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Kim J. Burchiel

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Kim J. Burchiel

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Kim J. Burchiel

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Kim J. Burchiel, Hadley Clarke, Michael Haglund and John D. Loeser

✓ Forty patients were followed for an average period of 8½ years after 44 consecutive suboccipital craniotomies for trigeminal neuralgia. Among these patients, 36 had microvascular decompression (MVD) of the nerve, four had repeat trigeminal rhizotomy after MVD was not successful in controlling their pain, and four had primary trigeminal rhizotomies. Of the 36 patients undergoing MVD, 17 (47%) experienced recurrent postoperative neuralgic pain: in 11 (31%) pain recurrence was major, and in six (17%) it was minor. Among the eight patients undergoing rhizotomy, four (50%) had major pain recurrences and one (13%) had a minor recurrence, for a 63% total recurrence rate. There was a strong statistical relationship between an operative finding of arterial cross-compression of the nerve and long-term complete pain relief. Patients with other compressive pathology (related to veins or bone structures) did not on the average fare as well. Despite this, there appeared to be no point in time in the postoperative interval when the patient could be considered “cured.” Major recurrences averaged 3.5% annually, and minor recurrences averaged 1.5% annually. The implications of these findings for the treatment of trigeminal neuralgia and the current understanding of the mechanism of MVD for this disorder are discussed.

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Jonathan P. Miller, Feridun Acar and Kim J. Burchiel

Object

Trigeminal neuralgia (TN) presents a diagnostic challenge because of the variety of symptoms, findings during microvascular decompression (MVD), and postsurgical outcomes observed among patients who suffer from this disorder. Recently, a new paradigm for classification of TN was proposed, based on the quality of pain. This study represents the first clinical analysis of this paradigm.

Methods

The authors analyzed 144 consecutive cases involving patients who underwent MVD for TN. Preoperative symptoms were classified into 1 of 2 categories based on the preponderance of shocklike (Type 1 TN) or constant (Type 2 TN) pain. Analysis of clinical characteristics, neurovascular pathology, and postoperative outcome was performed.

Results

Compared with Type 2 TN, Type 1 TN patients were older, were more likely to have right-sided symptoms, and reported a shorter duration of symptoms prior to evaluation. Previous treatment by percutaneous or radiosurgical procedures was not a predictor of symptoms, surgical findings, or outcome (p = 0.48). Type 1 TN was significantly more likely to be associated with arterial compression. Venous or no compression was more common among Type 2 TN patients (p < 0.01). Type 1 TN patients were also more likely to be pain-free immediately after surgery, and less likely to have a recurrence of pain within 2 years (p < 0.05). Although a subset of patients progressed from Type 1 to Type 2 TN over time, their pathological and prognostic profiles nevertheless resembled those of Type 1 TN.

Conclusions

Type 1 and Type 2 TN represent distinct clinical, pathological, and prognostic entities. Classification of patients according to this paradigm should be helpful to determine how best to treat patients with this disorder.

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Editorial

Depth electrodes and outcome

Kim J. Burchiel

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Justin S. Cetas, Targol Saedi and Kim J. Burchiel

Object

Nonmalignant pain has been treated in the past century with ablative, or more appropriately, destructive procedures. Although individual outcomes for these procedures have previously been described in the literature, to the authors' knowledge this is the first comprehensive and systematic review on this topic.

Methods

A US National Library of Medicine PubMed search was conducted for the following ablative procedures: cingulotomy, cordotomy, DREZ (also input as dorsal root entry zone), ganglionectomy, mesencephalotomy, myelotomy, neurotomy, rhizotomy, sympathectomy, thalamotomy, and tractotomy. Articles related to pain resulting from malignancy and those not in peer-reviewed journals were excluded. In reviewing pertinent articles, focus was placed on patient number, outcome, and follow-up.

Results

A total of 146 articles was included in the review. The large majority of studies (131) constituted Class III evidence. Eleven Class I and 4 Class II studies were found, of which nearly all (13 of 15) evaluated radiofrequency rhizotomies for different pain origins, including lumbar facet syndrome, cervical facet pain, and Type I or typical trigeminal neuralgia. Overall, support for ablative procedures for nonmalignant pain is derived almost entirely from Class III evidence; despite a long history of use in neurosurgery, the evidence supporting destructive procedures for benign pain conditions remains limited.

Conclusions

Newly designed prospective standardized studies are required to define surgical indications and outcomes for these procedures, to provide more systematic review, and to advance the field.

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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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Kim J. Burchiel