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Object: Trigeminal neuralgia (TN) presents a diagnostic challenge because of the variety of symptoms, findings during microvascular decompression (MVD), and postsurgical outcomes observed among patients who suffer from this disorder. Recently, a new paradigm for classification of TN was proposed, based on the quality of pain. This study represents the first clinical analysis of this paradigm., Methods: The authors analyzed 144 consecutive cases involving patients who underwent MVD for TN. Preoperative symptoms were classified into 1 of 2 categories based on the preponderance of shocklike (Type 1 TN) or constant (Type 2 TN) pain. Analysis of clinical characteristics, neurovascular pathology, and postoperative outcome was performed., Results: Compared with Type 2 TN, Type 1 TN patients were older, were more likely to have right-sided symptoms, and reported a shorter duration of symptoms prior to evaluation. Previous treatment by percutaneous or radiosurgical procedures was not a predictor of symptoms, surgical findings, or outcome (p = 0.48). Type 1 TN was significantly more likely to be associated with arterial compression. Venous or no compression was more common among Type 2 TN patients (p < 0.01). Type 1 TN patients were also more likely to be pain-free immediately after surgery, and less likely to have a recurrence of pain within 2 years (p < 0.05). Although a subset of patients progressed from Type 1 to Type 2 TN over time, their pathological and prognostic profiles nevertheless resembled those of Type 1 TN., Conclusions: Type 1 and Type 2 TN represent distinct clinical, pathological, and prognostic entities. Classification of patients according to this paradigm should be helpful to determine how best to treat patients with this disorder.

Object: Neurovascular compression (NVC) of the trigeminal nerve is associated with trigeminal neuralgia (TN), but also occurs in many patients without facial pain. This study is designed to identify anatomical characteristics of NVC associated with TN., Methods: Thirty patients with Type 1 TN (intermittent shocklike pain) and 15 patients without facial pain underwent imaging for analysis of 30 trigeminal nerves ipsilateral to TN symptoms, 30 contralateral to TN symptoms, and 30 in asymptomatic patients. Patients underwent 3-T MR imaging including balanced fast-field echo and MR angiography. Images were fused and reconstructed into virtual cisternoscopy images that were evaluated to determine the presence and degree of NVC. Reconstructed coronal images were used to measure nerve diameter and crosssectional area., Results: The incidence of arterial NVC in asymptomatic nerves, nerves contralateral to TN symptoms, and nerves ipsilateral to TN symptoms was 17%, 43%, and 57%, respectively. The difference between symptomatic and asymptomatic nerves was significant regarding the presence of NVC, nerve distortion, and the site of compression (p < 0.001, Fisher exact test). The most significant predictors of TN were compression of the proximal nerve (odds ratio 10.4) and nerve indentation or displacement (odds ratio 4.3). There was a tendency for the development of increasingly severe nerve compression with more advanced patient age across all groups. Decreased nerve size was observed in patients with TN but did not correlate with the presence or extent of NVC., Conclusions: Trigeminal NVC occurs in asymptomatic patients but is more severe and more proximal in patients with TN. This information may help identify patients who are likely to benefit from microvascular decompression.

Object: Microvascular decompression (MVD) is an effective treatment for trigeminal neuralgia (TN). However, many patients do not experience complete pain relief, and relapse can occur even after an initial excellent result. This study was designed to identify characteristics associated with improved long-term outcome after MVD., Methods: One hundred seventy-nine consecutive patients who had undergone MVD for TN at the authors' institution were contacted, and 95 were enrolled in the study. Patients provided information about preoperative pain characteristics including preponderance of shock-like (Type 1 TN) or constant (Type 2 TN) pain, preoperative duration, trigger points, anticonvulsant therapy response, memorable onset, and pain-free intervals. Three groups were defined based on outcome: 1) excellent, pain relief without medication; 2) good, mild or intermittent pain controlled with low-dose medication; and 3) poor, severe persistent pain or need for additional surgical treatment. Results Type of TN pain (Type 1 TN vs Type 2 TN) was the only significant predictor of outcome after MVD., Results: were excellent, good, and poor for Type 1 TN versus Type 2 TN patients in 60 versus 25%, 24 versus 39%, and 16 versus 36%, respectively. Among patients with each TN type, there was a significant trend toward better outcome with greater proportional contribution of Type 1 TN (lancinating) symptoms (p < 0.05)., Conclusions: Pain relief after MVD is strongly correlated with the lancinating pain component, and therefore type of TN pain is the best predictor of long-term outcome after MVD. Application of this information should be helpful in the selection of TN patients likely to benefit from MVD.

Object: Hardware infection is a common occurrence after the implantation of neurostimulation and intrathecal drug delivery devices. The authors investigated whether the application of a neomycin/polymyxin solution directly into the surgical wound decreases the incidence of perioperative infection., Methods: Data from all stereotactic and functional hardware procedures performed at the Oregon Health & Science University over a 5-year period were reviewed. All patients received systemic antibiotic prophylaxis. For the last 18 months of the 5-year period, wounds were additionally injected with a solution consisting of 40 mg neomycin and 200,000 U polymyxin B sulfate diluted in 10 ml normal saline. The primary outcome measure was infection of the hardware requiring explantation., Results: Six hundred fourteen patients underwent hardware implantation. Among 455 patients receiving only intravenous antibiotics, the infection rate was 5.7%. Only 2 (1.2%) of 159 patients receiving both intravenous and local antibiotics had an infection. The wounds in both of these patients were compromised postoperatively: 1 patient had entered a swimming pool, and the other had undergone a general surgery procedure that exposed the hardware. If these patients are excluded from analysis, the effective infection rate using a combined intravenous and local antibiotic prophylaxis is 0%. There were no complications due to toxicity., Conclusions: The combination of local neomycin/polymyxin with systemic antibiotic therapy can lead to a significantly lower rate of postoperative infection than when systemic antibiotics are used alone.

Object: The authors report on a novel technique to identify neurovascular compression in trigeminal neuralgia (TN). Using 3D reconstructed high-resolution balanced fast-field echo (BFFE) images fused with 3D time-of-flight (TOF) magnetic resonance (MR) angiography and Gd-enhanced 3D spoiled gradient recalled sequence, it is possible to objectively visualize the trigeminal nerve and nearby arteries and veins., Methods: Magnetic resonance imaging was performed in 18 patients with unilateral TN using 3 sequences: BFFE, 3D TOF angiography, and 3D Gd-enhanced imaging. The images were imported into OsiriX imaging software; after their fusion, a 3D false-color reconstruction was produced using surface rendering. The reconstructed images objectively differentiate nerves and vessels and can be viewed from any angle, including the anticipated surgical approach., Results: Fifteen patients were predicted to have neurovascular compression on the symptomatic side (9 arterial and 6 venous compressions). All patients had a vascular structure that was identical in location and configuration to that predicted on preoperative analysis. The 3 patients without predicted compression underwent surgical exploration because they manifested the classic symptoms. As expected, exploration in 2 of these patients revealed no offending vessel. The third patient had a small vein embedded in the trigeminal nerve that was beyond the resolution of the 3D Gd-enhanced study., Conclusions: Combining BFFE with MR angiography and Gd-enhanced MR images capitalizes on the advantages of both techniques, enabling MR angiography and contrast-enhanced MR imaging discrimination of vascular structures at BFFE resolution. This results in an unambiguous 3D image that can be used to identify the neurovascular compression and plan the surgical approach.

A Chiari malformation Type I may remain asymptomatic until the patient has reached adulthood and acute presentation of symptoms occurs. In several clinical and experimental studies it has been shown that essential hypertension is associated with vascular compression of the brainstem, particularly of the rostral ventrolateral medulla oblongata. Nevertheless, two cases of Chiari malformation and neurogenic arterial hypertension have been reported. In this article the authors describe a patient with Chiari malformation Type I and neurogenic arterial hypertension. A simple suboccipital decompression not only provided neurological improvement, but also led to resolution of the hypertension. In cases of Chiari malformation and concomitant neurogenic arterial hypertension, careful preoperative clinical and neuroimaging assessments may reveal the cause of the arterial hypertension. Resolution of neurogenic arterial hypertension may be expected even in a case of simple suboccipital decompression.

Object: Lumbosacral spondylolisthesis (LSS) is a common disorder that often requires a stabilization and fusion procedure. The aim of this study was to determine the early neuroimaging-detected results of instrumentation-assisted (in situ) fusion with no attempt at surgical reduction of the deformity in patients with low-grade LSS. The neuroimaging results were evaluated to determine the extent of reduction and its correlation with different parameters., Methods: Thirty patients with low-grade LSS underwent short-segment transpedicular screw fixation; surgical reduction was not attempted. All patients underwent plain anteroposterior and lateral lumbar radiography, flexion-extension lateral lumbar radiography, and computerized tomography and magnetic resonance imaging of the lumbar spine before and after surgery. Postoperative measurements were determined on the late (9 to 12-month) postoperative radiographs. The findings were recorded and grouped. Correlation analysis was performed among the radiological findings, body mass index, age, and sex. Paired-sample t-tests were performed for each paired group to determine statistically significant differences. There was no significant difference in extent of deformity reduction in patients with different lordotic angles, sagittal-plane rotation angles, and intervertebral disc heights. The extent of reduction was statistically significant at the L4-5 level (p < 0.05), in patients younger than 50 years of age (p < 0.05), and in those in whom the facet joint angle was increased (p < 0.05)., Conclusions: The authors found that in cases of low-grade LSS, short-segment posterior stabilization (in situ fusion and fixation) does not require surgical reduction and in fact is associated with a measurable reduction when used as the sole treatment.

The history of spinal surgery represents an important aspect of spine-related sciences. The development of the treatment strategies of spine-related disorders has predominantly been recorded in the Western literature. In this paper, a Turkish physician, Serefeddin Sabuncuoğlu (1385-1468), and his treatise, Cerrahiyetül Haniye (Imperial Surgery), are presented. Three sections of this book regarding spinal disorders (spinal dislocations, sciatica, and back pain) are reviewed. The techniques described were used by Sabuncuoğlu in the 1400s. In conclusion, the language and illustrations of this treatise are unique. Compared with current approaches, there are no major differences in the principles of treating spinal traumas despite the passage of almost 500 years.