pre-requisite before spinal surgery in the UK, the standard and effectiveness of the process have not been assessed previously. This study assesses standard of written consent for elective lumbar decompressive surgery for degenerative disc disease across different regions and specialties in the UK; level of patient recall of the consent content; and identifies factors which affect patient recall. METHODS: Consent forms of 153 in-patients from 4 centres a, b, c, d were reviewed. Written documentation of intended benefits, alternative treatments and operative risks was assessed. Of them, 108 patients were interviewed within 24 h before or after surgeries to assess recall. RESULTS: The written documentation rates of the operative risks showed significant inter-centre variations in haemorrhage and sphincter disturbance (P = 0.000), but not for others. Analysis of pooled data showed variations in written documentation of risks (P 14 days compared to <2 days before their surgeries had higher recall for paralysis (65.2 vs 43.7%) and recurrence (17.4 vs 2.8%). Patient recall was independent of consenter grade. CONCLUSION: Overall, the standard of written consent for elective lumbar spinal decompressive surgery was sub-optimal, which was partly reflected in the poor patient recall. While consenter seniority did not affect patient recall, younger age and longer consent-to-surgery time improved it

Brain–Machine Interfaces: The Role of the Neurosurgeon

The neurotechnology field is set to expand rapidly in the coming years as technological innovations in hardware and software are translated to the clinical setting. Given our unique access to patients with neurological disorders, expertise with which to guide appropriate treatments and technical skills to implant brain-machine interfaces (BMIs), neurosurgeons have a key role to play in the progress of this field. We outline the current state and key challenges in this rapidly advancing field including implant technology, implant recipients, implantation methodology, implant function, ethical, regulatory and economic considerations. Our key message is to encourage the neurosurgical community to proactively engage in collaborating with other healthcare professionals, engineers, scientists, ethicists and regulators in tackling these issues. By doing so, we will equip ourselves with the skills and expertise to drive the field forward and avoid being mere technicians in an industry driven by those around us

Neuroablative surgical treatments for pain due to cancer.

Cancer pain is common and challenging to manage - it is estimated that approximately 30% of cancer patients have pain that is not adequately controlled by analgesia. This paper discusses safe and effective neuroablative treatment options for refractory cancer pain. Current management of cancer pain predominantly focuses on the use of medications, resulting in a relative loss of knowledge of these surgical techniques and the erosion of the skills required to perform them. Here, we review surgical methods of modulating various points of the neural axis with the aim to expand the knowledge base of those managing cancer pain. Integration of neuroablative approaches may lead to higher rates of pain relief, and the opportunity to dose reduce analgesic agents with potential deleterious side effects. With an ever-increasing population of cancer patients, it is essential that neurosurgeons maintain or train in these techniques in tandem with the oncological multi-disciplinary team

Autonomic neurosurgery: from microvascular decompression to image guided stimulation

The paper reviews mechanisms underlying autonomic disorders, with a focus on cardiovascular dysfunction. Neurosurgical approaches are described for medically refractory hypertension and orthostatic hypotension. After review of microvascular decompression of the rostral ventrolateral medulla, stereotactic CT and MRI guided deep brain stimulation of the periaqueductal grey matter (PAG) is evaluated. Results are presented from patient studies showing reductions in blood pressure with ventral PAG stimulation and increases in blood pressure with dorsal PAG stimulation. A rationale for the treatment of autonomic disorders by neurosurgical intervention is discussed

Halo Femoral Traction for 1 Week Between Staged Anterior and Posterior Fusion Surgeries for Severe Adolescent Scoliosis Is Effective and Safe.

OBJECTIVE: To report the outcomes of halo femoral traction (HFT) used for 1 week between anterior release and definitive posterior fusion in adolescents with severe rigid scoliosis. METHODS: A retrospective single-center review of 22 consecutive patients (mean age at surgery, 14.1 years; range, 10.5-18.2 years; 17 girls) with severe, rigid scoliosis treated with anterior release, followed by HFT for 7 days prior to posterior instrumented fusion. Cobb angles were measured preoperatively, 1 week after anterior release and traction, after posterior fusion, and at a minimum 2-year follow-up. Complications were recorded. RESULTS: Mean preoperative Cobb angle was 97° (range, 80°-118°), correcting to 52° with anterior release and HFT and 31° after posterior fusion. This equated to a 68% deformity correction and was maintained at final follow-up. Three traction-related complications were experienced, including 1 case of neck pain and 2 cases of brachial plexopathy that resolved with traction weight reduction. CONCLUSIONS: Three-staged deformity correction using HFT for 1 week only offers gradual correction of the spine over sufficient time to optimize deformity correction yet minimizes neurologic dysfunction

Geodiversity assessment of Paraná state (Brazil): an innovative approach

Geodiversity is considered as the natural range of geological, geomorphological, and soil features, including their assemblages, relationships, properties, interpretations, and systems. A method developed for the quantitative assessment of geodiversity was applied to Parana ́ , a Brazilian state with an area of about 200,000 km2. The method is based on the overlay of a grid over different maps at scales ranging from 1/500,000 to 1/650,000, with the final Geodiversity Index the sum of five partial indexes calculated on a 25 9 25 km grid. The partial indexes represent the main components of geodi- versity, including geology (stratigraphy and lithology), geomorphology, paleontology, and soils. The fifth partial index covers mineral occurrences of geodiversity, such precious stones and metals, energy and industrial minerals, mineral waters, and springs. The Geodiversity Index takes the form of an isoline map that can be used as a tool in land-use planning, particularly in identifying priority areas for conservation, management, and use of natural resources at the state level.The Portuguese authors express their gratitude for the financial support given by the Fundacao para a Ciencia e a Tecnologia to the Centro de Geologia da Universidade do Porto, which partially supports this research. The Brazilian author expresses his gratitude for the financial support given by the CNPq (Conselho Nacional de Desenvolvimento Cientifico e Tecnologico) (Process Number 200074/2011-3)

DyNeuMo Mk-1: Design and pilot validation of an investigational motion-adaptive neurostimulator with integrated chronotherapy.

There is growing interest in using adaptive neuromodulation to provide a more personalized therapy experience that might improve patient outcomes. Current implant technology, however, can be limited in its adaptive algorithm capability. To enable exploration of adaptive algorithms with chronic implants, we designed and validated the 'Picostim DyNeuMo Mk-1' (DyNeuMo Mk-1 for short), a fully-implantable, adaptive research stimulator that titrates stimulation based on circadian rhythms (e.g. sleep, wake) and the patient's movement state (e.g. posture, activity, shock, free-fall). The design leverages off-the-shelf consumer technology that provides inertial sensing with low-power, high reliability, and relatively modest cost. The DyNeuMo Mk-1 system was designed, manufactured and verified using ISO 13485 design controls, including ISO 14971 risk management techniques to ensure patient safety, while enabling novel algorithms. The system was validated for an intended use case in movement disorders under an emergency-device authorization from the Medicines and Healthcare Products Regulatory Agency (MHRA). The algorithm configurability and expanded stimulation parameter space allows for a number of applications to be explored in both central and peripheral applications. Intended applications include adaptive stimulation for movement disorders, synchronizing stimulation with circadian patterns, and reacting to transient inertial events such as posture changes, general activity, and walking. With appropriate design controls in place, first-in-human research trials are now being prepared to explore the utility of automated motion-adaptive algorithms