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Deep brain stimulation for psychiatric disorders: where we are now

Daniel R. Cleary, Alp Ozpinar, Ahmed M. Raslan, and Andrew L. Ko

Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.

Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.

This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.

InNeurosurgical Focus Volume 38 (2015): Issue 6 (Jun 2015): Deep Brain Stimulation Applications

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Trigeminal neuralgia without neurovascular compression presents earlier than trigeminal neuralgia with neurovascular compression

Andrew L. Ko, Albert Lee, Ahmed M. Raslan, Alp Ozpinar, Shirley McCartney, and Kim J. Burchiel

OBJECT

Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). To characterize what may be distinct patient populations, the authors examined age at onset in patients with TN with and without NVC.

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患者的回顾性研究erior fossa surgery for Type I TN at Oregon Health & Science University from 2009 to 2013 was undertaken. Charts were reviewed, and imaging and operative data were collected for patients with and without NVC. Mean, median, and the empirical cumulative distribution of onset age were determined. Statistical analysis was performed using Student t-test, Wilcoxon and Kolmogorov-Smirnoff tests, and Kaplan-Meier analysis. Multivariate analysis was performed using a Cox proportional hazards model.

RESULTS

The charts of 219 patients with TN were reviewed. There were 156 patients who underwent posterior fossa exploration and microvascular decompression or internal neurolysis: 129 patients with NVC and 27 without NVC. Mean age at symptoms onset for patients with and without NVC was 51.1 and 42.6 years, respectively. This difference (8.4 years) was significant (t-test: p = 0.007), with sufficient power to detect an effect size of 8.2 years. Median age between groups with and without NVC was 53.25 and 41.2 years, respectively (p = 0.003). Histogram analysis revealed a bimodal age at onset in patients without NVC, and cumulative distribution of age at onset revealed an earlier presentation of symptoms (p = 0.003) in patients without NVC. Chi-square analysis revealed a trend toward female predominance in patients without NVC, which was not significant (p = 0.08). Multivariate analysis revealed that age at onset was related to NVC but not sex, symptom side or distribution, or patient response to medical treatment.

CONCLUSIONS

NVC is neither sufficient nor necessary for the development of TN. Patients with TN without NVC may represent a distinct population of younger, predominantly female patients. Further research into the pathophysiology underlying this debilitating disease is needed.

In开云手机版app下载安装最新版神经外科杂志》卷123开云体育app官方网站下载入口 (2015):Issue 6 (Dec 2015)

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Correlation of preoperative MRI with the long-term outcomes of dorsal root entry zone lesioning for brachial plexus avulsion pain

Andrew L. Ko, Alp Ozpinar, Jeffrey S. Raskin, Stephen T. Magill, Ahmed M. Raslan, and Kim J. Burchiel

OBJECT

损伤区(DREZotomy背根的条目) is an effective treatment for brachial plexus avulsion (BPA) pain. The role of preoperative assessment with MRI has been shown to be unreliable for determining affected levels; however, it may have a role in predicting pain outcomes. Here, DREZotomy outcomes are reviewed and preoperative MRI is examined as a possible prognostic factor.

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A retrospective review was performed of an institutional database of patients who had undergone brachial plexus DREZ procedures since 1995. Preoperative MRI was examined to assess damage to the DREZ or dorsal horn, as evidenced by avulsion of the DREZ or T2 hyperintensity within the spinal cord. Phone interviews were conducted to assess the long-term pain outcomes.

RESULTS

Between 1995 and 2012, 27 patients were found to have undergone cervical DREZ procedures for BPA. Of these, 15 had preoperative MR images of the cervical spine available for review. The outcomes were graded from 1 to 4 as poor (no significant relief), good (more than 50% pain relief), excellent (more than 75% pain relief), or pain free, respectively. Overall, DREZotomy was found to be a safe, efficacious, and durable procedure for relief of pain due to BPA. The initial success rate was 73%, which declined to 66% at a median follow-up time of 62.5 months. Damage to the DREZ or dorsal horn was significantly correlated with poorer outcomes (p = 0.02). The average outcomes in patients without MRI evidence of DREZ or dorsal horn damage was significantly higher than in patients with such damage (3.67 vs 1.75, t-test; p = 0.001). A longer duration of pain prior to operation was also a significant predictor of treatment success (p = 0.004).

CONCLUSIONS

Overall, the DREZotomy procedure has a 66% chance of achieving meaningful pain relief on long-term follow-up. Successful pain relief is associated with the lack of damage to the DREZ and dorsal horn on preoperative MRI.

InJournal of Neurosurgery Volume 124 (2016): Issue 5 (May 2016)

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Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression

Andrew L. Ko, Alp Ozpinar, Albert Lee, Ahmed M. Raslan, Shirley McCartney, and Kim J. Burchiel

OBJECT

Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or “nerve combing,” as a treatment for TN without NVC.

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这是一个回顾性研究泰的所有情况pe 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory–Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression.

RESULTS

A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome.

CONCLUSIONS

This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.

InJournal of Neurosurgery Volume 122 (2015): Issue 5 (May 2015)

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Direct heart shunt placement for CSF diversion: technical note

Ziev B. Moses, Alp Ozpinar, Muhammad M. Abd-El-Barr, Luis G. Quinonez, Sitaram M. Emani, and Liliana C. Goumnerova

The authors report a complex case of an 18-year-old male with a history of hydrocephalus secondary to intraventricular hemorrhage of prematurity, with more than 30 previous shunt revisions, who presented to the authors' institution with shunt malfunction. After exhausting his peritoneal cavity and pleural space as possible distal sites of shunt placement, he underwent a direct heart shunt placement when it was discovered he had thrombosis of his subclavian vein precluding a standard wire-guided atrial cannulation. His course was complicated by postoperative distal catheter migration and repeat surgery for reimplantation of the shunt directly into the atrium. At the 16-month follow-up visit, the patient showed no symptoms of shunt malfunction or pericardial effusion. Imaging studies demonstrated a functioning shunt system. This is the second reported successful ventricle to direct heart shunt placement in an adult. The authors report on the technical aspects of the case and review the relevant literature.

InJournal of Neurosurgery: Pediatrics Volume 18 (2016): Issue 6 (Dec 2016)

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Patient perception of scoliosis correction surgery on Instagram

Nitin Agarwal, Amaan Rahman, Rachel Jacobs, Tavis Taylor, Nallammai Muthiah, Nima Alan, Alp Ozpinar, Daryl Fields, and David Kojo Hamilton

OBJECTIVE

Patient feedback surveys provide important insight into patient outcomes, satisfaction, and perioperative needs. Recent critiques have questioned provider-initiated surveys and their capacity to accurately gauge patient perspectives due to intrinsic biases created by question framing. In this study, the authors sought to evaluate provider-independent, patient-controlled social media Instagram posts in order to better understand the patient experience following scoliosis correction surgery.

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Twitter and Instagram were queried for posts with two tagged indicators, #scoliosissurgery or @scoliosissurgery, resulting in no relevant Twitter posts and 25,000 Instagram posts. Of the initial search, 24,500 Instagram posts that did not directly involve the patient’s own experience were eliminated. Posts were analyzed and coded for the following criteria: the gender of the patient, preoperative or postoperative timing discussed in the post, and classified themes related to the patient’s experiences with scoliosis correction surgery.

RESULTS

女性87.6%对th Instagram的帖子eir experience following scoliosis correction surgery. The initial postoperative stage of surgery was mentioned in 7.6% of Instagram posts. The most common theme on Instagram involved offering or seeking online support from other patients, which constituted 85.2% of all posts. Other common themes included concern about the surgical scar (31.8%), discussing the results of treatment (28.8%), and relief regarding results (21.2%).

CONCLUSIONS

Social media provided a platform to analyze unprompted feedback from patients. Patients were most concerned with their scoliosis correction surgery in the period of time 2 weeks or more after surgery. Themes that were most commonly found on Instagram posts were offering or seeking online support from other patientsand concern about the surgical scar. Patient-controlled social media platforms, like Instagram, may provide a useful mechanism for healthcare providers to understand the patient experience following scoliosis correction surgery. Such platforms may help in evaluating postoperative satisfaction and improving postoperative quality of care.

InNeurosurgical Focus Volume 51 (2021): Issue 5 (Nov 2021): Innovations in Neurosurgical Quality and Safety

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Stereotactic radiosurgery for intradural spine tumors using cone-beam CT image guidance

Andrés Monserrate, Benjamin Zussman, Alp Ozpinar, Ajay Niranjan, John C. Flickinger, and Peter C. Gerszten

OBJECTIVE

Cone-beam CT (CBCT) image guidance technology has been widely adopted for spine radiosurgery delivery. There is relatively little experience with spine radiosurgery for intradural tumors using CBCT image guidance. This study prospectively evaluated a series of intradural spine tumors treated with radiosurgery. Patient setup accuracy for spine radiosurgery delivery using CBCT image guidance for intradural spine tumors was determined.

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Eighty-two patients with intradural tumors were treated and prospectively evaluated. The positioning deviations of the spine radiosurgery treatments in patients were recorded. Radiosurgery was delivered using a linear accelerator with a beam modulator and CBCT image guidance combined with a robotic couch that allows positioning correction in 3 translational and 3 rotational directions. To measure patient movement, 3 quality assurance CBCTs were performed and recorded in 30 patients: before, halfway, and after the radiosurgery treatment. The positioning data and fused images of planning CT and CBCT from the treatments were analyzed to determine intrafraction patient movements. From each of 3 CBCTs, 3 translational and 3 rotational coordinates were obtained.

RESULTS

The radiosurgery procedure was successfully completed for all patients. Lesion locations included cervical (22), thoracic (17), lumbar (38), and sacral (5). Tumor histologies included schwannoma (27), neurofibromas (18), meningioma (16), hemangioblastoma (8), and ependymoma (5). The mean prescription dose was 17 Gy (range 12–27 Gy) delivered in 1–3 fractions. At the halfway point of the radiation, the translational variations and standard deviations were 0.4 ± 0.5, 0.5 ± 0.8, and 0.4 ± 0.5 mm in the lateral (x), longitudinal (y), and anteroposterior (z) directions, respectively. Similarly, the variations immediately after treatment were 0.5 ± 0.4, 0.5 ± 0.6, and 0.6 ± 0.5 mm along x, y, and z directions, respectively. The mean rotational angles were 0.3° ± 0.4°, 0.3° ± 0.4°, and 0.3° ± 0.4° along yaw, roll, and pitch, respectively, at the halfway point and 0.5° ± 0.5°, 0.4° ± 0.5°, and 0.2° ± 0.3° immediately after treatment.

CONCLUSIONS

Radiosurgery offers an alternative treatment option for intradural spine tumors in patients who may not be optimal candidates for open surgery. CBCT image guidance for patient setup for spine radiosurgery is accurate and successful in patients with intradural tumors.

InNeurosurgical Focus Volume 42 (2017): Issue 1 (Jan 2017): Spinal Radiosurgery

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Safety of lateral access to the concave side for adult spinal deformity

Joshua T. Wewel, Alp Ozpinar, Corey T. Walker, David O. Okonkwo, Adam S. Kanter, and Juan S. Uribe

OBJECTIVE

Minimally invasive surgery (MIS) techniques, particularly lateral lumbar interbody fusion (LLIF), have become increasingly popular for adult spinal deformity (ASD) correction. Much discussion has been had regarding theoretical and clinical advantages to addressing coronal curvature from the convex versus concave side of the curve. In this study, the authors aimed to broadly evaluate the clinical outcomes of addressing ASD with circumferential MIS (cMIS) techniques while accessing the lumbar coronal curvature from the concave side.

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A multi-institution, retrospective chart and radiographic review was performed for all ASD patients with at least a 10° curvature, as defined by the Scoliosis Research Society, who underwent cMIS correction. The data collected included convex versus concave access to the coronal curve, durable or sensory femoral nerve injury lasting longer than 6 weeks, vascular injury, visceral injury, and any additional major complication, with at least a 2-year follow-up. Neither health-related quality-of-life metrics nor spinopelvic parameters were included within the scope of this study.

RESULTS

A total of 152 patients with ASD treated with cMIS correction via lateral access were identified and analyzed. Of these, 126 (82.9%) were approached from the concave side and 26 (17.1%) were approached from the convex side. In the concave group, 1 (0.8%) motor and 4 (3.2%) sensory deficit cases remained at 6 weeks after the operation. No vascular, visceral, or catastrophic intraoperative injuries were encountered in the concave group. Of the 26 patients in the convex group, 2 (7.7%) experienced motor deficits lasting longer than 6 weeks and 5 (19.2%) had lower-extremity sensory deficits.

CONCLUSIONS

It has been reported that lateral access to the convex side is associated with similar clinical and radiographic outcomes with fewer complications when compared with access to the concave side. Advantages to approaching the lumbar spine from the concave side include using one incision to access multiple levels, breaking the operative table to assist with curvature correction, easier access to the L4–5 disc space, the ability to release the contracted side, and, often, avoidance of the need to access or traverse the thoracic cavity. This study illustrates the largest reported cohort of concave access for cMIS scoliosis correction; few postoperative sensory and motor deficits were found.

InJournal of Neurosurgery: Spine Volume 35: Issue 1 (Jul 2021)

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Incidence of adjacent-segment surgery following stand-alone lateral lumbar interbody fusion

Gautam Nayar, Souvik Roy, Waseem Lutfi, Nitin Agarwal, Nima Alan, Alp Ozpinar, D. Kojo Hamilton, David O. Okonkwo, and Adam S. Kanter

OBJECTIVE

Adjacent-segment disease (ASD) requiring operative intervention is a relatively common long-term consequence of lumbar fusion surgery. Although the incidence of ASD requiring reoperation is well described for traditional posterior lumbar approaches (2.5%–3.9% per year), it remains poorly characterized for stand-alone lateral lumbar interbody fusion (LLIF). In this study, the authors report their institutional experience with ASD requiring reoperation after LLIF over an extended follow-up period of 4 years.

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Medical records were reviewed for 276 consecutive patients who underwent stand-alone LLIF by a single surgeon for degenerative spinal disorders. Inclusion criteria (single-stage, stand-alone LLIF without posterior supplementation, with no prior lumbar instrumentation, and a minimum of 4 years of follow-up) were met by 182 patients, who were analyzed for operative ASD incidence (per-year rate), demographics, and Oswestry Disability Index (ODI) score. Operative ASD was strictly defined as new-onset pathology following index surgery at directly adjacent levels to the prior construct. Operative, rather than symptomatic or radiographic, ASD was analyzed to provide a consistent and impactful endpoint while avoiding retrospective diagnosis.

RESULTS

这项研究的182名患者手术ASD rate of 3.3% (n = 6 procedures) over 4 years of follow-up, for an incidence on Kaplan-Meier survival analysis of 0.88% (95% CI 0.67%–1.09%) per year. In comparing patients with operative ASD with those without, there were no significant differences in mean age (53.7 vs 56.2 years), male sex (33.3% vs 44.9%), smoking status (16.7% vs 25.0%), or number of levels fused (mean 1.33 vs 1.46). The operative ASD cohort had a greater mean BMI (37.3 vs 30.2, p < 0.01). Operative ASD patients had lower baseline ODI scores (33.8 vs 48.3, p = 0.02); however, no difference was observed in ODI at 6 weeks (34.0 vs 39.0) or 3 months (16.0 vs 32.8) postoperatively.

CONCLUSIONS

The incidence of ASD in LLIF for degenerative lumbar etiologies in this cohort was 0.88% (95% CI 0.67%–1.09%) per year. Meanwhile, the reported reoperation rates for ASD in posterior spinal approaches was 2.5% to 3.9% per year, which implies that LLIF may be preferable for well-selected patients.

InJournal of Neurosurgery: Spine Volume 35: Issue 3 (Sep 2021)

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Impact of endplate-implant area mismatch on rates and grades of subsidence following stand-alone lateral lumbar interbody fusion: an analysis of 623 levels

Nitin Agarwal, Michael D. White, Xiaoran Zhang, Nima Alan, Alp Ozpinar, David J. Salvetti, Zachary J. Tempel, David O. Okonkwo, Adam S. Kanter, and D. Kojo Hamilton

OBJECTIVE

Stand-alone lateral lumbar interbody fusion (LLIF) is a useful minimally invasive approach for select spinal disorders, but implant subsidence may occur in up to 30% of patients. Previous studies have suggested that wider implants reduce the subsidence rate. This study aimed to evaluate whether a mismatch of the endplate and implant area can predict the rate and grade of implant subsidence.

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The authors conducted a retrospective review of prospectively collected data on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 surgical levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria. Thirty patients had radiographic evidence of implant subsidence. The endplates above and below the implant were measured.

RESULTS

A total of 30 patients with implant subsidence were identified. Of these patients, 6 had Marchi grade 0, 4 had grade I, 12 had grade II, and 8 had grade III implant subsidence. There was no statistically significant correlation between the endplate-implant area mismatch and subsidence grade or incidence. There was also no correlation between endplate-implant width and length mismatch and subsidence grade or incidence. However, there was a strong correlation between the usage of the 18-mm-wide implants and the development of higher-grade subsidence (p = 0.002) necessitating surgery. There was no significant association between the degree of mismatch or Marchi subsidence grade and the presence of postoperative radiculopathy. Of the 8 patients with 18-mm implants demonstrating radiographic subsidence, 5 (62.5%) required reoperation. Of the 22 patients with 22-mm implants demonstrating radiographic subsidence, 13 (59.1%) required reoperation.

CONCLUSIONS

There was no correlation between endplate-implant area, width, or length mismatch and Marchi subsidence grade for stand-alone LLIF. There was also no correlation between either endplate-implant mismatch or Marchi subsidence grade and postoperative radiculopathy. The data do suggest that the use of 18-mm-wide implants in stand-alone LLIF may increase the risk of developing high-grade subsidence necessitating reoperation compared to the use of 22-mm-wide implants.

InJournal of Neurosurgery: Spine Volume 33: Issue 1 (Jul 2020)

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