✓Trigeminal neuropathic pain is a syndrome of severe, constant facial pain related to disease of or injury to the trigeminal nerve or ganglion. Causes of this type of pain can include injury from sinus or dental surgery, skull and/or facial trauma, or intentional destruction for therapeutic reasons (deafferentation) as well as intrinsic pathological conditions in any part of the trigeminal system. Motor cortex stimulation (MCS) is a relatively new technique that has shown some promise in the treatment of trigeminal neuropathic pain. This technique has the potential to revolutionize the treatment of chronic pain. The authors present a review of the literature, focusing on surgical technique, device programming, safety, and efficacy, and suggest some initial guidelines for standardization of these aspects. It is important to evaluate MCS critically in a prospective, controlled fashion.
Jaimie M. Henderson and Shivanand P. Lad
Anna Chang, Eleonora M. Lad and Shivanand P. Lad
✓Hippocrates is widely considered the father of medicine. His contributions revolutionized the practice of medicine and laid the foundation for modern-day neurosurgery. He inspired several generations to follow his vision, by pioneering the rigorous clinical evaluation of cranial and spinal disorders and combining this approach with a humanistic and ethical perspective focused on the individuality of the patient. His legacy has forever shaped the field of medicine and his cumulative works on head injuries and spinal deformities led to the basic understanding of many of the fundamental neurosurgical principles in use today.
Shivanand P. Lad, Chirag G. Patil, Eleonora Maries Lad and Maxwell Boakye
Pathological vertebral fractures (PVFs) are an increasingly important cause of disability and have many clinical and economic implications. The authors examined trends in epidemiology and surgical management of pathological vertebral fractures in the US between 1993 and 2004.
The Nationwide Inpatient Sample database was used to analyze data collected from 1993 through 2004 to determine general trends in PVFs. Patients with PVFs were identified using the appropriate International Classification of Diseases, 9th Revision (ICD-9) diagnostic code (ICD-9 733.13). Trends in vertebral augmentation procedures and spinal fusions as well as comparison with incidences of other major pathological fractures, such as hip and upper limb, were also examined.
In 2004, there were more than 55,000 inpatient admissions for PVFs. The majority of patients admitted were women (78%) in the 65 to 84 year–age group (60%). Medicare accounted for greater than 80% of insurance, and nearly 50% of all patients were admitted from the emergency department. The mean duration of hospitalization has continued to decrease, from 8.1 days in 1993 to 5.4 days in 2004. The mortality rate has remained relatively constant at approximately 1.5%. The discharge disposition has continued to change with an increasing number of patients being discharged to other institutions such as nursing homes and rehabilitation facilities. There was a staggering increase in the number of vertebral augmentation procedures performed between 1993 and 2004. The “national bill” for inpatient hospitalizations for PVFs totaled $1.3 billion in 2004.
With the continued aging of the population, PVFs represent an important cause of disability and a significant source of healthcare resource utilization.
Jordan M. Komisarow, Theodore Pappas, Megan Llewellyn and Shivanand P. Lad
On June 5, 1968, having won the Democratic Party presidential primary in California, Senator Robert F. Kennedy delivered a victory speech to supporters at the Ambassador Hotel in downtown Los Angeles. Just after 12:15 am (Pacific daylight savings time), a lone assassin shot Kennedy 3 times at point-blank range. One of the bullets struck Kennedy in the right posterior auricular region. Within the ensuing 26 hours, Kennedy was transported to 2 hospitals, underwent emergency surgery, and eventually died of severe brain injury. Although this story has been repeated in the press and recounted in numerous books, this is the first analysis of the senator’s injuries and subsequent surgical care to be reported in the medical literature. The authors review eyewitness reports on the mechanism of injury, the care rendered for 3 hours prior to the emergency craniotomy, the clinical course, and, ultimately, the autopsy.
Paul Kalanithi, Ryan D. Schubert, Shivanand P. Lad, Odette A. Harris and Maxwell Boakye
This study provides the first US national data regarding frequency, cost, and mortality rate of traumatic subdural hematoma (SDH), and identifies demographic factors affecting morbidity and death in patients with traumatic SDH undergoing surgical drainage.
A retrospective analysis was conducted by querying the Nationwide Inpatient Sample, the largest all-payer database of nonfederal community hospitals. All cases of traumatic SDH were identified using ICD-9 codes. The study consisted of 2 parts: 1) trends data, which were abstracted from the years 1993–2006, and 2) univariate analysis and multivariate logistic regression of demographic variables on inhospital complications and deaths for the years 1993–2002.
Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006. Inhospital deaths decreased from 16.4% to 11.6% for traumatic SDH. Average costs increased 67% to $47,315 per admission. For the multivariate regression analysis, between 1993 and 2002, 67,864 patients with traumatic SDH underwent operative treatment. The inhospital mortality rate was 14.9% for traumatic SDH drainage, with an 18% inhospital complication rate. Factors affecting inhospital deaths included presence of coma (OR = 2.45) and more than 2 comorbidities (OR = 1.60). Increased age did not worsen the inhospital mortality rate.
Nationally, frequency and cost of traumatic SDH cases are increasing rapidly.
Shivanand P. Lad, Chirag G. Patil, Edward R. Laws Jr. and Laurence Katznelson
✓ Cushing's syndrome can present a complex problem of differential diagnosis. Of cases in which hypercortisolemia results from an adrenocorticotropic hormone (ACTH)–dependent process, approximately 80% are due to a pituitary adenoma (Cushing's disease [CD]), 10% are due to adrenal lesions, and the remaining 10% are secondary to ectopic ACTH secretion. For patients with CD, surgical removal of the pituitary adenoma is the treatment of choice. Thus, localization of the source of ACTH secretion is critical in guiding timely treatment decisions.
Inferior petrosal sinus sampling (IPSS) is considered to be the gold standard for confirming the origin of ACTH secretion in patients with Cushing's syndrome.
The authors present an overview of IPSS—both the technique and its interpretation—as well as a summary of recent studies. A number of other techniques are discussed including sampling from the cavernous sinus, the jugular vein, and multiple sites to aid the diagnosis and lateralization of ACTH-producing pituitary adenomas. Management is best undertaken by a comprehensive multidisciplinary team taking into account the results of all the biochemical and imaging studies available, to provide the best advice in patient treatment decisions.
Chirag G. Patil, Shivanand P. Lad, Griffith R. Harsh, Edward R. Laws Jr. and Maxwell Boakye
Information about complications, patient outcomes, and mortality rate after transsphenoidal surgery (TSS) for Cushing's disease has been derived largely from single-institution series. In this study the authors report on inpatient death, morbidity, and outcomes following TSS for Cushing's disease on a national level.
All patients in the Nationwide Inpatient Sample (NIS) database who had undergone transsphenoidal resection of a pituitary tumor for Cushing's disease between 1993 and 2002 were included in the study. The number of cases per year, length of stay (LOS), and rates of inpatient complications, death, and adverse outcomes (death or discharge to institution other than home) were abstracted. Univariate and multivariate analyses were performed to determine the effects of patient and hospital characteristics on outcome measures.
According to the NIS, there were an estimated 3525 cases of TSS for Cushing's disease in the US between 1993 and 2002. During this period, there was a trend toward a small increase in the number of TSSs for Cushing's disease. The in-hospital mortality rate was 0.7%, and the complication rate was 42.1%. Diabetes insipidus (15%), fluid and electrolyte abnormalities (12.5%), and neurological deficits (5.6%) were the most common complications reported. Multivariate analysis showed that complications were more likely in patients with pre-operative comorbidities. Patients older than 64 years were much more likely to have an adverse outcome (odds ratio [OR] 20.8) and a prolonged hospital stay (OR 2.2). Women were less likely than men to have an adverse outcome (OR 0.3). A single postoperative complication increased the mean LOS by 3 days, more than tripled the odds of an adverse outcome, and increased the hospital charges by more than US $7000.
The authors provided a national perspective on trends, inpatient complications, and outcomes after TSS for Cushing's disease in the US. Postoperative complications had a significantly negative effect on LOS, adverse outcome, and resource utilization. Advanced age and multiple preoperative comorbidities were identified as important risk factors, and their effects on patient outcomes were quantified.
Chirag G. Patil, Shivanand P. Lad, Laurence Katznelson and Edward R. Laws Jr.
✓ Cushing's disease is associated with brain atrophy and cognitive deficits. Excess glucocorticoids cause retraction and simplification of dendrites in the hippocampus, and this morphological change probably accounts for the hippocampal volume loss. Mechanisms by which glucocorticoids affect the brain include decreased neurogenesis and synthesis of neurotrophic factors, impaired glucose utilization, and increased actions of excitatory amino acids. In this review, the timing, pathology, and pathophysiology of the brain atrophy in Cushing's disease are discussed. The correlation of atrophy with cognitive deficits and its reversibility is also reviewed.
Shivanand P. Lad, Chirag G. Patil, Christopher Ho, Michael S. B. Edwards and Maxwell Boakye
Previous investigations of health outcome after spinal surgery for tethered cord syndrome (TCS) have been single-institution studies. The aim of this study was to report inpatient complications and outcomes on a nationwide level.
The Nationwide Inpatient Sample (NIS) was used to identify patients who underwent spinal surgery for TCS in the US between 1993 and 2002. Patients who had a primary diagnosis of TCS (ICD-9 742.59) and also underwent spinal laminectomies were included in this study. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on variables such as mortality rate, nonfatal complications, LOS, and adverse outcomes in general (defined as death or discharge to an institution rather than home).
The NIS sample included data on 9733 patients with TCS who underwent surgery. The means for mortality rate, complication rate, and LOS, respectively, were 0.0005%, 9.48%, and 5.6 days. Postoperative hemorrhages or hematomas (mean rate 2.3%) were the most common complications reported. Age and complications were the only significant predictors of adverse outcome on multivariate analysis. Patients older than 65 years had a threefold increase in risk of adverse outcome compared with patients 18 to 44 years of age. On average, one postoperative complication led to a 3-day increase in mean LOS and added more than $9000 to hospital charges.
This study provides a national perspective on inpatient complications and outcomes after spinal surgery for TCS in the United States. The authors have demonstrated the impact of age, complications, and medical comorbidities on the outcome of surgery for patients with this common disorder.