Asunto(s)
Terapia por Estimulación Eléctrica/métodos , Trastorno Obsesivo Compulsivo/terapia , Síndrome de Tourette/terapia , Bulimia Nerviosa/complicaciones , Terapia por Estimulación Eléctrica/instrumentación , Electrodos Implantados , Estética , Femenino , Humanos , Relaciones Interpersonales , Trastorno Obsesivo Compulsivo/complicaciones , Pruebas Psicológicas , Pared Torácica/cirugía , Síndrome de Tourette/complicaciones , Adulto JovenRESUMEN
Although ample evidence suggests that high-frequency deep brain stimulation (DBS) is an effective therapy in patients with Tourette syndrome (TS), its pathophysiology and the neurophysiological mechanisms underlying these benefits remain unclear. The DBS targets mainly used to date in TS are located within the basal ganglia-thalamo-cortical circuit compromised in this syndrome: the medial and ventral thalamic nuclei, which are way stations within the circuit, the globus pallidus and the nucleus accumbens. Neuronal activity can be electrophysiologically recorded from deep brain structures during DBS surgery (intraoperative microrecordings) or within few days after DBS electrode implantation (local field potentials, LFPs). Recordings from the thalamus in patients with TS showed that the power in low-frequency oscillations (2-15 Hz) was higher than power in high frequency oscillations (<45 Hz) and that activity in gamma band (25-45 Hz) increases when patients' clinical status improved. Effective thalamic DBS for tic reduction seems to increase high frequency band oscillations (25-45 Hz). The same oscillatory pattern persists after DBS for 1 year, therefore showing that in TS DBS does not induce persistent neuroplastic changes in the neural activity in the stimulated structures. Neurophysiological recordings from deep brain structures suggest that tics originate not from the cortex but from neuronal dysfunction in deep brain structures such as the thalamus and globus pallidus. In conclusion, DBS can induce its beneficial effects in TS by modulating specific neural rhythms in the cortico-basal ganglia thalamic network. DBS could reduce tics related increased low-frequency activity by shifting the basal ganglia-thalamic oscillation power to higher frequencies.
Asunto(s)
Encéfalo/fisiopatología , Estimulación Encefálica Profunda , Fenómenos Electrofisiológicos/fisiología , Síndrome de Tourette/patología , Síndrome de Tourette/fisiopatología , HumanosRESUMEN
OBJECTIVE: Evaluation of safety and efficacy of dexmedetomidine in deep brain stimulation (DBS) surgery. MATERIALS AND METHODS: A cohort of 23 patients, candidates for DBS for Parkinson's disease, Tourette syndrome, or obsessive-compulsive disorder, was randomized in two groups: dexmedetomidine group and control group. Standard anesthesiologic parameters were recorded and analyzed, together with the need for other medications. A ten-degree scale (visual analog scale) assessing patient discomfort during DBS also was recorded at the end of surgery. RESULTS: The results demonstrated good stability of intraoperative monitoring: no respiratory depression and good overall cooperation with the neurologist, while no side-effects were recorded. CONCLUSIONS: Our conclusion is that dexmedetomidine should be considered as a valuable option for sedation in poorly collaborating patients undergoing DBS surgery.
Asunto(s)
Analgésicos no Narcóticos/uso terapéutico , Estimulación Encefálica Profunda/métodos , Dexmedetomidina/uso terapéutico , Trastorno Obsesivo Compulsivo/terapia , Enfermedad de Parkinson/terapia , Síndrome de Tourette/terapia , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Examen Neurológico , Dimensión del DolorRESUMEN
OBJECT: The purpose of this study was to evaluate the efficacy of intra-operative computerized tomography (CT) scanning in the analysis of bone removal accuracy during anterior cervical corpectomy, in order to allow any necessary immediate correction in the event of inadequate bone removal. METHODS: From September 2009 to December 2010 we performed an intra-operative (CT) scan using the O-Arm(™) Image system to assess the rate of central and lateral decompression in all patients treated for cervical spondylotic myelopathy by anterior cervical corpectomy and fusion. RESULTS: Out of a population of 187 patients admitted to our department, with a diagnosis of myelopathy due to spondylotic degenerative cervical stenosis, 15 patients underwent a surgical treatment with anterior cervical corpectomy and fusion. There were nine males (60%) and six females (40%); the mean age was 52.4 years, ranging from 41 to 57 years. The pre-operative radiologic investigations (MRI and CT scans) revealed in the nine patients (60%) the extent of the compression to one vertebral body (C4 one case, C5 four cases, C6 four cases), while in the six cases (40%) the compression regarded two vertebral body (C3 and C4 one case, C4 and C5 two cases, C5 and C6 three cases). During surgery, when the decompression was judged completely, a CT scan was performed: in 11 cases (73.3%) the decompression was considered adequate, while in four cases (26.7%) it was deemed insufficient and the surgical strategy was changed in order to optimize the bone removal. In these cases an additional scan was taken to prove the efficacy of decompression, achieved in all patients. CONCLUSION: Intra-operative CT scan performed during cervical corpectomy is a really useful tool in helping to ensure complete bone removal and the adequacy of surgery. The O-arm(™) Image system grants optimal image quality, allowing correctly assessing the rate of decompression and, in any case of doubt, allows an intra-operative evaluation of the final correct positioning of the graft.
Asunto(s)
Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Descompresión Quirúrgica , Adulto , Femenino , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
In the past years, local field potential (LFP) signals recorded from the subthalamic nucleus (STN) in patients undergoing deep brain stimulation (DBS) for Parkinson's disease (PD) disclosed that DBS has a controversial effect on STN beta oscillations recorded 2-7 days after surgery for macroelectrode implantation. Nothing is known about these DBS-induced oscillatory changes 30 days after surgery. We recorded STN LFPs during ongoing DBS in 7 patients with PD, immediately (hyperacute phase) and 30 days (chronic phase) after surgery. STN LFP recordings showed stationary intranuclear STN beta LFP activity in hyperacute and chronic phases, confirming that beta peaks were also present in chronic recordings. Power spectra of nuclei with significant beta activity (54% of the sample) showed that it decreased significantly during DBS (p=0.021) under both recording conditions. The time course of beta activity showed more evident DBS-induced changes in the chronic than in the hyperacute phase (p=0.014). DBS-induced changes in STN beta LFPs in patients undergoing DBS in chronic phase provide useful information for developing a new neurosignal-controlled adaptive DBS system.
Asunto(s)
Ritmo beta/fisiología , Estimulación Encefálica Profunda/métodos , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/fisiología , Anciano , Análisis de Varianza , Enfermedad Crónica , Electrodos Implantados , Electroencefalografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/clasificación , Factores de TiempoRESUMEN
Chronic lumbar pain due to degenerative disc disease affects a large number of people, including those of fully active age. The usual self-repair system observed in nature is a spontaneous attempt at arthrodesis, which in most cases leads to pseudoarthrosis. In recent years, many possible surgical fusion techniques have been introduced; PLIF is one of these. Because of the growing interest in minimally invasive surgery and the unsatisfactory results reported in the literature (mainly due to the high incidence of morbidity and complications), a new titanium lumbar interbody cage (I-FLY) has been developed to achieve solid bone fusion by means of a stand-alone posterior device. The head of the cage is blunt and tapered so that it can be used as a blunt spreader, and the core is small, which facilitates self-positioning. From 2003 to 2007, 119 patients were treated for chronic lumbar discopathy (Modic grade III and Pfirrmann grade V) with I-FLY cages used as stand-alone devices. All patients were clinically evaluated preoperatively and after 1 and 2 years by means of a neurological examination, visual analogue score (VAS) and Prolo Economic and Functional Scale. Radiological results were evaluated by polyaxial computed tomography (CT) scan and flexion-extension radiography. Fusion was defined as the absence of segmental instability on flexion-extension radiography and Bridwell grade I or II on CT scan. Patients were considered clinical "responders" if VAS evaluation showed any improvement over baseline values and a Prolo value >7 was recorded. At the last follow-up examination, clinical success was deemed to have been achieved in 90.5% of patients; the rate of bone fusion was 99.1%, as evaluated by flexion-extension radiography, and 92.2%, as evaluated by CT scan. Morbidity (nerve root injury, dural lesions) and complications (subsidence and pseudoarthrosis) were minimal. PLIF by means of the stand-alone I-FLY cage can be regarded as a possible surgical treatment for chronic low-back pain due to high-degree DDD. This technique is not demanding and can be considered safe and effective, as shown by the excellent clinical and radiological success rates.
Asunto(s)
Degeneración del Disco Intervertebral/cirugía , Dolor de la Región Lumbar/cirugía , Vértebras Lumbares/cirugía , Fusión Vertebral/instrumentación , Distribución de Chi-Cuadrado , Femenino , Humanos , Degeneración del Disco Intervertebral/complicaciones , Dolor de la Región Lumbar/etiología , Masculino , Dimensión del Dolor , Estudios Prospectivos , Estadísticas no ParamétricasRESUMEN
BACKGROUND: Parkinson's patients, on average, gain weight after deep brain stimulation (DBS). OBJECTIVE: To determine potential differences in weight gain when comparing the subthalamic nucleus and the globus pallidus internus target. METHODS: A retrospective analysis was performed on the prospective, randomized cohort of National Institutes of Health COMPARE trial DBS patients who received unilateral subthalamic nucleus or globus pallidus internus DBS. Baseline weights were recorded before DBS surgery and at 6, 12, and 18 months postoperatively. Relationships between weight change and changes in Beck Depression Inventory score, Unified Parkinson's Disease Rating Scale (UPDRS) motor score (part III) (also the dyskinesia duration and disability subscores from UPDRS IV), and Hoehn-Yahr stage were determined via Spearman's rank-order correlation coefficients. Regression analyses were performed to investigate the effects of potential factors on weight change over time. RESULTS: Patients in the COMPARE DBS cohort gained a significant amount of weight, a mean of 4.86 lb (standard deviation = 8.73) (P = .001), but there was no significant difference between subthalamic nucleus and globus pallidus internus targets (weight gain of 4.29 ± 6.79 and 5.38 ± 10.32 lb, respectively; P = .68). Weight gain did not correlate with Beck Depression Inventory score change, UPDRS motor score, dyskinesia duration, dyskinesia disability change, or the Hoehn-Yahr stage (P = .62, .21, and .31, respectively). No specific variable was associated with weight gain, and there were no differences in binge eating post-surgery in either target. CONCLUSION: There were significant changes in weight over time after DBS therapy. However, neither Beck Depression Inventory score change nor UPDRS score change or dyskinesia was correlated with weight gain. No significant factor was associated with the weight change.
Asunto(s)
Estimulación Encefálica Profunda/efectos adversos , Globo Pálido/fisiología , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/fisiología , Aumento de Peso/fisiología , Estudios de Cohortes , Estimulación Encefálica Profunda/métodos , Estudios de Seguimiento , Humanos , Enfermedad de Parkinson/fisiopatología , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
Tourette's syndrome is a chronic neurobehavioral disorder that can demonstrate refractoriness to conservative treatments, or to invasive nonsurgical treatments such as botulinum toxin infiltration, or to psychobehavioral treatments. In these cases, the surgical option is often proposed, either with lesional interventions, or more recently with deep brain stimulation (DBS). This latter modality is currently preferred because of its reversibility and modularity. Some relevant issues, however, still persist in terms of appropriate indication to treatment, selection of target, and follow-up evaluation.
Asunto(s)
Estimulación Encefálica Profunda/métodos , Síndrome de Tourette/terapia , Adulto , Mapeo Encefálico , Dominancia Cerebral/fisiología , Femenino , Globo Pálido/fisiopatología , Humanos , Cápsula Interna/fisiopatología , Núcleos Talámicos Intralaminares/fisiopatología , Masculino , Núcleo Accumbens/fisiopatología , Conducta Social , Síndrome de Tourette/fisiopatología , Síndrome de Tourette/psicologíaRESUMEN
Although lesional, neuroimaging, and brain stimulation studies have provided an insight into the neural mechanisms of judgement and decision-making, all these works focused on the cerebral cortex, without investigating the role of subcortical structures such as the basal ganglia. Besides being an effective therapeutic tool, deep brain stimulation (DBS) allows local field potential (LFP) recordings through the stimulation electrodes thus providing a physiological "window" on human subcortical structures. In this study we assessed whether subthalamic nucleus LFP oscillations are modulated by processing of moral conflictual, moral nonconflictual, and neutral statements. To do so, in 16 patients with Parkinson's disease (8 men) bilaterally implanted with subthalamic nucleus (STN) electrodes for DBS, we recorded STN LFPs 4 days after surgery during a moral decision task. During the task, recordings from the STN showed changes in LFP oscillations. Whereas the 14--30 Hz band (beta) changed during the movement executed to perform the task, the 5--13 Hz band (low-frequency) changed when subjects evaluated the content of statements. Low-frequency band power increased significantly more during conflictual than during nonconflictual or neutral sentences. We conclude that STN responds specifically to conflictual moral stimuli, and could be involved in conflictual decisions of all kinds, not only those for moral judgment. LFP oscillations provide novel direct evidence that the neural processing of conflictual decision-making spreads beyond the cortex to the basal ganglia and encompasses a specific subcortical conflict-dependent component.
Asunto(s)
Conflicto Psicológico , Toma de Decisiones/fisiología , Estimulación Encefálica Profunda , Principios Morales , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/fisiología , Anciano , Ganglios Basales/fisiología , Corteza Cerebral/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Neurológicos , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/psicologíaRESUMEN
BACKGROUND: Deep brain stimulation (DBS) is a commonly performed surgical technique for the treatment of movement disorders, and recent surgical trials concerning the treatment of a wider range of disorders have recently been published. Despite DBS being non-ablative and minimally invasive, numerous complications and side effects have been recorded. In particular, concerning the growing interest in novel indications for DBS, an enthusiastic approach has put neurosurgeons at risk of underestimating some of the complications that might be associated with specific characters of the treated disease. OBJECTIVE: Our objective was to evaluate hardware failures and rates of infective complications in correlation to the different indications to DBS, in order to ascertain whether DBS in Tourette syndrome (TS) is characterized by specific risks and pitfalls. METHODS: We retrospectively reviewed our experience of 531 procedures on 272 patients treated for various movement disorders, among which 39 patients were treated for conservative treatmentrefractory TS. RESULTS: A statistically significant association of infective complications was found with the TS subgroup. CONCLUSIONS: It is our belief that specific behavioral characters of the TS patients may be put into association with this specific complication and need to be considered carefully when indicating DBS as treatment of choice for these patients.
Asunto(s)
Estimulación Encefálica Profunda/instrumentación , Electrodos Implantados/efectos adversos , Reacción a Cuerpo Extraño/etiología , Síndrome de Tourette/terapia , Adolescente , Adulto , Mapeo Encefálico , Remoción de Dispositivos , Evaluación de la Discapacidad , Dominancia Cerebral/fisiología , Falla de Equipo , Femenino , Globo Pálido/fisiopatología , Humanos , Núcleos Talámicos Intralaminares/fisiopatología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Núcleo Accumbens/fisiopatología , Evaluación de Procesos y Resultados en Atención de Salud , Calidad de Vida , Conducta Social , Tomografía Computarizada por Rayos X , Síndrome de Tourette/diagnóstico , Síndrome de Tourette/fisiopatología , Adulto JovenRESUMEN
This study presents a simple decision-support system for the detection of tic events during the Tourette Syndrome (TS). The system is based on a triaxial accelerometer placed on the patient's trunk. TS is a neurological disorder that emerges during childhood and that is characterized by a large spectrum of involuntary/compulsive movements and sounds. 12 subjects with chronic TS participated in the study and the tic events were both measured by the proposed device and visually classified through video recording. 3D-acceleration timeseries were combined through a module operator and their noise was eliminated by a median filter. Signal to noise ratio was improved by a nonlinear energy operator. Finally, a time-variant threshold was used to detect tic events. The automatic tic recognition showed a performance around 80 % in terms of sensitivity, specificity and accuracy. In conclusion, this simple, automatic and unobtrusive method offers an alternative approach to quantitatively assess the tic events in clinical and non clinical environments. This overcomes the limitations of the current motor tic evaluation which is done by clinical observation and/or video-inspection in specialized neurological centres.
Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Monitoreo Ambulatorio/métodos , Reconocimiento de Normas Patrones Automatizadas/métodos , Tics/diagnóstico , Síndrome de Tourette/fisiopatología , Aceleración , Adolescente , Adulto , Algoritmos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis de Regresión , Sensibilidad y Especificidad , Tics/etiología , Grabación en VideoRESUMEN
STUDY DESIGN: Radiographic study. OBJECTIVE: More detailed anatomical knowledge of the C2 pedicle is required to optimize and minimize the risk of screw placement. The aim of this study was to evaluate the linear and angular dimensions of the true C2 pedicle using axial computed tomography. BACKGROUND DATA: Although earlier studies have analyzed the anatomy of the C2 pars interarticularis, little attention has been focused on the dimensions of the C2 pedicle. METHODS: Ninety-three patients (47 males, 46 females; mean age 48.4 y) who had previous cervical spinal computed tomography imaging were evaluated for this study. Axial images of the C2 pedicle were selected and the following pedicle parameters were determined: pedicle width (the mediolateral diameter of the pedicle isthmus, perpendicular to the pedicle axis) and pedicle transverse angle (PTA, ie, the angle between the pedicle axis and the midline of the vertebral body). RESULTS: The overall mean pedicle width was 5.8+/-1.2 mm. The mean pedicle width in male patients (6.0+/-1.3 mm) was greater than that in the female patients (5.6+/-1.1 mm). This difference was not found to be statistically significant (P=0.679). The overall mean PTA was 43.9+/-3.9 degrees. The mean PTA in male patients was 43.2+/-3.8 degrees, whereas that in female patients was 44.7+/-3.7 degrees. CONCLUSIONS: Given the significant variability in pedicle widths and the need for precise trajectory planning in pedicle cannulation, preoperative planning is absolutely mandatory. A significant percentage of patients have pedicle widths that may not accommodate screw fixation. In addition, the angle of entry into the C2 pedicle must be carefully measured for safe instrumentation at this level.
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Vértebra Cervical Axis/diagnóstico por imagen , Vértebra Cervical Axis/cirugía , Tornillos Óseos , Fusión Vertebral/métodos , Vértebra Cervical Axis/anatomía & histología , Femenino , Humanos , Fijadores Internos , Masculino , RadiografíaRESUMEN
Deep brain stimulation (DBS) of the ventralis oralis (VO) complex of the thalamus improves tics in patients with Tourette syndrome (TS). To neurophysiologically describe the VO complex we recorded, in seven patients with TS undergoing DBS electrode implantation, single-unit activity during surgery and local field potentials (LFPs) a few days after surgery. Single unit recordings showed that the VO complex is characterized by a localized pattern of bursting neuronal activity. LFP spectra demonstrated that VO of TS patients has a prominent oscillatory activity at low frequencies (2-7 Hz) and in the alpha-band (8-13 Hz), and a virtually absent beta activity. In each patient, the main LFP frequency significantly correlated with single-unit interburst frequency. In conclusion, we observed an oscillatory bursting activity in the VO as target region in patients with severe TS undergoing DBS surgery.
Asunto(s)
Potenciales de Acción/fisiología , Potenciales Evocados/fisiología , Neuronas/fisiología , Tálamo/patología , Síndrome de Tourette/patología , Adulto , Estimulación Encefálica Profunda/métodos , Femenino , Humanos , Masculino , Microelectrodos , Persona de Mediana Edad , Análisis Espectral/métodos , Tálamo/fisiopatología , Síndrome de Tourette/terapia , Adulto JovenRESUMEN
Local field potentials (LFPs) recorded through electrodes implanted in patients with Parkinson's disease (PD) for deep brain stimulation (DBS) provided physiological information about the human basal ganglia. However, LFPs were always recorded 2-7 days after electrode implantation ("acute" condition). Because changes in the tissue surrounding the electrode occur after DBS surgery and could be relevant for LFPs, in this work we assessed whether impedance and LFP pattern are a function of the time interval between the electrode implant and the recordings. LFPs and impedances were recorded from 11 patients with PD immediately after (T-0h), 2 h after (T-2h), 2 days after (T-48h), and 1 month after (T-30d, "chronic" condition) surgery. Impedances at T-0h were significantly higher than at all the other time intervals (T-2h, p=0.0005; T-48h, p=0.0002; T-30d, p=0.003). Correlated with this change (p=0.005), the low-frequency band (2-7 Hz) decreased at all time intervals (p=0.0005). Conversely, the low- (8-20 Hz) and the high-beta (21-35 Hz) bands increased in time (low-beta, p=0.003; high beta, p=0.022), but did not change between T-48h and T-30d. Our results suggest that DBS electrode impedance and LFP pattern are a function of the time interval between electrode implant and LFP recordings. Impedance decrease could be related to changes in the electrode/tissue interface and in the low-frequency band. Conversely, beta band modulations could raise from the adaptation of the neural circuit. These findings confirm that results from LFP analysis in the acute condition can be extended to the chronic condition and that LFPs can be used in novel closed-loop DBS systems.
Asunto(s)
Estimulación Encefálica Profunda/métodos , Potenciales Evocados/fisiología , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/terapia , Subtálamo/fisiología , Anciano , Análisis de Varianza , Biofisica , Estimulación Eléctrica/métodos , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Análisis Espectral/métodos , Estadística como Asunto , Factores de Tiempo , Tomografía Computarizada por Rayos X/métodosRESUMEN
OBJECTIVES: This study aimed to assess the long-term results of deep brain stimulation (DBS) for patients affected with Gilles de la Tourette syndrome, documenting refractoriness to conservative treatments. MATERIAL AND METHODS: Starting from November 2004, 36 patients diagnosed with a Tourette syndrome refractory to conventional and innovative treatments (refractory Tourette syndrome) were operated on for DBS positioning at our dedicated Tourette Clinic. A total number of 79 procedures were carried out: 67 at the thalamic intralaminar/ventralis oralis (Vo/CM-Pf) target, 2 at the posterior Gpi, and 10 at the nucleus accumbens. The target of the DBS procedure was chosen on the basis of clinical manifestations expressed by the single patient. Six out of the ten procedures centered at the Nucleus Accumbens were undertaken on the basis of a persistent behavioral comorbidity in spite of a good response over tic frequency and severity after a first DBS procedure (two interventions at the Vo/CM-Pf and one at the Gpi, bilaterally). RESULTS: All the patients were treated bilaterally except one, treated at the right Vo/CM-Pf because of vascular physiologic abnormalities at the left hemisphere. Two patients refused further treatments after DBS intervention (one of them requiring and obtaining complete removal of the DBS implant with no postsurgical complications documented) and were excluded from follow-up evaluation. Statistically significant improvements were reached for all the other patients concerning the evaluation scales used (Yale Global Tic Severity Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, Yale-Brown Obsessive Compulsive Scale, and a 10-point visual analog scale for self-evaluation of the impact of TS on social integration of the patient). CONCLUSIONS: Gilles de la Tourette syndrome is a complex neuropsychiatric disorder with a significant prevalence in the general population. More than 50% of the patients with TS present a behavioral comorbidity, and anxiety and depression are, to various degrees, associated to this "waxing and waning" clinical picture. DBS in our experience proved to be a valid treatment modality for those patients who fail to respond to conservative treatment modalities. A multidisciplinary team is nevertheless necessary to properly handle this complex therapeutic option.
RESUMEN
Despite the availability of both pharmacological and behavioral therapies for Gilles de la Tourette Syndrome (GTS), a subgroup of patients suffer intractable disease and require treatment through non-conservative means. Since 1955, various neurosurgical procedures have been considered as a potential resort for this severely affected sub-group; this article reviews the neurosurgical treatment for GTS, with in-depth discussion on deep brain stimulation (DBS). Internationally, 39 cases of GTS undergoing DBS treatment have been published. Yet, despite the small numbers of patients assessed in centers involved and the inconsistency of postoperative assessment between centres, DBS has been considered the most promising neurosurgical procedure. Patients resorting to surgical measures often carry the additional burden of a diverse range of behavioral disturbances found to significantly impair health-related quality of life; comorbid psychopathologies must be considered when postoperatively evaluating the benefits of DBS. The authors acknowledge that out of the 39 documented cases of GTS treated with DBS, 18 cases originate from Italy; thus, it seems both relevant and pertinent to recount and present the lived Italian experience of that subgroup of GTS treated by DBS, for the first time. Recommendations from such experience are presented.
Asunto(s)
Encéfalo/cirugía , Estimulación Encefálica Profunda/métodos , Síndrome de Tourette/terapia , Humanos , ItaliaRESUMEN
BACKGROUND CONTEXT: Successful placement of pedicle screws in the cervical spine requires a sufficient three-dimensional understanding of pedicle morphology to allow accurate identification of the screw axis. PURPOSE: The goal of the present study was to assess morphologic trends from one level to the next with respect to linear and angular parameters associated with the subaxial cervical pedicles. STUDY DESIGN/SETTING: We evaluated the pedicle morphology of cervical spine using axial and sagittal computed tomography (CT) imaging. The C3-C7 vertebrae in 122 patients (610 vertebrae) were evaluated (age range, 14-93; mean, 48 years). METHODS: Thin cut (2.5mm thickness) axial CT images were measured. Sagittal reconstructions were obtained using 1.25-mm thickness slices. The following pedicle parameters were assessed: pedicle width (PW, the mediolateral diameter of the pedicle isthmus, perpendicular to the pedicle axis), pedicle height (PH, rostro-caudal dimension of the pedicle determined on the sagittal image), maximal screw length (MSL, distance from the posterior cortex of the lateral mass to the anterior wall of the vertebral body along the pedicle axis), and pedicle transverse angle (PTA, angle between the pedicle axis and the midline vertebral body). RESULTS: The overall mean PW and PH ranged from 4.7 to 6.5mm and 6.4 to 7.0mm, respectively. For both these parameters there was a trend toward increasing size proceeding caudally in the cervical spine. The mean PW and PH was greater in males than in females, and this difference was statistically significant at all levels (p<.0001). The overall mean MSL ranged from 29.9 to 32.9 mm. All intersections of the pedicle axis and the posterior cortex of the lateral mass were located at the most lateral portion of the lateral mass for the C3-C6 vertebrae. The overall mean PTA ranged from 37.8 degrees to 45.3 degrees . The overall mean PTA was approximately 44 degrees from C3 to C6 and 37.8 degrees at C7. CONCLUSION: The findings of our radiological anatomical study suggest that the preoperative CT scans of patients undergoing cervical transpedicular fixation should be thoroughly analyzed and close attention paid to the pedicle size and its angulation. The placement of cervical pedicle screws should be individualized for each patient and based on detailed preoperative planning.
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Tornillos Óseos , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Fusión Vertebral/métodos , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/anatomía & histología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fusión Vertebral/instrumentación , Adulto JovenRESUMEN
Deep brain stimulation (DBS) has been used in a small number of patients with Tourette's syndrome and results on tics and comorbidities have been promising. The choice of the DBS target appears to influence the effectiveness; preliminary studies and case reports suggest that certain target areas may be more effective than others in patients with specific symptoms and comorbidities. Clinical data on the effect of DBS on tics and behavioral symptoms support its use in patients with severe, refractory Tourette's syndrome, particularly in younger adults who have a greater severity and prevalence of tics and comorbidities, and are more likely to experience social impairment. Although DBS has shown potential as an 'add-on' therapy for Tourette's syndrome patients failing to show adequate improvement with conventional conservative treatments, several issues remain to be resolved, including patient selection, choice of target, and adverse effects. Successful DBS requires an experienced multidisciplinary team for the management of these complex pre-, peri- and postoperative issues. Future studies should include establishment of consistent inclusion criteria and specific practical requirements for clinical trials, evaluation of the impact of DBS on non-tic symptoms and their influence on outcome, social impairment and quality of life, and the identification of optimum neurophysiologically based DBS targets for improved efficacy in specific patient subtypes.
Asunto(s)
Estimulación Encefálica Profunda/efectos adversos , Síndrome de Tourette/terapia , Humanos , Grupo de Atención al Paciente , Selección de Paciente , Calidad de Vida , Síndrome de Tourette/diagnósticoRESUMEN
There is debate over the cognitive and behavioral effects of deep brain stimulation (DBS) of the subthalamic nucleus (STN) in advanced Parkinson's disease (PD). To evaluate these effects, we performed a prospective, naturalistic controlled, 3-year follow-up study. A total of 65 PD patients were enrolled, of whom 32 underwent STN-DBS (PD-DBS) and 33, even though eligible for this treatment, declined surgery and chose other therapeutic procedures (PD-control). Motor and neuropsychological functions were assessed in all the subjects at baseline (T0) and 36 months (T36). The PD-DBS patients were also evaluated at 1, 6, 12, and 24 months after surgery (T1, T6, T12, and T24). At T1, compared with T0, the PD-DBS patients recorded worse logical executive function task and verbal fluency (FAS) scores, whereas their performance of memory tasks remained stable. At T12, their cognitive profile had returned within the pre-DBS range, thereafter remaining stable until T36. FAS scores at T36 were significantly worse in the PD-DBS compared with the PD-control patients. This is the first long-term naturalistic controlled study of cognitive functions in PD patients submitted to STN-DBS. Our results confirm previous reports of a worsening of verbal fluency after DBS, but show that STN-DBS seems to be relatively safe from a cognitive standpoint, as the short-term worsening of frontal-executive functions was found to be transient.