2019/05/17 by Kyle I. Swanson, Kris A. Smith, Zaman Mirzadeh +1 · 1 voice
Medicine · #Neurological disorders and treatments #Botulinum Toxin and Related Neurological Disorders #Pain Management and Treatment
paper · pdf · doi:10.1093/ons/opz075
openalex publication_date 2019/05/17 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
Most neurosurgical procedures can be categorized into 4 divisions: cerebro-vascular, neuro-oncology, spine, and stereotactic and functional neurosurgery. Stereotactic and functional neurosurgery can be further subcategorized into epilepsy, movement disorders, and pain. The major categories of neurosurgery overlap extensively, as do the subcategories of stereotactic and functional neurosurgery. Recent advances in stereotactic and functional neurosurgery have been validated through rigorous clinical trials over the past decade, deepening our understanding of these disorders. The benefits of surgical treatment of epilepsy and ablative procedures for movement disorders and chronic pain are well documented. Neuromodulation is a treatment strategy that aims to regulate neural circuits by electrical stimulation or chemical agents. There is a well-defined role for neuromodulation in the management of epilepsy, movement disorders, and pain treatment, and this role appears to be expanding. Deep brain stimulation (DBS) and spinal cord stimulation are common neuromodulation therapies. DBS is approved by the US Food and Drug Administration to treat Parkinson disease, essential tremor, and epilepsy. It is also approved for treatment of primary dystonia and obsessive compulsive disorder in selected patients via a humanitarian device exemption. Responsive neurostimulation and vagal nerve stimulation are also approved neuromodulation therapies for epilepsy. Spinal cord stimulation is used for chronic pain syndromes affecting the back or extremities and is considered for patients in whom lumbar spine surgery has failed. The aim of functional neurosurgery is to restore function in patients. This section will outline the techniques and principles behind the methods that are used to accomplish this goal. All patients in the case presentations gave written informed consent for diagnostic imaging and treatment. Institutional review board approval was not sought and was unnecessary. CHAPTER 1: TEMPORAL LOBECTOMY FOR EPILEPSY Case Presentation A 42-yr-old right-handed woman presented with epilepsy. She had her first convulsive seizure when she was 31 yr of age, although she reported having had staring spells for several years before that first seizure. At the time of her first seizure, she underwent electroencephalography (EEG) and was started on single-agent medical management. She was seizure-free for 8 yr before having a recurrence of complex partial seizures several times a month that affected the left side of her body. Despite changing antiepileptic medication and starting a second agent, she continued to have seizures. She described an aura, including strange smells, that preceded the events. She underwent prolonged video EEG in the epilepsy monitoring unit, which confirmed a right temporal lobe seizure origin. Magnetic resonance imaging (MRI) demonstrated atrophy of the hippocampus on the right. Questions Where is the “safe zone” for temporal lobectomy on the left (dominant) side? 4 to 5 cm from the anterior tip 6 to 7 cm from the anterior tip 8 to 9 cm from the anterior tip There is no safe zone on the dominant hemisphere What is the most common cause of intractable temporal lobe epilepsy? Brain tumor Herpes simplex virus Arteriovenous malformation Mesial temporal sclerosis Which of the following is not a potentially curative surgical treatment option for epilepsy? Temporal lobectomy Selective amygdalohippocampectomy (SAH) Vagus nerve stimulation Laser thermal ablation Which of the following is a consequence of resecting too much of the temporal lobe? Aphasia Contralateral quadrant homonymous hemianopsia Contralateral hemiplegia All of the above Decision Making: Treatment of Epilepsy Epilepsy is a disease of recurrent, often unprovoked, seizures. If left untreated, recurrent seizures can result in injury from falls and trauma, cognitive and memory decline, or even sudden death. The first-line treatment of epilepsy is antiepileptic drugs (AEDs). However, approximately one-third of patients with epilepsy will continue to have uncontrolled seizures despite trials of multiple AEDs, often in combination. If trials of 2 well-tolerated, appropriately chosen AEDs, either as separate monotherapies or in combination, have failed to control the seizures, the patient is considered to have medically refractory epilepsy and is unlikely to achieve seizure freedom with medical management alone. Patients with medically refractory epilepsy should be referred to an epilepsy center for evaluation to determine whether they are candidates for epilepsy surgery that either epilepsy or seizure for Epilepsy whether an epilepsy patient is a for a surgical treatment often the following the seizure be to The to this be to a as a tumor or that is on or to a of that not be a is by having patients an EEG with video often for a prolonged in an EEG monitoring are this to seizures. Patients also to the to for as temporal sclerosis most common cause of temporal lobe that the patient to seizures. and of the and also seizure of further seizure and or of the brain functional or If an with is on by or with the patient to If the is or the brain for monitoring a much and of seizure with the a monitoring can be by on the brain and by into the brain to can be through in the in a The patient is to an epilepsy monitoring unit, the are in for a or to time to multiple seizures and of seizure If the seizures can be the patient will surgery to the seizure If the patient has seizure from in the or no can be the patient for neuromodulation as nerve to the of seizures. for stimulation to and Treatment for Temporal Epilepsy Temporal Most patients with temporal lobe epilepsy have seizures from the the and Mesial temporal sclerosis is the most common for these patients. appropriately selected patients with medically temporal lobe epilepsy, temporal lobectomy has been demonstrated to be to medical management in a with approximately of surgical patients seizure This is in of the of multiple medical seizure in these patients. Temporal lobectomy of the anterior temporal the and the hippocampus the to the of the The of anterior temporal as from the temporal the temporal on the the dominant is to 4 to 5 in the be to 6 to 7 temporal lobe can the of which over the of the temporal of the and can cause homonymous too on the dominant temporal lobe can to in to of the anterior which in the of the to the can result in Despite the of temporal lobectomy for seizure the surgery is an of the in the 2 to the temporal A temporal lobectomy or is via a temporal The is used for an with of seizures by temporal lobe epilepsy in the temporal lobe and the will the temporal and an The is to as much as to of of temporal lobectomy and has been a that the seizure freedom with is that with temporal patients continue to have seizures, option is the of the temporal with of the anterior temporal to the temporal to an a a in which a is in the temporal to the temporal of the and a in which the is in the for temporal temporal temporal temporal with from This video can be in the of the to this in and the Laser Laser thermal also as thermal is a for a seizure Laser ablation is a that a and a in the of a is to the in the and the and the brain The is by resonance to Laser ablation has been used as an to by the the of the and are that the seizure freedom is that for temporal lobectomy or Neuromodulation for Epilepsy Patients with seizures or multiple seizure are not candidates for seizure patients with seizures from as result in and However, these patients be candidates for stimulation therapies that the of seizures. 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epilepsy. surgical treatment of epilepsy is Temporal lobectomy is in patients. is an treatment with potentially cognitive in seizure be with a temporal Neuromodulation of epilepsy in a patient seizure CHAPTER FOR EPILEPSY Case Presentation A woman in was refractory to medical including of was an the to with the seizure to the left and the Questions What is an for hemiplegia malformation seizure Mesial temporal sclerosis A and and much of the can be in a one-third one-third one-third Which of the following is not a surgical Which of the following is It is a common of nerve of and of is left homonymous hemianopsia with is in of Treatment for Epilepsy can be used to treat epilepsy and a of the brain is or from the This is for patients with of epilepsy when the seizure a of the It is used when seizures be by medication and when surgery is not an or are 2 that cause seizures. are in have an disease that has to a brain The with is approximately is an The is in have for circuits in the 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the The multiple has also been used to treat of seizure to of the multiple with from of multiple with from This video can be in the of the to this in and the of Case the patient was from and started following 4 she was and the she continued to antiepileptic to Questions is and hemiplegia are for which this is the anterior of the is to be resecting can result in as is a can also to as and The for epilepsy surgery are and A can be an treatment for seizures or a the hemisphere to over by the hemisphere that was in and is It is for patients for whom the for is or in whom the of the hemisphere CHAPTER DBS FOR Case Presentation A 7 yr before to our was with Parkinson disease yr the of and was started on the first 4 well to that on left as well as and the 2 had of the and of when be with This affected in with At the time of was Parkinson 7 times a that an a Questions Which DBS for Parkinson DBS is as a treatment when therapies have been DBS treat of Parkinson disease, as cognitive and of DBS 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to patients to medical the appears to have a on patients to the has a and in The of a the US Food and Drug Administration to in the of DBS for Parkinson disease to that this of and this can be considered in patients have had Parkinson disease for 4 yr and have had for 4 of Case demonstrated cognitive The case was a DBS and was for The the device 2 the patient was to medication by which was to the of medication from 7 times a to times a to Questions DBS is a treatment of It can be considered in patients with 4 yr of Parkinson disease and 4 of to medical It is for The patients time in the the and the are for Parkinson have in medication following DBS the with DBS the is used to or the This for of stimulation is the of the DBS to for clinical and which side of stimulation or can be used to the of the techniques can be used by the or in with to The is to the and the and is to the of can cause to DBS for Parkinson disease has been to of The can be considered in patients have had Parkinson disease for 4 yr and have had for 4 DBS the and is in the of Parkinson disease and and CHAPTER Case Presentation A woman presented with a of pain. 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The be to the and an the pain. are the most common that patients to for However, the of is not cause or be to and surgical treatment are and the of the the imaging as well as diagnostic and is a of primary that a as or the of primary of to the or of the or nerve from spinal disease, and as affecting the and nerve The for should of the spine and the brain to for patients with should to a diagnostic nerve Treatment of Most patients with have no cause for these the treatment is with an surgical treatment be Treatment management of treatment with as or management and Treatment treatment 2 The first is to the patient with The second is to a a to an nerve can the of The and can be and with times with a The or can also be for a with a which result in of is with have also been used to treat of the nerve with is treatment option that pain Treatment Patients to a nerve be candidates for an this the is is in the to the the of the The nerve is and a of is the of a with the recurrence of as well as in the of the surgical treatment option for is a via surgical of the nerve and the neural This is a as of the nerve the spinal to the of these surgical are considered to be ablative A option is nerve are the of in the and to an that is in the or The are the from the to the of this are that is no further into the and not ablation of the Patients a to to before The that are used for spinal cord stimulation trials can be used in the for nerve or surgical which a for of the be of this the of with an and to control of The of a diagnostic nerve and a is for patients are with in the the of with from have is a that has and surgical treatment to do not have an when medication and treatment further for should be before with surgical treatment treatment of primary is that the of the is the is to the pain and Most surgical treatment are ablative with the of nerve benefits can be this has a of recurrence of of Case The patient underwent a of nerve with pain management a of nerve The pain 7 and in in her pain. She underwent of the of and a left At 6 the she reported that she was with her to which had her pain. years the patient to the and reported that her despite multiple the She had the device she not was and the was She that the device be to Questions The nerve to the and of these will be in the of the nerve will cause Neuromodulation via electrical stimulation is a treatment option for chronic pain of a of the nerve in the is not a The nerve is not can be a and the to the is most do not have an be a of disease that can be the pain. treatment for primary and A nerve can an role in the of and should be before surgical treatment. The of a diagnostic of surgical treatment. CHAPTER Case Presentation A was referred by for neurosurgical The patient had a of right The of was and the in and and the and started affecting in to The not and had with the this treatment left with a which was also Questions What is the cause of or too much of the nerve nerve of the nerve What is the most common with Where of the nerve zone as the nerve the Where the nerve and the nerve The The What surgical is used for of to that used for of the nerve and is a that of of the are in and with the of can to be to a of the as the the or the However, the most with a to an from the to and There is of the The can be a as well as a of for patients. they result in of for the and The is in the of syndromes It from of the nerve to zone from the The most common this is the anterior by the At a can also be as the on resonance of the nerve the zone the by a with from resonance of the brain a of the nerve the left with from for Treatment as and are is a US Food and Drug treatment option for that in partial of the with treatment. The are or into the The of is to 5 and the of is to 6 a patients 2 to 4 times with and which over to the disease of are in and which for patients. Treatment of the nerve is an treatment for with or partial of are reported in the of to to the treatment of the of a of the nerve zone of the to a that to the the The is and a The is the and the nerve in surgical treatment for of that are for are of Patients from of the The of the nerve to the nerve also a of with an as as to in surgical case the of the of do not surgery and can for several before with a of a be for of the a can be used to the from the nerve and to the of the of the the in and the The is from the of the a left with the an with from A is used to the from the nerve to The is to the a from the with from for the anterior and the with from This video can be in the of the to this in and the resonance for a to the from the with from This video can be in the of the to this in and the of Case a the right The patient underwent a for treatment of of the zone was by a of and the was the A was The of a failed to the nerve A was and the was from the nerve by the to the to Questions The cause of is to be