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Andrew H. Milby, Casey H. Halpern, Wensheng Guo and Sherman C. Stein

Object

Diagnosis of cervical spinal injury (CSI) is an essential aspect of the trauma evaluation. This task is especially difficult in patients who are not clinically able to be evaluated (unevaluable) because of distracting painful injuries, intoxication, or concomitant head injury. For this population, the appropriate use of advanced imaging techniques for cervical spinal clearance remains undetermined. This study was undertaken to estimate the prevalence of unstable CSI, particularly among patients in whom clinical evaluation is impossible or unreliable.

Methods

Estimates of the prevalence of CSI in populations consisting of all trauma patients, alert patients only, and clinically unevaluable patients only were determined by variance-weighted pooling of data from 65 publications (281,864 patients) that met criteria for review.

Results

The overall prevalence of CSI among all trauma patients was 3.7%. The prevalence of CSI in alert patients was 2.8%, whereas unevaluable patients were at increased risk of CSI with a prevalence of 7.7% (p = 0.007). Overall, 41.9% of all CSI cases were considered to exhibit instability.

Conclusions

Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.

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Allen L. Ho, Elizabeth Erickson-Direnzo, Arjun V. Pendharkar, Chih-Kwang Sung and Casey H. Halpern

Tremulous voice is a characteristic feature of a multitude of movement disorders, but when it occurs in individuals diagnosed with essential tremor, it is referred to as essential vocal tremor (EVT). For individuals with EVT, their tremulous voice is associated with significant social embarrassment and in severe cases may result in the discontinuation of employment and hobbies. Management of EVT is extremely difficult, and current behavioral and medical interventions for vocal tremor result in suboptimal outcomes. Deep brain stimulation (DBS) has been proposed as a potential therapeutic avenue for EVT, but few studies can be identified that have systematically examined improvements in EVT following DBS. The authors describe a case of awake bilateral DBS targeting the ventral intermediate nucleus for a patient suffering from severe voice and arm tremor. They also present their comprehensive, multidisciplinary methodology for definitive treatment of EVT via DBS. To the authors’ knowledge, this is the first time comprehensive intraoperative voice evaluation has been used to guide microelectrode/stimulator placement, as well as the first time that standard pre- and post-DBS assessments have been conducted, demonstrating the efficacy of this tailored DBS approach.

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Allen L. Ho, Anne-Mary N. Salib, Arjun V. Pendharkar, Eric S. Sussman, William J. Giardino and Casey H. Halpern

Alcohol use disorder (AUD) is a difficult to treat condition with a significant global public health and cost burden. The nucleus accumbens (NAc) has been implicated in AUD and identified as an ideal target for deep brain stimulation (DBS). There are promising preclinical animal studies of DBS for alcohol consumption as well as some initial human clinical studies that have shown some promise at reducing alcohol-related cravings and, in some instances, achieving long-term abstinence. In this review, the authors discuss the evidence and concepts supporting the role of the NAc in AUD, summarize the findings from published NAc DBS studies in animal models and humans, and consider the challenges and propose future directions for neuromodulation of the NAc for the treatment of AUD.

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Daniel R. Kramer, Casey H. Halpern, Dana L. Buonacore, Kathryn R. McGill, Howard I. Hurtig, Jurg L. Jaggi and Gordon H. Baltuch

Deep brain stimulation (DBS) is the treatment of choice for otherwise healthy patients with advanced Parkinson disease who are suffering from disabling dyskinesias and motor fluctuations related to dopaminergic therapy. As DBS is an elective procedure, it is essential to minimize the risk of morbidity. Further, precision in targeting deep brain structures is critical to optimize efficacy in controlling motor features. The authors have already established an operational checklist in an effort to minimize errors made during DBS surgery. Here, they set out to standardize a strict, step-by-step approach to the DBS surgery used at their institution, including preoperative evaluation, the day of surgery, and the postoperative course. They provide careful instruction on Leksell frame assembly and placement as well as the determination of indirect coordinates derived from MR images used to target deep brain structures. Detailed descriptions of the operative procedure are provided, outlining placement of the stereotactic arc as well as determination of the appropriate bur hole location, lead placement using electrophysiology, and placement of the internal pulse generator. The authors also include their approach to preventing postoperative morbidity. They believe that a strategic, step-by-step approach to DBS surgery combined with a standardized checklist will help to minimize operating room mistakes that can compromise targeting and increase the risk of complication.

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Allen L. Ho, Eric S. Sussman, Arjun V. Pendharkar, Dan E. Azagury, Cara Bohon and Casey H. Halpern

Obesity is one of the most serious public health concerns in the US. While bariatric surgery has been shown to be successful for treatment of morbid obesity for those who have undergone unsuccessful behavioral modification, its associated risks and rates of relapse are not insignificant. There exists a neurological basis for the binge-like feeding behavior observed in morbid obesity that is believed to be due to dysregulation of the reward circuitry. The authors present a review of the evidence of the neuroanatomical basis for obesity, the potential neural targets for deep brain stimulation (DBS), as well as a rationale for DBS and future trial design. Identification of an appropriate patient population that would most likely benefit from this type of therapy is essential. There are also significant cost and ethical considerations for such a neuromodulatory intervention designed to alter maladaptive behavior. Finally, the authors present a consolidated set of inclusion criteria and study end points that should serve as the basis for any trial of DBS for obesity.

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Allen L. Ho, Yagmur Muftuoglu, Arjun V. Pendharkar, Eric S. Sussman, Brenda E. Porter, Casey H. Halpern and Gerald A. Grant

OBJECTIVE

Stereoelectroencephalography (SEEG) has increased in popularity for localization of epileptogenic zones in drug-resistant epilepsy because safety, accuracy, and efficacy have been well established in both adult and pediatric populations. Development of robot-guidance technology has greatly enhanced the efficiency of this procedure, without sacrificing safety or precision. To date there have been very limited reports of the use of this new technology in children. The authors present their initial experience using the ROSA platform for robot-guided SEEG in a pediatric population.

METHODS

Between February 2016 and October 2017, 20 consecutive patients underwent robot-guided SEEG with the ROSA robotic guidance platform as part of ongoing seizure localization and workup for medically refractory epilepsy of several different etiologies. Medical and surgical history, imaging and trajectory plans, as well as operative records were analyzed retrospectively for surgical accuracy, efficiency, safety, and epilepsy outcomes.

RESULTS

A total of 222 leads were placed in 20 patients, with an average of 11.1 leads per patient. The mean total case time (± SD) was 297.95 (± 52.96) minutes and the mean operating time per lead was 10.98 minutes/lead, with improvements in total (33.36 minutes/lead vs 21.76 minutes/lead) and operative (13.84 minutes/lead vs 7.06 minutes/lead) case times/lead over the course of the study. The mean radial error was 1.75 (± 0.94 mm). Clinically useful data were obtained from SEEG in 95% of cases, and epilepsy surgery was indicated and performed in 95% of patients. In patients who underwent definitive epilepsy surgery with at least a 3-month follow-up, 50% achieved an Engel class I result (seizure freedom). There were no postoperative complications associated with SEEG placement and monitoring.

CONCLUSIONS

In this study, the authors demonstrate that rapid adoption of robot-guided SEEG is possible even at a SEEG-naïve institution, with minimal learning curve. Use of robot guidance for SEEG can lead to significantly decreased operating times while maintaining safety, the overall goals of identification of epileptogenic zones, and improved epilepsy outcomes.

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Kai J. Miller, Casey H. Halpern, Mark F. Sedrak, John A. Duncan III and Gerald A. Grant

OBJECTIVE

Stereotactic laser ablation and neurostimulator placement represent an evolution in staged surgical intervention for epilepsy. As this practice evolves, optimal targeting will require standardized outcome measures that compare electrode lead or laser source with postprocedural changes in seizure frequency. The authors propose and present a novel stereotactic coordinate system based on mesial temporal anatomical landmarks to facilitate the planning and delineation of outcomes based on extent of ablation or region of stimulation within mesial temporal structures.

METHODS

The body of the hippocampus contains a natural axis, approximated by the interface of cornu ammonis area 4 and the dentate gyrus. The uncal recess of the lateral ventricle acts as a landmark to characterize the anterior-posterior extent of this axis. Several volumetric rotations are quantified for alignment with the mesial temporal coordinate system. First, the brain volume is rotated to align with standard anterior commissure–posterior commissure (AC-PC) space. Then, it is rotated through the axial and sagittal angles that the hippocampal axis makes with the AC-PC line.

RESULTS

Using this coordinate system, customized MATLAB software was developed to allow for intuitive standardization of targeting and interpretation. The angle between the AC-PC line and the hippocampal axis was found to be approximately 20°–30° when viewed sagittally and approximately 5°–10° when viewed axially. Implanted electrodes can then be identified from CT in this space, and laser tip position and burn geometry can be calculated based on the intraoperative and postoperative MRI.

CONCLUSIONS

With the advent of stereotactic surgery for mesial temporal targets, a mesial temporal stereotactic system is introduced that may facilitate operative planning, improve surgical outcomes, and standardize outcome assessment.

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Jared M. Pisapia, Casey H. Halpern, Noel N. Williams, Thomas A. Wadden, Gordon H. Baltuch and Sherman C. Stein

Object

Roux-en-Y gastric bypass is the gold standard treatment for morbid obesity, although failure rates may be high, particularly in patients with a BMI > 50 kg/m2. With improved understanding of the neuropsychiatric basis of obesity, deep brain stimulation (DBS) offers a less invasive and reversible alternative to available surgical treatments. In this decision analysis, the authors determined the success rate at which DBS would be equivalent to the two most common bariatric surgeries.

Methods

Medline searches were performed for studies of laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), and DBS for movement disorders. Bariatric surgery was considered successful if postoperative excess weight loss exceeded 45% at 1-year follow-up. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment by LAGB, LRYGB, DBS, or no surgical treatment. A sensitivity analysis in which major parameters were systematically varied within their 95% CIs was used.

Results

Fifteen studies involving 3489 and 3306 cases of LAGB and LRYGB, respectively, and 45 studies involving 2937 cases treated with DBS were included. The operative successes were 0.30 (95% CI 0.247–0.358) for LAGB and 0.968 (95% CI 0.967–0.969) for LRYGB. Sensitivity analysis revealed utility of surgical complications in LRYGB, probability of surgical complications in DBS, and success rate of DBS as having the greatest influence on outcomes. At no values did LAGB result in superior outcomes compared with other treatments.

Conclusions

Deep brain stimulation must achieve a success rate of 83% to be equivalent to bariatric surgery. This high-threshold success rate is probably due to the reported success rate of LRYGB, despite its higher complication rate (33.4%) compared with DBS (19.4%). The results support further research into the role of DBS for the treatment of obesity.

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Allen L. Ho, Austin Y. Feng, Lily H. Kim, Arjun V. Pendharkar, Eric S. Sussman, Casey H. Halpern and Gerald A. Grant

Stereoelectroencephalography (SEEG) is an intracranial diagnostic measure that has grown in popularity in the United States as outcomes data have demonstrated its benefits and safety. The main uses of SEEG include 1) exploration of deep cortical/sulcal structures; 2) bilateral recordings; and 3) 3D mapping of epileptogenic zones. While SEEG has gradually been accepted for treatment in adults, there is less consensus on its utility in children. In this literature review, the authors seek to describe the current state of SEEG with a focus on the more recent technology-enabled surgical techniques and demonstrate its efficacy in the pediatric epilepsy population.

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Sukhmeet K. Sandhu, Casey H. Halpern, Venus Vakhshori, Keyvan Mirsaeedi-Farahani, John T. Farrar and John Y. K. Lee

OBJECT

Neurosurgeons are frequently the primary physicians measuring pain relief in patients with trigeminal neuralgia (TN). Unfortunately, the measurement of pain can be complex. The Brief Pain Inventory–Facial (BPI-Facial) is a reliable and validated multidimensional tool that consists of 18 questions. It measures 3 domains of pain: 1) pain intensity (worst and average pain intensity), 2) interference with general activities of daily living (ADL), and 3) face-specific pain interference. The objective of this paper is to determine the patient-reported minimum clinically important difference (MCID) using the BPI-Facial.

METHODS

The authors conducted a retrospective study of 234 patients with TN seen in a single neurosurgeon's office. Patients completed baseline and 1-month follow-up BPI-Facial questionnaires. The MCID was calculated using an anchor-based approach in which the defined anchor was the 7-point patient global impression of change (PGIC). Two statistical methods were employed: mean change score and optimal cutoff point.

RESULTS

Using the mean change score method, the investigators calculated the MCID for the 3 domains of the BPIFacial: 44% and 30% improvement in pain intensity at its worst and average, respectively, 54% improvement in interference with general ADL, and 63% improvement in interference with facial ADL. Using the optimal cutoff point method, they also calculated the MCID for the 3 domains of the BPI-Facial: 57% and 28% improvement in pain intensity at its worst and average, respectively, 75% improvement in interference with general ADL, and 62% improvement in interference with facial ADL.

CONCLUSIONS

The BPI-Facial is a multidimensional pain scale that measures 3 domains of pain. Although 2 statistical methods were used to calculate the MCID, the optimal cutoff point method was the superior one because it used data from the majority of subjects included in this study. A 57% improvement in pain intensity at its worst and a 28% improvement in pain intensity at its average were the MCIDs for patients with facial pain. A greater improvement was needed to achieve the MCID for interference with general and facial ADL. A 75% improvement in interference with general ADL and a 62% improvement in interference with facial ADL were needed to achieve an MCID. While pain intensity is easier to measure, pain's interference with ADL may be more important for patient outcomes when designing or evaluating interventions in the field of TN. The BPI-Facial is a useful instrument to measure changes in multidimensional aspects of pain in patients with TN.