ObjectThe authors conducted a study to evaluate the published results of vagal nerve stimulation (VNS) for medically refractory seizures according to evidence-based criteria.MethodsThe authors performed a review of available literature published between 1980 and 2010. Inclusion criteria for articles included more than 10 patients evaluated, average follow-up of 1 or more years, inclusion of medically refractory epilepsy, and consistent preoperative surgical evaluation. Articles were divided into 4 classes of evidence according to criteria established by the American Academy of Neurology.ResultsA total of 70 publications were reviewed, of which 20 were selected for review based on inclusion and exclusion criteria. There were 2 articles that provided Class I evidence, 7 that met criteria for Class II evidence, and 11 that provided Class III evidence.The majority of evidence supports VNS usage in partial epilepsy with a seizure reduction of 50% or more in the majority of cases and freedom from seizure in 6%–27% of patients who responded to stimulation. High stimulation with a gradual increase in VNS stimulation over the first 6 weeks to 3 months postoperatively is well supported by Class I and II data. Predictors of positive response included absence of bilateral interictal epileptiform activity and cortical malformations.ConclusionsVagal nerve stimulation is a safe and effective alternative for adult and pediatric populations with epilepsy refractory to medical and other surgical management.
Background Traditional C1-2 fixation involves placement of C1 lateral mass screws. Evolving techniques have led to the placement of C1 pedicle screws to avoid exposure of the C1-C2 joint capsule. Our minimal dissection technique utilizes anatomical landmarks with isolated exposure of C2 and the inferior posterior arch of C1. We evaluate this procedure clinically and radiographically through a technical report.
INTRODUCTION: Chronic subdural hematoma (CSDH) is a cause of significant morbidity and mortality which is often amenable to surgical drainage. The majority of patients recover rapidly after surgical intervention, but 5% to 30% experience recurrence. Although the use of drains after burr hole evacuation may lower recurrence, they are not used routinely because of a lack of evidence showing efficacy and a concern for increasing surgical morbidity. The aim of this study was to investigate the use of drains in reducing recurrence rates, and their influence on clinical outcome for those presenting with a CSDH.METHODS: Between November 2004 and 2007, 215 patients were randomized: 108 were assigned to drain and 107 to no drain. The primary outcome was recurrence requiring redrainage. The secondary outcomes included mortality at 30 days and 6 months, modified Rankin scale (mRS) score at the time of discharge and 6 months.RESULTS: The CSDH recurrence rate was 10 out of 108 (9.3%) in the drain group and 26 out of 107 (24%) in the non-drain group (χ 2 , P ϭ 0.003). At 6 months, the mortality rate was 10 out of 106 (9.4%) and 19 out of 105 (18.1%), respectively (χ 2 , P = 0.042). A greater proportion had favorable mRS scores (0-3) in the drain group at the time of discharge (81 out of 97 [84%] versus 64 out of 95 [67%], χ 2 , P = 0.009). In addition, a significantly greater proportion of patients with a drain were discharged with a Glasgow Coma Scale score of 15 (76 out of 94 [81%] versus 62 out of 97 [63%], χ 2 , P = 0.007) and without a neurological deficit (47 out of 93 [51%] versus 63 out of 96 [66%]; χ 2 , P = 0.036). There was no difference in the rate of inpatient medical or surgical complications between the study groups.CONCLUSION: The use of drain with burr hole drainage reduces the recurrence rate for CSDH and is associated with better functional status at discharge and lower rates of mortality at 6 months.
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