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Contemporary concepts of pain surgery

JNSPG 75th Anniversary Invited Review Article

Kim J. Burchiel and Ahmed M. Raslan

Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.

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Ashwin Viswanathan and Kim J. Burchiel

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Jorge L. Eller, Ahmed M. Raslan and Kim J. Burchiel

Based on specific, objective, and reproducible criteria, a classification scheme for trigeminal neuralgia (TN) and related facial pain syndromes is proposed. Such a classification scheme is based on information provided in the patient's history and incorporates seven diagnostic criteria, as follows. 1) and 2) Trigeminal neuralgia Types 1 and 2 (TN1 and TN2) refer to idiopathic, spontaneous facial pain that is either predominantly episodic (as in TN1) or constant (as in TN2) in nature. 3) Trigeminal neuropathic pain results from unintentional injury to the trigeminal nerve from trauma or surgery. 4) Trigeminal deafferentation pain results from intentional injury to the nerve by peripheral nerve ablation, gangliolysis, or rhizotomy in an attempt to treat either TN or other related facial pain. 5) Symptomatic TN results from multiple sclerosis. 6) Postherpetic TN follows a cutaneous herpes zoster outbreak in the trigeminal distribution. 7) The category of atypical facial pain is reserved for facial pain secondary to a somatoform pain disorder and requires psychological testing for diagnostic confirmation. The purpose of a classification scheme like this is to advocate a more rigorous, standardized natural history and outcome studies for TN and related facial pain syndromes.

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Eric M. Thompson, Kim J. Burchiel and Ahmed M. Raslan

For confirming the correct location of the radiofrequency electrode before creation of a lesion, percutaneous CT-guided trigeminal tractotomy–nucleotomy is most commonly performed with the patient prone and awake. However, for patients whose facial pain and hypersensitivity are so severe that the patients are unable to rest their face on a support (as required with prone positioning), awake CT-guided tractotomy-nucleotomy might not be feasible. The authors describe 2 such patients, for whom percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia was successful. One patient was a 79-year-old man with profound left facial postherpetic neuralgia, who was unable to tolerate awake CT-guided tractotomy-nucleotomy, and the other was a 45-year-old woman with intractable hemicranial pain that developed after a right frontal lesionectomy for epilepsy. Each patient underwent a percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia. No complications occurred, and each patient reported excellent pain relief for up to 6 and 3 months after surgery, respectively. Percutaneous intraoperative CT-guided tractotomy-nucleotomy performed on anesthetized patients is effective for facial postherpetic neuralgia and postoperative hemicranial neuralgia.

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Katherine G. Holste, Frances A. Hardaway, Ahmed M. Raslan and Kim J. Burchiel

OBJECTIVE

Nervus intermedius neuralgia (NIN) or geniculate neuralgia is a rare facial pain condition consisting of sharp, lancinating pain deep in the ear and can occur alongside trigeminal neuralgia (TN). Studies on the clinical presentation, intraoperative findings, and ultimately postoperative outcomes are extremely limited. The aim of this study was to examine the clinical presentation and surgical findings, and determine pain-free survival after sectioning of the nervus intermedius (NI).

METHODS

The authors conducted a retrospective chart review and survey of patients who were diagnosed with NIN at one institution and who underwent neurosurgical interventions. Pain-free survival was determined through chart review and phone interviews using a modified facial pain and quality of life questionnaire and represented as Kaplan-Meier curves.

RESULTS

The authors found 15 patients with NIN who underwent microsurgical intervention performed by two surgeons from 2002 to 2016 at a single institution. Fourteen of these patients underwent sectioning of the NI, and 8 of 14 had concomitant TN. Five patients had visible neurovascular compression (NVC) of the NI by the anterior inferior cerebellar artery in most cases where NVC was found. The most common postoperative complaints were dizziness and vertigo, diplopia, ear fullness, tinnitus, and temporary facial nerve palsy. Thirteen of the 14 patients reportedly experienced pain relief immediately after surgery. The mean length of follow-up was 6.41 years (range 8 months to 14.5 years). Overall recurrence of any pain was 42% (6 of 14), and 4 patients (isolated NIN that received NI sectioning alone) reported their pain was the same or worse than before surgery at longest follow-up. The median pain-free survival was 4.82 years ± 14.85 months. The median pain-controlled survival was 6.22 years ± 15.78 months.

CONCLUSIONS

In this retrospective review, sectioning of the NI produced no major complications, such as permanent facial weakness or deafness, and was effective for patients when performed in addition to other procedures. After sectioning of the NI, patients experienced 4.8 years pain free and experienced 6.2 years of less pain than before surgery. Alone, sectioning of the NI was not effective. The pathophysiology of NIN is not entirely understood. It appears that neurovascular compression plays only a minor role in the syndrome and there is a high degree of overlap with TN.

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Treatment of hemiballismus with stereotactic pallidotomy

Case report and review of the literature

Konstantin V. Slavin, Thomas K. Baumann and Kim J. Burchiel

Hemiballismus is a relatively rare movement disorder that is characterized by uncontrolled, random, large-amplitude movements of the limbs. It is usually caused by a vascular lesion that involves the contralateral subthalamic nucleus (STN) (also known as the nucleus hypothalamicus or corpus luysi) and its afferent and efferent pathways.

The authors present a case of medically intractable hemiballismus in a 70-year-old woman who was successfully treated with stereotactic posteroventral pallidotomy. In agreement with the data reported earlier by other groups, the microrecording performed during the pallidotomy showed a decreased rate of firing of the pallidal neurons, supporting the theory of impaired excitatory input from the STN to the internal part of the globus pallidus.

Stereotactic pallidotomy may be the procedure of choice in the treatment of medically intractable hemiballismus. Intraoperative microrecording significantly improves the precision of the stereotactic targeting and should be considered a standard part of the pallidotomy protocol.

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R. Lorie Jacob, Jonah Geddes, Shirley McCartney and Kim J. Burchiel

OBJECT

The objective of this study was to compare the cost of deep brain stimulation (DBS) performed awake versus asleep at a single US academic health center and to compare costs across the University HealthSystem Consortium (UHC) Clinical Database.

METHODS

Inpatient and outpatient demographic and hospital financial data for patients receiving a neurostimulator lead implant (from the first quarter of 2009 to the second quarter of 2014) were collected and analyzed. Inpatient charges included those associated with International Classification of Diseases, Ninth Revision (ICD-9) procedure code 0293 (implantation or replacement of intracranial neurostimulator lead). Outpatient charges included all preoperative charges ≤ 30 days prior to implant and all postoperative charges ≤ 30 days after implant. The cost of care based on reported charges and a cost-to-charge ratio was estimated. The UHC database was queried (January 2011 to March 2014) with the same ICD-9 code. Procedure cost data across like hospitals (27 UHC hospitals) conducting similar DBS procedures were compared.

RESULTS

Two hundred eleven DBS procedures (53 awake and 158 asleep) were performed at a single US academic health center during the study period. The average patient age ( ± SD) was 65 ± 9 years old and 39% of patients were female. The most common primary diagnosis was Parkinson’s disease (61.1%) followed by essential and other forms of tremor (36%). Overall average DBS procedure cost was $39,152 ± $5340. Asleep DBS cost $38,850 ± $4830, which was not significantly different than the awake DBS cost of $40,052 ± $6604. The standard deviation for asleep DBS was significantly lower (p ≤ 0.05). In 2013, the median cost for a neurostimulator implant lead was $34,052 at UHC-affiliated hospitals that performed at least 5 procedures a year. At Oregon Health & Science University, the median cost was $17,150 and the observed single academic health center cost for a neurostimulator lead implant was less than the expected cost (ratio 0.97).

CONCLUSIONS

In this single academic medical center cost analysis, DBS performed asleep was associated with a lower cost variation relative to the awake procedure. Furthermore, costs compared favorably to UHC-affiliated hospitals. While asleep DBS is not yet standard practice, this center exclusively performs asleep DBS at a lower cost than comparable institutions.

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Jamal M. Taha, Jacques Favre, Thomas K. Baumann and Kim J. Burchiel

The goals of this study were to analyze the effect of pallidotomy on parkinsonian tremor and to ascertain whether an association exists between microrecording findings and tremor outcome.

Forty-four patients with Parkinson's disease (PD) who had drug-induced dyskinesia, bradykinesia, rigidity, and tremor underwent posteroventral pallidotomy. Using a 1-μ-tip tungsten electrode, microrecordings were obtained through one to three tracts, starting 10 mm above the pallidal base. Tremor severity was measured on a patient-rated, 100-mm Visual Analog Scale (VAS), both preoperatively and 3 to 9 months (mean 6 months) postoperatively.

Preoperatively, tremor was rated as 50 mm or greater in 24 patients (55%) and as less than 25 mm in 13 patients (30%). Postoperatively, tremor was rated as 50 mm or greater in five patients (11%) and less than 25 mm in 29 patients (66%). The difference was significant (p = 0.0001). Four patients (9%) had no postoperative tremor. Tremor improved by at least 50% in eight (80%) of 10 patients in whom tremor-synchronous cells were recorded (Group A) and in 12 (35%) of 34 patients in whom tremor-synchronous cells were not recorded (Group B). This difference was significant (p = 0.03). Tremor improved by at least 50 mm in all (100%) of the seven Group A patients with severe (>= 50 mm) preoperative tremor and in nine (53%) of 17 Group B patients with severe preoperative tremor. This difference was also significant (p = 0.05).

The authors proffer two conclusions: 1) after pallidotomy, tremor improves by at least 50% in two-thirds of patients with PD who have severe (>= 50 mm on the VAS) preoperative tremor; and 2) better tremor control is obtained when tremor-synchronous cells are included in the lesion.

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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.

METHODS

This was a retrospective review of all cases of Type 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.