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Deep brain stimulation of the globus pallidus internus versus the subthalamic nucleus in isolated dystonia

Suzhen Lin, Yiwen Wu, Hongxia Li, Chencheng Zhang, Tao Wang, Yixin Pan, Lu He, Ruinan Shen, Zhengdao Deng, Bomin Sun, Jianqing Ding, and Dianyou Li

OBJECTIVE

Surgical procedures involving deep brain stimulation (DBS) of the globus pallidus internus (GPi) or subthalamic nucleus (STN) are well-established treatments for isolated dystonia. However, selection of the best stimulation target remains a matter of debate. The authors’ objective was to compare the effectiveness of DBS of the GPi and the STN in patients with isolated dystonia.

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In this matched retrospective cohort study, the authors searched an institutional database for data on all patients with isolated dystonia who had undergone bilateral implantation of DBS electrodes in either the GPi or STN in the period from January 30, 2014, to June 30, 2017. Standardized assessments of dystonia and health-related quality of life using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and SF-36 were conducted before and at 1, 6, and 12 months after surgery. No patients were lost to the 6-month follow-up; 5 patients were lost to the 12-month follow-up.

RESULTS

Both GPi (14 patients) and STN (16 patients) stimulation produced significant improvement in dystonia and quality of life in all 30 patients found in the database search. At the 1-month follow-up, however, the percentage improvement in the BFMDRS total movement score was significantly (p = 0.01) larger after STN DBS (64%) than after GPi DBS (48%). At the 12-month follow-up, the percentage improvement in the axis subscore was significantly (p = 0.03) larger after GPi DBS (93%) than after STN DBS (83%). Also, the total amount of electrical energy delivered was significantly (p = 0.008) lower with STN DBS than with GPi DBS (124 ± 52 vs 192 ± 65 μJ, respectively).

CONCLUSIONS

The GPi and STN are both effective targets in alleviating dystonia and improving quality of life. However, GPi stimulation may be better for patients with axial symptoms. Moreover, STN stimulation may produce a larger clinical response within 1 month after surgery and may have a potential economic advantage in terms of lower battery consumption.

InJournal of Neurosurgery Volume 132: Issue 3 (Mar 2020)

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Pediatric patients with malignant brain tumor treated at children’s hospitals: association with fewer unplanned readmissions

Kristie Q. Liu, Shivani D. Rangwala, Talia A. Wenger, Mmerobasi U. Kanu, Jane S. Han, Li Ding, William J. Mack, Mark D. Krieger, and Frank J. Attenello

OBJECTIVE

小儿原发性脑瘤是铅ing cause of death among childhood cancers. Guidelines recommend specialized care with a multidisciplinary team and focused treatment protocols to optimize outcomes in this patient population. Furthermore, readmission is a key metric of patient outcomes and has been used to inform reimbursement. However, no prior study has analyzed national database–level records to evaluate the role of care in a designated children’s hospital following pediatric tumor resection and its impact on readmission rates. The goal of this study was to investigate whether treatment at a children’s hospital rather than a nonchildren’s hospital has a significant effect on outcome.

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The Nationwide Readmissions Database records from 2010 to 2018 were analyzed retrospectively to evaluate the effect of hospital designation on patient outcomes after craniotomy for brain tumor resection, and results are reported as national estimates. Univariate and multivariate regression analyses of patient and hospital characteristics were conducted to evaluate if craniotomy for tumor resection at a designated children’s hospital was independently associated with 30-day readmissions, mortality rate, and length of stay.

RESULTS

A total of 4003 patients who underwent craniotomy for tumor resection were identified using the Nationwide Readmissions Database, with 1258 of these cases (31.4%) treated at children’s hospitals. Patients treated at children’s hospitals were associated with decreased likelihood of 30-day hospital readmission (OR 0.68, 95% CI 0.48–0.97, p = 0.036) compared to patients treated at nonchildren’s hospitals. There was no significant difference in index mortality between patients treated at children’s hospitals and those treated at nonchildren’s hospitals.

CONCLUSIONS

The authors found that patients undergoing craniotomy for tumor resection at children’s hospitals were associated with decreased rates of 30-day readmission, with no significant difference in index mortality. Future prospective studies may be warranted to confirm this association and identify components contributing to improved outcomes in care at children’s hospitals.

InJournal of Neurosurgery: Pediatrics Volume 32: Issue 3 (Sep 2023)

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Myelomeningocele repair at pediatric hospitals: association with routine discharge and shorter hospital stay

Jane S. Han, Shivani D. Rangwala, Brandon B. Ge, Kristie Q. Liu, Li Ding, William J. Mack, Susan Durham, Mark D. Krieger, and Frank J. Attenello

OBJECTIVE

Postnatal repair for myelomeningocele (MMC) is a time-sensitive and technically challenging procedure. More experienced hospitals may provide improved outcomes for the complexity of care associated with these patients. No prior study has investigated the impact of MMC treatment at pediatric hospitals. The authors sought to examine the effect of pediatric hospital designation on patients undergoing postnatal MMC repair to identify factors associated with maximizing improved patient outcomes.

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The Nationwide Readmissions Database records from 2010 to 2018 were analyzed retrospectively to determine the effect of hospital designation on patient outcomes after postnatal MMC repair. Univariate and multivariate regression analyses of patient and hospital characteristics were conducted to evaluate if MMC repair at a designated pediatric hospital was independently associated with patient outcomes of perinatal infection rates, discharge disposition, and length of stay.

RESULTS

Of the total of 6353 pediatric patients who underwent postnatal MMC repair between 2010 and 2018, 2224 (35.0%) received care at a pediatric hospital. Those with an extreme level of disease burden as defined by the all patient refined diagnosis-related group severity of illness index were more likely to be treated at a pediatric hospital (p = 0.03). Patients undergoing repair at a pediatric hospital were also associated with a decreased likelihood of perinatal infection (OR 0.54, 95% CI 0.35–0.83, p = 0.005); greater likelihood of routine disposition (OR 4.85, 95% CI 2.34–10.06, p < 0.0001); and shorter length of stay (incidence rate ratio 0.88, 95% CI 0.77–0.995, p = 0.04).

CONCLUSIONS

Pediatric patients requiring intervention for postnatal repair of MMC may benefit from the multidisciplinary subspeciality care offered at pediatric hospitals. The authors found that postnatal repair of MMC at pediatric hospitals was associated with a greater likelihood of improved patient outcomes.

InJournal of Neurosurgery: Pediatrics Volume 32: Issue 3 (Sep 2023)

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Readmissions after ventricular shunting in pediatric patients with hydrocephalus: a Nationwide Readmissions Database analysis

Daniel A. Donoho, Ian A. Buchanan, Shivani D. Rangwala, Arati Patel, Li Ding, Steven L. Giannotta, Frank J. Attenello, William J. Mack, J. Gordon McComb, and Mark D. Krieger

OBJECTIVE

Cerebrospinal fluid diversion via ventricular shunting is a common surgical treatment for hydrocephalus in the pediatric population. No longitudinal follow-up data for a multistate population-based cohort of pediatric patients undergoing ventricular shunting in the United States have been published. In the current review of a nationwide population-based data set, the authors aimed to assess rates of shunt failure and hospital readmission in pediatric patients undergoing new ventricular shunt placement. They also review patient- and hospital-level factors associated with shunt failure and readmission.

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Included in this study was a population-based sample of pediatric patients with hydrocephalus who, in 2010–2014, had undergone new ventricular shunt placement and had sufficient follow-up, as recorded in the Nationwide Readmissions Database. The authors analyzed the rate of revision within 6 months, readmission rates at 30 and 90 days, and potential factors associated with shunt failure including patient- and hospital-level variables and type of hydrocephalus.

RESULTS

A total of 3520 pediatric patients had undergone initial ventriculoperitoneal shunt placement for hydrocephalus at an index admission. Twenty percent of these patients underwent shunt revision within 6 months. The median time to revision was 44.5 days. Eighteen percent of the patients were readmitted within 30 days and 31% were readmitted within 90 days. Different-hospital readmissions were rare, occurring in ≤ 6% of readmissions. Increased hospital volume was not protective against readmission or shunt revision. Patients with grade 3 or 4 intraventricular hemorrhage were more likely to have shunt malfunctions. Patients who had private insurance and who were treated at a large hospital were less likely to be readmitted.

CONCLUSIONS

In a nationwide, population-based database with longitudinal follow-up, shunt failure and readmission were common. Although patient and hospital factors were associated with readmission and shunt failure, system-wide phenomena such as insufficient centralization of care and fragmentation of care were not observed. Efforts to reduce readmissions in pediatric patients undergoing ventricular shunt procedures should focus on coordinating care in patients with complex neurological diseases and on reducing healthcare disparities associated with readmission.

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Ictal EEG desynchronization during low-voltage fast activity for prediction of surgical outcomes in focal epilepsy

Lingli Hu, Kai Xiong, Lingqi Ye, Yuyu Yang, Cong Chen, Shan Wang, Yao Ding, Zhongjin Wang, Wenjie Ming, Zhe Zheng, Hongjie Jiang, Hong Li, Junming Zhu, Cenglin Xu, Yi Wang, Meiping Ding, Zhong Chen, Yingcai Wu, and Shuang Wang

OBJECTIVE

The authors investigated alterations in functional connectivity (FC) and EEG power during ictal onset patterns of low-voltage fast activity (LVFA) in drug-resistant focal epilepsy. They hypothesized that such changes would be useful to classify epilepsy surgical outcomes.

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In a cohort of 79 patients with drug-resistant focal epilepsy who underwent stereoelectroencephalography (SEEG) evaluation as well as resective surgery, FC changes during the peri-LVFA period were measured using nonlinear regression (h2) and power spectral properties within/between three regions: the seizure onset zone (SOZ), early propagation zone (PZ), and noninvolved zone (NIZ). Desynchronization and power desynchronizationh2indices were calculated to assess the degree of EEG desynchronization during LVFA. Multivariate logistic regression was employed to control for confounding factors. Finally, receiver operating characteristic curves were generated to evaluate the performance of desynchronization indices in predicting surgical outcome.

RESULTS

Fifty-three patients showed ictal LVFA and distinct zones of the SOZ, PZ, and NIZ. Among them, 39 patients (73.6%) achieved seizure freedom by the final follow-up. EEG desynchronization, measured byh2analysis, was found in the seizure-free group during LVFA: FC decreased within the SOZ and between regions compared with the pre-LVFA and post-LVFA periods. In contrast, the non–seizure-free group showed no prominent EEG desynchronization. Theh2desynchronization index, but not the power desynchronization index, enabled classification of seizure-free versus non–seizure-free patients after resective surgery.

CONCLUSIONS

EEG desynchronization during the peri-LVFA period, measured by within-zone and between-zoneh2analysis, may be helpful for identifying patients with favorable postsurgical outcomes and also may potentially improve epileptogenic zone identification in the future.

InJournal of Neurosurgery Volume 139: Issue 1 (Jul 2023)

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Contralateral C7 to C7 nerve root transfer in reconstruction for treatment of total brachial plexus palsy: anatomical basis and preliminary clinical results

Guo-Bao Wang, Ai-Ping Yu, Chye Yew Ng, Gao-Wei Lei, Xiao-Min Wang, Yan-Qun Qiu, Jun-Tao Feng, Tie Li, Qing-Zhong Chen, Qian-Ru He, Fei Ding, Shu-Sen Cui, Yu-Dong Gu, Jian-Guang Xu, Su Jiang, and Wen-Dong Xu

OBJECTIVE

Contralateral C7 (CC7) nerve root has been used as a donor nerve for targeted neurotization in the treatment of total brachial plexus palsy (TBPP). The authors aimed to study the contribution of C7 to the innervation of specific upper-limb muscles and to explore the utility of C7 nerve root as a recipient nerve in the management of TBPP.

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这是一个部分的调查。1)解剖斯图dy: the C7 nerve root was dissected and its individual branches were traced to the muscles in 5 embalmed adult cadavers bilaterally. 2) Clinical series: 6 patients with TBPP underwent CC7 nerve transfer to the middle trunk of the injured side. Outcomes were evaluated with the modified Medical Research Council scale and electromyography studies.

RESULTS

In the anatomical study there were consistent and predominantly C7-derived nerve fibers in the lateral pectoral, thoracodorsal, and radial nerves. There was a minor contribution from C7 to the long thoracic nerve. The average distance from the C7 nerve root to the lateral pectoral nerve entry point of the pectoralis major was the shortest, at 10.3 ± 1.4 cm. In the clinical series the patients had been followed for a mean time of 30.8 ± 5.3 months postoperatively. At the latest follow-up, 5 of 6 patients regained M3 or higher power for shoulder adduction and elbow extension. Two patients regained M3 wrist extension. All regained some wrist and finger extension, but muscle strength was poor. Compound muscle action potentials were recorded from the pectoralis major at a mean follow-up of 6.7 ± 0.8 months; from the latissimus dorsi at 9.3 ± 1.4 months; from the triceps at 11.5 ± 1.4 months; from the wrist extensors at 17.2 ± 1.5 months; from the flexor carpi radialis at 17.0 ± 1.1 months; and from the digital extensors at 22.8 ± 2.0 months. The average sensory recovery of the index finger was S2. Transient paresthesia in the hand on the donor side, which resolved within 6 months postoperatively, was reported by all patients.

CONCLUSIONS

The C7 nerve root contributes consistently to the lateral pectoral nerve, the thoracodorsal nerve, and long head of the triceps branch of the radial nerve. CC7 to C7 nerve transfer is a reconstructive option in the overall management plan for TBPP. It was safe and effective in restoring shoulder adduction and elbow extension in this patient series. However, recoveries of wrist and finger extensions are poor.

InJournal of Neurosurgery: Spine Volume 29: Issue 5 (Nov 2018)

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