Despite a time-dependent deterioration in the success rate of GKS for medically intractable TN, the authors' study showed that > 50% of patients can be expected to have a good outcome based on their scoring system, with approximately 33% having an ideal outcome (pain free with no need for medications). Long-term data, as those presented here, are important when counseling patients on their treatment options.

The results indicate that trigeminal nerve atrophy can be depicted noninvasively in patients with trigeminal neuralgia.

OBJECT Traumatic head injury (THI) is a highly prevalent condition in the United States, and concern regarding excess radiation-related cancer mortality has placed focus on limiting the use of CT in the evaluation of pediatric patients with THI. Given the success of rapid-acquisition MRI in the evaluation of ventriculoperitoneal shunt malfunction in pediatric patient populations, this study sought to evaluate the sensitivity of MRI in the setting of acute THI. METHODS Medical records of 574 pediatric admissions for THI to a Level 1 trauma center over a 10-year period were retrospectively reviewed to identify patients who underwent both CT and MRI examinations of the head within a 5-day period. Thirty-five patients were found, and diagnostic images were available for 30 patients. De-identified images were reviewed by a neuroradiologist for presence of any injury, intracranial hemorrhage, diffuse axonal injury (DAI), and skull fracture. Radiology reports were used to calculate interrater reliability scores. Baseline demographics and concordance analysis was performed with Stata version 13. RESULTS The mean age of the 30-patient cohort was 8.5 ± 6.7 years, and 63.3% were male. The mean Injury Severity Score was 13.7 ± 9.2, and the mean Glasgow Coma Scale score was 9 ± 5.7. Radiology reports noted 150 abnormal findings. CT scanning missed findings in 12 patients; the missed findings included DAI (n = 5), subarachnoid hemorrhage (n = 6), small subdural hematomas (n = 6), cerebral contusions (n = 3), and an encephalocele. The CT scan was negative in 3 patients whose subsequent MRI revealed findings. MRI missed findings in 13 patients; missed findings included skull fracture (n = 5), small subdural hematomas (n = 4), cerebral contusions (n = 3), subarachnoid hemorrhage (n = 3), and DAI (n = 1). MRI was negative in 1 patient whose preceding CT scan was read as positive for injury. Although MRI more frequently reported intracranial findings than CT scanning, there was no statistically significant difference between CT and MRI in the detection of any intracranial injury (p = 0.63), DAI (p = 0.22), or intracranial hemorrhage (p = 0.25). CT scanning tended to more frequently identify skull fractures than MRI (p = 0.06). CONCLUSIONS MRI may be as sensitive as CT scanning in the detection of THI, DAI, and intracranial hemorrhage, but missed skull fractures in 5 of 13 patients. MRI may be a useful alternative to CT scanning in select stable patients with mild THI who warrant neuroimaging by clinical decision rules.

Osteomyelitis is an infection of the bone that can involve the vertebral column. A rare cause of vertebral osteomyelitis is Mycobacterium bovis after intravesical Bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder. In this report, we describe the case of a 64-year-old male presenting with constitutional symptoms, progressive thoracic kyphosis, and intractable T11 and T12 radiculopathies over the proceeding six months. A CT scan revealed erosive, lytic changes of the T12 and L1 vertebrae with compression of the T12 vertebra. An MRI demonstrated T11-12 osteomyelitis with intervening discitis and extensive paraspinal enhancement with a corresponding hyperintensity on a short tau inversion recovery (STIR) sequence. A needle aspiration grew out Mycobacterial tuberculosis complex that was pansensitive to all antimicrobial agent therapies, except pyrazinamide on culture, a finding consistent with an M. bovis infection. The patient’s infection and neurologic compromise resolved after transthoracic T11-12 vertebrectomies with decompression of the spinal cord and nerve roots as well as T10-L1 instrumented fusion and protracted antimicrobial therapy. The epidemiology and natural history of M. bovis osteomyelitis are reviewed and the authors emphasize a mechanism of vertebral inoculation to explain the predilection of M. bovis osteomyelitis in males after intravesical BCG therapy.

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Object The traditional methods for managing symptomatic chronic subdural hematoma (SDH) include evacuation via a bur hole or craniotomy, both with or without drain placement. Because chronic SDH frequently occurs in elderly patients with multiple comorbidities, the bedside approach afforded by the subdural evacuating port system (SEPS) is an attractive alternative method that is performed under local anesthesia and conscious sedation. The goal of this study was to evaluate the radiographic and clinical outcomes of SEPS as compared with traditional methods. Methods A prospectively maintained database of 23 chronic SDHs treated by bur hole or craniotomy and of 23 chronic SDHs treated by SEPS drainage at Tufts Medical Center was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcome was collected. The volume of SDH before and after treatment was semiautomatically measured using imaging software. Results There was no significant difference in initial SDH volume (94.5 cm(3) vs 112.6 cm(3), respectively; p = 0.25) or final SDH volume (31.9 cm(3) vs 28.2 cm(3), respectively; p = 0.65) between SEPS drainage and traditional methods. In addition, there was no difference in mortality (4.3% vs 9.1%, respectively; p = 0.61), length of stay (11 days vs 9.1 days, respectively; p = 0.48), or stability of subdural evacuation (94.1% vs 83.3%, respectively; p = 0.60) for the SEPS and traditional groups at an average follow-up of 12 and 15 weeks, respectively. Only 2 of 23 SDHs treated by SEPS required further treatment by bur hole or craniotomy due to inadequate evacuation of subdural blood. Conclusions The SEPS is a safe and effective alternative to traditional methods of evacuation of chronic SDHs and should be considered in patients presenting with a symptomatic chronic SDH.

Lumbar microdiscectomy, which relies on the operating microscope for visualization, was first described in the late 1970s. This operation is considered the gold standard procedure for patients who require surgery for symptomatic lumbar disc herniation causing radiculopathy that has not improved with conservative measures. A new approach to the management of symptomatic lumbar disc herniation, microendoscopic discectomy, was introduced in 1997. This operation utilizes a tubular retractor system and a microendoscope for visualization rather than the operating microscope. As it is a new procedure, long-term outcomes have not yet been established for this operation. However, recent literature suggests that microendoscopic discectomy may be as effective as the traditional lumbar microdiscectomy in relieving radiculopathy. This article describes the operative techniques and outcomes reported in the literature for both lumbar microdiscectomy and microendoscopic discectomy.