Percutaneous trigeminal rhizotomy

Percutaneous trigeminal rhizotomy

Percutaneous trigeminal rhizotomy are invasive percutaneous techniques for trigeminal neuralgia that remain safe, simple, and effective for achieving good pain control while minimizing procedural risk 1).

It has been associated with serious complications related to the cannulation of the foramen ovale. Some of these complications, such as internal carotid artery injury, are potentially lethal.

Neuronavigation was proposed as a method to increase the procedure’s safety. All of the techniques described so far rely on pre- or intraoperative computed tomography scanning. Lepski et al. present a simple method based on magnetic resonance imaging (MRI) (radiation free) used to target the foramen ovale under navigation guidance.

This method proved to be safe and effective, and it is especially recommended for young, inexperienced neurosurgeons. 2).

Types

Percutaneous radiofrequency trigeminal rhizotomy

Percutaneous balloon compression trigeminal rhizotomy

Percutaneous glycerol trigeminal rhizotomy.

Although all 3 techniques are generally safe, efficient, and effective, a clear consensus has not been reached regarding their specific indications and degree of efficacy 3).

They differ in method and specificity of nerve injury. BC selectively injures larger pain fibers while sparing small fibers and does not require an awake, cooperative patient. Pain control rates up to 91% at 6 months and 66% at 3 years have been reported. RF allows somatotopic nerve mapping and selective division lesioning and provides pain relief in up to 97% of patients initially and 58% at 5 years. Multiple treatments improve outcomes but carry significant morbidity risk. GR offers similar pain-free outcomes of 90% at 6 months and 54% at 3 years but with higher complication rates (25% vs 16%) compared with BC. Advantages of percutaneous techniques include shorter procedure duration, minimal anesthesia risk, and in the case of GR and RF, immediate patient feedback 4).

In a systematic review and meta-analysis Percutaneous radiofrequency trigeminal rhizotomy is associated with statistically significant higher odds for immediate pain relief and anesthesia and lower risk for post-operative herpes eruption as compared to Percutaneous glycerol trigeminal rhizotomy. Patients in the Percutaneous balloon compression trigeminal rhizotomy group had a statistically significant higher risk to develop post-operative mastication weakness and diplopia when compared to Percutaneous glycerol trigeminal rhizotomy 5).

Training

A real-time augmented reality simulator for percutaneous trigeminal rhizotomy was developed using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents’ performance was analyzed.

Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).

Because technical performance of percutaneous rhizotomy increases with training, we proposed that the skills in performing the procedure in our virtual reality model would also increase with PGY level, if our simulator models the actual procedure. Our results confirm this hypothesis and demonstrate construct validity 6).

References

1)

Cheng JS, Lim DA, Chang EF, Barbaro NM. A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery. 2014 Mar;10 Suppl 1:25-33; discussion 33. doi: 10.1227/NEU.00000000000001687. Review. Erratum in: Neurosurgery. 2014 Jun; 10 Suppl 2:372. PubMed PMID: 24509496.
2)

Lepski G, Filho PM, Ramina K, Bisdas S, Ernemann U, Tatagiba M, Morgalla M, Feigl G. MRI-Based Radiation-Free Method for Navigated Percutaneous Radiofrequency Trigeminal Rhizotomy. J Neurol Surg A Cent Eur Neurosurg. 2015 Jan 16. [Epub ahead of print] PubMed PMID: 25594821.
3)

Missios S, Mohammadi AM, Barnett GH. Percutaneous treatments for trigeminal neuralgia. Neurosurg Clin N Am. 2014 Oct;25(4):751-62. doi: 10.1016/j.nec.2014.06.008. Epub 2014 Aug 3. PubMed PMID: 25240662.
4)

Cheng JS, Lim DA, Chang EF, Barbaro NM. A Review of Percutaneous Treatments for Trigeminal Neuralgia. Neurosurgery. 2013 Sep 23. [Epub ahead of print] PubMed PMID: 24064481.
5)

Texakalidis P, Xenos D, Tora MS, Wetzel JS, Boulis NM. Comparative safety and efficacy of percutaneous approaches for the treatment of trigeminal neuralgia: A systematic review and meta-analysis. Clin Neurol Neurosurg. 2019 May 14;182:112-122. doi: 10.1016/j.clineuro.2019.05.011. [Epub ahead of print] Review. PubMed PMID: 31121470.
6)

Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853. PubMed PMID: 26103444.

Stereoelectroencephalography electrode implantation accuracy

Stereoelectroencephalography electrode implantation accuracy

The accuracy of stereoelectroencephalography electrode implantation is an important factor in maximizing its safety.

The implantation of deep brain electrodes for SEEG by using intraoperative CT O Arm® and the Vertek® articulated passive arm is a safe and effective technique with adequate accuracy 1).

Robot-assisted stereoelectroencephalography electrode placement is highly accurate and is significantly more accurate than optical frameless neuronavigation (ON). Larger safety margins away from vascular structures should be used when placing deep electrodes in young children and for trajectories that pass through thicker soft tissues such as the temporal region 2).


Patient-customized platforms are comparable in terms of safety, accuracy, and simplicity of use to the existing robotic devices for implantation of depth electrodes 3).


Rodionov et al., established a quality assurance (QA) process to aid advances in implantation accuracy.

The accuracy of three consecutive modifications of a frameless implantation technique was quantified in three cohorts comprising 22, 8, and 23 consecutive patients. The modifications of the technique aimed to increase accuracy of the bolt placement.

The lateral shift of the axis of the implanted bolt at the level of the planned entry point was reduced from a mean of 3.0 ± 1.6 mm to 1.4 ± 0.8 mm. The lateral shift of the axis of the implanted bolt at the level of the planned target point was reduced from a mean of 3.8 ± 2.5 mm to 1.6 ± 0.9 mm.

This QA framework helped to isolate and quantify the factors introducing inaccuracy in SEEG implantation, and to monitor ongoing accuracy and the effect of technique modifications 4).


Granados et al., presented a method robust to electrode bending that can accurately segment contact positions and bolt orientation. The techniques presented will allow further characterisation of bending within different brain regions 5).


References

1)

Narváez-Martínez Y, García S, Roldán P, Torales J, Rumià J. [Stereoelectroencephalography by using O-Arm(®) and Vertek(®) passive articulated arm: Technical note and experience of an epilepsy referral centre]. Neurocirugia (Astur). 2016 Nov – Dec;27(6):277-284. doi: 10.1016/j.neucir.2016.05.002. Spanish. PubMed PMID: 27345416.
2)

Sharma JD, Seunarine KK, Tahir MZ, Tisdall MM. Accuracy of robot-assisted versus optical frameless navigated stereoelectroencephalography electrode placement in children. J Neurosurg Pediatr. 2019 Jan 4;23(3):297-302. doi: 10.3171/2018.10.PEDS18227. PubMed PMID: 30611155.
3)

Yu H, Pistol C, Franklin R, Barborica A. Clinical Accuracy of Customized Stereotactic Fixtures for Stereoelectroencephalography. World Neurosurg. 2018 Jan;109:82-88. doi: 10.1016/j.wneu.2017.09.089. Epub 2017 Sep 22. PubMed PMID: 28951181.
4)

Rodionov R, O’Keeffe A, Nowell M, Rizzi M, Vakharia VN, Wykes V, Eriksson SH, Miserocchi A, McEvoy AW, Ourselin S, Duncan JS. Increasing the accuracy of 3D EEG implantations. J Neurosurg. 2019 May 17:1-8. doi: 10.3171/2019.2.JNS183313. [Epub ahead of print] PubMed PMID: 31100733.
5)

Granados A, Vakharia V, Rodionov R, Schweiger M, Vos SB, O’Keeffe AG, Li K, Wu C, Miserocchi A, McEvoy AW, Clarkson MJ, Duncan JS, Sparks R, Ourselin S. Automatic segmentation of stereoelectroencephalography (SEEG) electrodes post-implantation considering bending. Int J Comput Assist Radiol Surg. 2018 May 7. doi: 10.1007/s11548-018-1740-8. [Epub ahead of print] PubMed PMID: 29736800.

Intrathecal Drug Delivery Device Infection

Intrathecal Drug Delivery Device Infection

A major complication of Intrathecal Drug Delivery Device (IDDD) implantationis infection.

Morgalla et al., assessed IDD-related complications in 51 patients who had IDD systems implanted for the treatment of chronic pain or spasticity.

Twelve patients (23.5%) presented a total of 22 complications. The main type of complication was catheter-related (50%), followed by pump failure, infection, and inappropriate refilling 1).


Device-related and surgical wound infection occurred in 12 patients (3%), and nine were regarded as severe in the series of Taira et al., 2).

Risk Factors

Patients with extremely low muscle bulk, visceral pumps may be impractical or impossible, with increased risks of dehiscence and infection 3).


Periodic refills of intrathecal implanted pumps do not seem to be a risk factor for infection if standard sterile refill procedures are performed. In a study, it was clear that comorbid infections from other parts of the body do not present as a risk for device contamination 4).

Prevention

Follett et al., concluded from the available data that the most effective antiinfection measures consist of adherence to published guidelines and recommendations that apply to surgical site infections (SSIs) in general 5).


The use of vancomycin powder in patients with implants in the series of is series of Ghobrial et al., did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls 6).


The combination of local neomycin/polymyxin with systemic antibiotic therapy can lead to a significantly lower rate of postoperative infection than when systemic antibiotics are used alone 7).


The subfascial implantation technique was associated with a reduced rate of local wound and pump infections and provided optimal cosmetic results as compared with that observed in retrospective cases 8).

Treatment

The current standard of care in the treatment of IDDD infection necessitates that the pump be explanted and the infection treated prior to implantation of a new IDDD. This process leads to long hospital stays, interruptions in optimal medical management, and a high risk for dangerous drug withdrawals.


Infections can be treated with repetitive local application of gentamicin-impregnated collagen fleece 9).


Leibold et al., describe a technique that allows for the explantation of the infected pump and implantation of a new pump concurrently, which they have named the “Turner Switch” technique in honor of its inventor.

The authors conducted a retrospective analysis of cases of infected IDDDs in which patients underwent simultaneous explantation of the infected pump and implantation of a new pump. Demographics and clinical data were collected.

Data from a total of 17 patients (11 male, 6 female) who underwent simultaneous IDDD explantation and implantation to treat infections were analyzed from a 3-year period. No patients experienced infection of the newly implanted pump or catheter. Of the 17 patients, 14 (82.4%) had baclofen pumps to treat spasticity and 3 (17.6%) had fentanyl pumps to treat chronic pain. The median hospital stay was 7 days, with 16 of 17 (94.1%) patients able to be discharged home or to a facility with a level of care similar to their preoperative care. All patients ultimately experienced complete resolution of their initial infections. Five patients (29.4%) required a return to the operating room within the next 5 months (for repair of a CSF leak in 2 cases, for treatment of infection at the old pump site in 2 cases, and for treatment of a CSF leak compounded with infection in 1 case). No patient experienced infection of the newly implanted pump or catheter.

IDDD infections represent a large portion of morbidity associated with these devices. The current standard of care for deep pump infections requires pump explantation and a course of antibiotics prior to reimplantation of the IDDD. The authors demonstrate the effectiveness of a procedure involving simultaneous explantation of an infected pump and implantation of a new pump on the contralateral side in the treatment of IDDD infections 10).


Ingale et al., suggested that consideration should be given to selective dorsal rhizotomy (SDR) as an alternative in patients previously implanted with Intrathecal Drug Delivery systems complicated by infection or nearing end of battery life 11).

Case reports

A patient with pump-site infection and Escherichia coli meningitis secondary to transcolonic perforation of an intrathecal baclofen pump catheter. While this is rare, we review the intraoperative precautions and best practices that should be taken to prevent and manage this unusual complication 12).


Intrathecal drug delivery device infection with Mycobacterium fortuitum was not been reported previously. Aliabadi et al., reported a case of an implanted baclofen pump infection and associated mycobacterium meningitis due to Mycobacterium fortuitum. The entire pump system was removed and the patient was treated successfully with a prolonged regimen of antibiotics 13).


In a case neurological complaints were pain and dysaesthesiae in the lower back and thigh, as well as paresis of the ileopsoas muscle. MRI of the lumbar spine showed an intradural-extramedullary mass at the level of L1 homogeneously enhancing with gadolinium. This mass was situated at the tip of an intrathecal catheter implanted 11 years before for a morphine trial infusion as therapy for phantom pain after amputation of the right arm. Now, removal of the catheter was performed. Cultures of lumbar CSF and the catheter tip demonstrated coagulase negative staphylococcus. Antibiotic medication with cephalosporines was given for 6 weeks. After removal of the catheter, the patient was free of pain and he progressively regained full neurological function. Although most catheter-associated granulomas reported so far were sterile in nature, bacterial infection should still be considered even years after catheter placement 14).


A patient who experienced a prolonged course of intrathecal baclofen withdrawal syndrome after removal of an implantable baclofen pump for treatment of pump infection and meningitis. The current literature outlines management options for the acute management of this syndrome. In this report the authors discuss the long-term presentation of this syndrome and suggest a treatment strategy for management of the syndrome. A 37-year-old man who presented with a baclofen pump infection and meningitis experienced acute onset of intrathecal baclofen withdrawal syndrome 12 hours after the pump had been surgically removed. The patient’s symptoms evolved into a severe, treatment-refractory withdrawal syndrome lasting longer than 1 month. Oral baclofen replacement with adjunctive administration of parenteral gamma-aminobutyric acid agonists only served to stabilize the patient’s critical condition throughout his hospital course. Replacement of the baclofen pump and restoration of intrathecal delivery of the medication was necessary to trigger the patient’s dramatic recovery and complete reversal of the withdrawal syndrome within approximately 48 hours. These findings indicate that a more direct method of treating infected baclofen pumps than immediate surgical removal is necessary to prevent the onset of intrathecal baclofen withdrawal syndrome. Various options for preventing the onset of the syndrome while simultaneously treating the infection are discussed 15).

References

1)

Morgalla M, Fortunato M, Azam A, Tatagiba M, Lepski G. High-Resolution Three-Dimensional Computed Tomography for Assessing Complications Related to Intrathecal Drug Delivery. Pain Physician. 2016 Jul;19(5):E775-80. PubMed PMID: 27389121.
2)

Taira T, Ueta T, Katayama Y, Kimizuka M, Nemoto A, Mizusawa H, Liu M, Koito M, Hiro Y, Tanabe H. Rate of complications among the recipients of intrathecal baclofen pump in Japan: a multicenter study. Neuromodulation. 2013 May-Jun;16(3):266-72; discussion 272. doi: 10.1111/ner.12010. Epub 2012 Dec 14. PubMed PMID: 23240625.
3)

Waqar M, Ellenbogen JR, Kumar R, Sneade C, Zebian B, Williams D, Pettorini BL. Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients. J Neurosurg Pediatr. 2014 Oct;14(4):409-13. doi: 10.3171/2014.6.PEDS13686. Epub 2014 Aug 1. PubMed PMID: 25084089.
4)

Dario A, Scamoni C, Picano M, Fortini G, Cuffari S, Tomei G. The infection risk of intrathecal drug infusion pumps after multiple refill procedures. Neuromodulation. 2005 Jan;8(1):36-9. doi: 10.1111/j.1094-7159.2005.05218.x. PubMed PMID: 22151381.
5)

Follett KA, Boortz-Marx RL, Drake JM, DuPen S, Schneider SJ, Turner MS, Coffey RJ. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology. 2004 Jun;100(6):1582-94. Review. PubMed PMID: 15166581.
6)

Ghobrial GM, Thakkar V, Singhal S, Oppenlander ME, Maulucci CM, Harrop JS, Jallo J, Prasad S, Saulino M, Sharan AD. Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: single institutional series in a high risk population. J Clin Neurosci. 2014 Oct;21(10):1786-9. doi: 10.1016/j.jocn.2014.04.007. Epub 2014 Jun 14. PubMed PMID: 24938386.
7)

Miller JP, Acar F, Burchiel KJ. Significant reduction in stereotactic and functional neurosurgical hardware infection after local neomycin/polymyxin application. J Neurosurg. 2009 Feb;110(2):247-50. PubMed PMID: 19263587.
8)

Kopell BH, Sala D, Doyle WK, Feldman DS, Wisoff JH, Weiner HL. Subfascial implantation of intrathecal baclofen pumps in children: technical note. Neurosurgery. 2001 Sep;49(3):753-6; discussion 756-7. PubMed PMID: 11523691.
9)

Peerdeman SM, de Groot V, Feller RE. In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece. J Neurosurg. 2010 Jun;112(6):1308-10. doi: 10.3171/2009.8.JNS081692. PubMed PMID: 19731988.
10)

Leibold AT, Weyhenmeyer J, Lee A. Simultaneous explantation and implantation of intrathecal pumps: a case series. J Neurosurg. 2019 Apr 12:1-7. doi: 10.3171/2019.1.JNS18919. [Epub ahead of print] PubMed PMID: 30978693.
11)

Ingale H, Ughratdar I, Muquit S, Moussa AA, Vloeberghs MH. Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children. Childs Nerv Syst. 2016 Feb;32(2):321-5. doi: 10.1007/s00381-015-2950-9. Epub 2015 Nov 9. PubMed PMID: 26552383.
12)

Devine OP, Harborne AC, Lo WB, Price R. Colonic perforation by an intrathecal baclofen pump catheter causing delayed Escherichia coli meningitis. BMJ Case Rep. 2017 Dec 20;2017. pii: bcr-2017-222539. doi: 10.1136/bcr-2017-222539. PubMed PMID: 29269368.
13)

Aliabadi H, Osenbach RK. Intrathecal Drug Delivery Device Infection and Meningitis due to Mycobacterium Fortuitum: A Case Report. Neuromodulation. 2008 Oct;11(4):311-4. do 10: i: 10.1111/j.1525-1403.2008.00181.x. PubMed PMID: 22151146.
14)

Lehmberg J, Scheiwe C, Spreer J, van Velthoven V. Late bacterial granuloma at an intrathecal drug delivery catheter. Acta Neurochir (Wien). 2006 Aug;148(8):899-901; discussion 901. Epub 2006 Jun 23. PubMed PMID: 16791432.
15)

Douglas AF, Weiner HL, Schwartz DR. Prolonged intrathecal baclofen withdrawal syndrome. Case report and discussion of current therapeutic management. J Neurosurg. 2005 Jun;102(6):1133-6. Review. PubMed PMID: 16028775.
× How can I help you?
WhatsApp WhatsApp us
%d bloggers like this: