Neurochirurgie
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The solution to the failed back syndrome will come from the surgeon who masters the technology, the pathology and the surgery and who understands the patient. The back is normally dynamic and the failed back is no longer dynamic. ⋯ Welfare systems that promote disability may undermine successful therapy. Solutions to great problems usually come from men who are passionate, observing and skilful.
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Conventional spinal cord stimulation (SCS) generates paraesthesia, as the efficacy of this technique is based on the relationship between the paraesthesia provided by SCS on the painful zone and an analgesic effect on the stimulated zone. Although this basic postulate is based on clinical evidence, it is clear that this relationship has never been formally demonstrated by scientific studies. There is a need for objective evaluation tools ("transducers") to transpose electrical signals to clinical effects and to guide therapeutic choices. ⋯ The Neuro-Mapping Locator (NML) software is dedicated to patients with failed back surgery syndrome, candidates for SCS lead implantation, to actively participate in the implantation procedure. Real-time geographical localization of the paraesthesia generated by percutaneous or multicolumn surgical SCS lead implanted under awake anaesthesia allows intraoperative lead programming and possibly lead positioning to be modified with the patient's cooperation. Software updates should enable us to refine objectives related to the use of this tool and minimize observational biases. The ultimate goals of NML software should not be limited to optimize one specific device implantation in a patient but also allow to compare instantaneously various stimulation strategies, by characterizing new technical parameters as "coverage efficacy" and "device specificity" on selected subgroups of patients. Another longer-term objective would be to organize these predictive factors into computer science ontologies, which could constitute robust and helpful data for device selection and programming of tomorrow's neurostimulators.
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The current definition of Failed Back Surgery Syndrome (FBSS) has a pejorative and restrictive connotation of blame and failure. Optimally, the evaluation of FBSS patients might be based on a multidimensional approach, involving an array of practitioners including spine surgeons, pain physicians, physiotherapists and behavioural specialists. Even though these clinical interactions should lead to a unique approach, one main problem comes from the fact that FBSS definition has varied over time and remains extremely controversial. There is now a need for global consensus about what we call FBSS, why, when and how. Discussing the name of this syndrome appears to be a logical starting point. ⋯ We propose to replace the FBSS acronym by POPS. The ultimate goal of this redefinition would be to guide the patient towards the future rather than the past and to reach a consensus, based on network discussions, concerning the following items: integrate pain mechanisms into the diagnostic process; implement the notion of a predominant ratio between mechanical/neuropathic pain mechanisms, which defines the potential target for treatment options; create a network supported by a database, to prospectively pool and analyse data, using homogeneous evaluation tools and ultimately define outcome predictors in this population.
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In the context of failed back surgery syndrome (FBSS) treatment, the current practice in neurostimulation varies from center-to-center and most clinical decisions are based on an individual diagnosis. Neurostimulation evaluation tools and pain relief assessment are of major concern, as they now constitute one of the main biases of clinical trials. Moreover, the proliferation of technological devices, in a fertile and unsatisfied market, fosters and only furthers the confusion. There are three options available to apply scientific debates to our daily neurostimulation practice: intentional ignorance, standardized evidence-based practice or alternative data mining approach. ⋯ By creating an international prospective database, the purpose of the PROBACK project was to set up a process of extraction and comparative analysis of data derived from the selection, implantation and follow-up of FBSS patients candidates for implanted neurostimulation. This evaluation strategy should help to change the opinions of each implanter and each health system towards a more rational decision-making approach subtended by mathematical reality.
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To evaluate our technique of implanting subdural grids by linear craniectomy under computer-assisted navigation for invasive electroencephalography in medically refractory epilepsy. ⋯ The implantation of 61 consecutive subdural grids for invasive electroencephalography through linear craniectomies was associated with no transient or permanent complications in this population. This letter-box technique appears to be practical and safe without limiting explorative efficacy.