Neurosurg Focus
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Review Historical Article
From sealing wax to bone wax: predecessors to Horsley's development.
Writers of neurosurgical history have traditionally maintained that the initial use of cranial bone wax for hemostasis in humans was developed and promoted by Sir Victor Horsley, the father of British neurosurgery. A thorough literature review, however, suggests that the use of bone wax for cranial bone hemostasis had its roots more than 50 years before Dr. Horsley's description in 1892. In this study the authors review the sources addressing this issue and establish due credit to the surgeons using bone wax for cranial bone hemostasis before Horsley. ⋯ The use of bone wax in cranial surgery was described by Henri Ferdinand Dolbeau, 50 years prior to Sir Victor Horsley's report in 1892. Nonetheless, it was Horsley who advocated and popularized its use in neurological surgery as an additional tool in the hemostatic and surgical armamentarium.
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Clinical Trial
CyberKnife radiosurgical rhizotomy for the treatment of atypical trigeminal nerve pain.
Patients with atypical trigeminal neuralgia (TN) have unilateral pain in the trigeminal distribution that is dull, aching, or burning in nature and is constant or nearly constant. Studies of most radiosurgical and surgical series have shown lower response rates in patients with atypical TN. This study represents the first report of the treatment of atypical TN with frameless CyberKnife stereotactic radiosurgery (SRS). ⋯ The authors have previously reported a 90% rate of excellent pain relief in patients with classic TN treated with CyberKnife SRS. Compared with patients with classic TN, patients with atypical TN have a lower rate of pain relief. Nevertheless, the nearly 60% rate of success after SRS achieved in this study is still comparable to or better than results achieved with any other treatment modality for atypical TN.
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Orbital tumors can be divided schematically into primary lesions, originating from the orbit itself, and secondary lesions, extending to the orbit from neighboring structures. These tumors are variable in their biological nature and in their location. The authors evaluate 41 cases of benign and malignant tumors involving the orbit and discuss the surgical challenge, which involves tumor removal, preserving visual function and cosmetic reconstruction. ⋯ Orbital tumors can be treated safely using transcranial approaches in many cases. Preoperative imaging can accurately define the compartments involved and the surgical approach needed for tumor removal. A multidisciplinary team of surgeons facilitates optimal tumor removal and skull base sealing as well as good cosmetic results.
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Many doctors involved in the critical care of head-injured patients understand intracranial pressure (ICP) as a number, characterizing the state of the brain pressure-volume relationships. However, the dynamics of ICP, its waveform, and secondarily derived indices portray useful information about brain homeostasis. ⋯ The optimal cerebral perfusion pressure (CPP) derived using the PRx is a new concept that may help to avoid excessive use of vasopressors in CPP-oriented therapy. However, the use of secondary ICP indices remains to be confirmed in clinical trials.
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Previously the authors demonstrated that peroneal and tibial intraneural ganglia arising from the superior tibiofibular joint may occasionally extend proximally within the epineurium to reach the sciatic nerve. The dynamic nature of these cysts, dependent on intraarticular pressures, may give rise to differing clinical and imaging presentations that have remained unexplained until now. To identify the pathogenesis of these unusual cysts and to correlate their atypical magnetic resonance (MR) imaging appearance, the authors retrospectively reviewed their own experience as well as the published literature on these types of intraneural ganglia. ⋯ This anatomical compartmentalization of intraneural cysts can be used to explain varied clinical and imaging patterns of cleavage planes for cyst formation and propagation. Compartmentalization elucidates the mechanism for cases of outer epineurial cysts in which there are primary ascent, sciatic cross-over, and descent of the lesion down terminal branches; correlates these cysts' atypical MR imaging features; and contrasts a different pattern of inner epineurial cysts in which ascent and descent occur without cross-over. The authors present data demonstrating that the dynamic phases of these intraneural ganglia frequently involve the sciatic nerve. Their imaging features are subtle and serve to explain the underrecognition and underreporting of the longitudinal extension of these cysts. Importantly, cysts extending to the sciatic nerve are still derived from the superior tibiofibular joint. Combined with the authors' previous experimental data, the current observations help the reader understand intraneural ganglia with a different, deeper degree of anatomical detail.