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Focused ultrasound surgery

W. Jeffrey Elias and Neal F. Kassell

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Predicting lesion size during focused ultrasound thalamotomy: a review of 63 lesions over 3 clinical trials

Aaron E. Bond and W. Jeffrey Elias


The goal of this study was to improve the predictability of lesion size during focused ultrasound (FUS) thalamotomy procedures.


Treatment profiles and T2-weighted MRI (T2 MRI) studies obtained in 63 patients who participated in 3 clinical trials of FUS thalamotomy from February 2011 to March 2015 were reviewed retrospectively. Four damage estimate models were compared with lesion sizes measured on postprocedural T2 MRI. Models were based on 54°C × 3 seconds, 240 cumulative equivalent minutes at 43°C, and simple thermal threshold analysis, which recorded the maximum diameter that reached a temperature of at least 51°C and 54°C. Energy requirements per °C thermal rise above 37°C were also recorded.


Lesion diameters from T2 MRI correlated poorly from the day of the procedure to day 1 postprocedure (mean increase 78% [SD 79%]). There was more predictability of lesion size from day 1 to day 30, with a mean reduction in lesion diameter of 11% (SD 24%). Of the 4 models tested, the most correlative model to day 1 findings on T2 MRI was a 51°C threshold. The authors observed an increase in the energy requirement for each subsequent treatment sonication, with the largest percentage increase from treatment sonication 1 to treatment sonication 2 (mean increase 20% in energy required per °C increase in temperature above 37°C).


At the margins, 51°C temperature threshold diameters correlated best to lesion diameters measured at day 1 with T2 MRI. The lesion size from T2 MRI decreases from day 1 to day 30 in a predictable manner, much more so than from the day of the procedure to day 1 postprocedure. Energy requirements per °C rise above 37°C continuously increase with each successive sonication.

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Editorial: Tremor

W. Jeffrey Elias

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Sacral stress fracture following lumbosacral arthrodesis

Case illustration

W. Jeffrey Elias, Mark E. Shaffrey, and Richard Whitehill

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Deep brain stimulation: the spectrum of application

W. Jeffrey Elias and Andres M. Lozano

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Introduction: Peripheral Nerve Surgery—Biology, Entrapment, and Injuries

Allan H. Friedman, W. Jeffrey Elias, and Rajiv Midha

Surgery aimed at repairing damaged peripheral nerves has a long history. Refuting the timehonored nihilism of Hippocrates and Galen that an injured nerve cannot regain function, a few adventurous medieval surgeons attempted to repair severed nerves. 6,8 However, the ability of a peripheral nerve repair to restore function was not generally accepted until 1800. 1,4 Neurosurgeons, beginning with Harvey Cushing, have had an interest in repairing damaged peripheral nerves. 2 Significant progress in the treatment of peripheral nerve injuries resulted from experience with the numerous injuries that occurred during World Wars I and II. 3,7,12 Surgeons steadily defined the anatomy of peripheral nerves and developed techniques for decompressing and repairing peripheral nerves. 9,11 Kline and Dejonge 5 developed an intraoperative electrophysiological technique for detecting axons regenerating across a damaged segment of nerve. In the second 2 decades of the 20th century, distal nerve transfers were rediscovered whereby the proximal end of a less essential nerve is used to reinnervate the distal end of a nerve, providing a more vital function. 10

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Catheter-tip mass mimicking a spinal epidural hematoma

Case report

Ricky Medel, Nader Pouratian, and W. Jeffrey Elias

As > 95,000 spinal drug-delivery devices have been implanted since their inception in the 1980s, the recognition of associated adverse effects is essential. Since 1985, numerous reports have described the presence of catheter-tip granulomas. In the current case, the authors describe a less frequent complication of epidural bupivacaine precipitation. Regardless of origin, these unusual lesions have been increasingly recognized as a rare but potentially devastating complication of intrathecal infusions.

A 34-year-old woman with an intrathecal pain-pump delivering fentanyl, bupivacaine, and clonidine for thoracic outlet syndrome presented with rapidly progressive neurological deficits and increasing neck and upper-extremity pain. Neuroimaging disclosed a C7–T1 mass that was thought to be a hematoma that occurred after a recent epidural steroid injection. On emergency surgical decompression by laminectomy, a chalky mass containing viscous fluid was identified surrounding an epidurally located catheter. Histopathological examination revealed a proteinaceous mass consistent with drug precipitate enveloped by fibrosis and mild inflammation. Postoperatively, the patient recovered with minimal neurological deficit. The presentation and clinical relevance are discussed in conjunction with a review of the pertinent literature.

Catheter-tip masses are a rare complication of implantable drug-delivery devices occurring in < 3% of all patients with intrathecal catheters. Regardless of the anatomical site, the most common presenting features are neurological deficits, worsening pain, and increasing requirements for pain medication. Expedient diagnosis and management are essential for physicians treating patients with spinal infusion devices to prevent significant neurological sequelae. Further investigation is warranted regarding the use of bupivacaine as an adjunct in permanent spinal infusion systems.

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Transoral digitally manipulated reduction of a ventrally displaced Type II odontoid fracture to aid in screw fixation

Case illustration

W. Jeffrey Elias, Patrick Ireland, and James B. Chadduck

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Introduction. Focused ultrasound

Nir Lipsman, W. Jeffrey Elias, Ryder P. Gwinn, and Julie G. Pilitsis

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Cortical and subcortical brain shift during stereotactic procedures

W. Jeffrey Elias, Kai-Ming Fu, and Robert C. Frysinger


The success of stereotactic surgery depends upon accuracy. Tissue deformation, or brain shift, can result in clinically significant errors. The authors measured cortical and subcortical brain shift during stereotactic surgery and assessed several variables that may affect it.


Preoperative and postoperative magnetic resonance imaging volumes were fused and 3D vectors of deviation were calculated for the anterior commissure (AC), posterior commissure (PC), and frontal cortex. Potential preoperative (age, diagnosis, and ventricular volume), intraoperative (stereotactic target, penetration of ventricles, and duration of surgery), and postoperative (volume of pneumocephalus) variables were analyzed and correlated with cortical (frontal cortex) and subcortical (AC, PC) deviations.


Of 66 cases, nine showed a shift of the AC by more than 1.5 mm, and five by more than 2.0 mm. The largest AC shift was 5.67 mm. Deviation in the x, y, and z dimensions for each case was determined, and most of the cortical and subcortical shift occurred in the posterior direction. The mean 3D vector deviations for frontal cortex, AC, and PC were 3.5 ± 2.0, 1.0 ± 0.8, and 0.7 ± 0.5 mm, respectively. The mean change in AC–PC length was −0.2 ± −0.9 mm (range −4.28 to 1.66 mm). The volume of postoperative pneumocephalus, assumed to represent cerebrospinal fluid (CSF) loss, was significantly correlated with shift of the frontal cortex (r = 0.640, 64 degrees of freedom, p < 0.001) and even more strongly with shift of the AC (r = 0.754, p < 0.001). No other factors were significantly correlated with AC shift. Interestingly, penetration of the ventricles during electrode insertion, whether unilateral or bilateral, did not affect volume of pneumocephalus.


Cortical and subcortical brain shift occurs during stereotactic surgery as a direct function of the volume of pneumocephalus, which probably reflects the volume of CSF that is lost. Clinically significant shifts appear to be uncommon, but stereotactic surgeons should be vigilant in preventing CSF loss.