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Background: A new generation of neurostimulation surgical leads is used to increase the success of spinal cord stimulation in difficult-to-treat indications such as failed back surgery syndrome. Minimal access spinal technologies (MASTs) have previously been used for surgical lead implantation. However, only a unilateral approach was possible, causing difficulties for median lead placement, and not always preventing laminectomy. A recent MAST technique was used to implant spinal cord stimulation leads without these limitations., Objective: To describe the MAST technique used in a pilot study., Methods: Twenty-four consecutive patients were implanted with a multicolumn surgical lead for refractory chronic back and leg pain by using the optic transligamentar MAST technique., Results: The MAST technique allowed median lead placement, facilitated visualization of the spine, and permitted transligamentar insertion that minimized scarring and muscle damage. No technique-related adverse events or lead revisions were reported., Conclusion: Use of a MAST approach could be useful in safe implantation of multicolumn surgical leads in difficult-to-treat, refractory lower back pain conditions such as failed back surgery syndrome.

Background: Awake brain surgery allows extensive intraoperative monitoring of not only motor and sensory functions and language but also executive functions., Objective: To administer the Stroop test intraoperatively to avoid dramatic side effects such as akinetic mutism and to monitor executive functions in an attempt to optimize the benefit/risk balance of surgery., Methods: A series of 9 adult patients with frontal glioma were operated on for gross tumor resection under local anesthesia. All procedures involved the anterior cingulate cortex (ACC)., Results: Three types of response to the Stroop test were observed: 3 patients had a Stroop effect only for stimulation of the contralateral ACC; 3 patients had a Stroop effect for stimulation of the ipsilateral ACC; and 3 patients had no Stroop effect. Preoperative and postoperative neuropsychological and surgical results are presented and discussed. Stimulation sites eliciting a Stroop effect are compared with published image-based data, and insight provided by these surgical data regarding ACC function and plasticity is discussed. No operative complication related to intraoperative administration of the Stroop test was observed., Conclusion: Administration of the Stroop test during resection of gliomas involving the ACC in adult patients is an option for intraoperative monitoring of executive functions during awake surgery. Globally, these results suggest functional compensation, mediated by plasticity mechanisms, by contralateral homologous regions of the ACC in adult patients with frontal glioma.

Background and Importance: There is large variation in the success of decompressive surgery for pudendal neuralgia (PN), the most chronic, disabling form of perineal pain. We attempt to determine whether spinal cord stimulation using new-generation multicolumn leads could form part of the treatment algorithm for refractory PN., Clinical Presentation: A man with PN that was unresponsive to conventional treatment demonstrated a neuropathic component and had a negative response to nerve infiltrations (so he was not indicated for decompressive surgery) and a positive response to perianal transcutaneous electrical nerve stimulation and was implanted with a 16-contact surgical lead at the level of conus medullaris, allowing multicolumn stimulation. Using transverse combinations, it was possible to obtain 100% paresthesia over the perineal area without unwanted dorsal root stimulation. Perineal and radicular pain was successfully relieved for up to 12 months (80% and 60% reduction in the visual analogue scale scores, respectively), with an improvement in all quality of life domains and a reduction in drug consumption., Conclusion: Spinal cord stimulation using a 16-contact lead may be a viable therapeutic option for patients with refractory PN for whom decompressive surgery is contraindicated.

Background: Failed back surgery syndrome represents one of the most frequent etiologies of chronic back pain and is a major public health issue. Neurostimulation has currently not been validated in the treatment of back pain because of technological limitations in implantable spinal cord stimulation (SCS) systems. New-generation leads using several columns of stimulation can generate longitudinal and/or transverse stimulation fields into the spinal cord., Objective: To investigate, through extensive stimulation testing, the capacity of multicolumn tripolar leads to achieve back territory paresthesia coverage in refractory failed back surgery syndrome patients., Methods: Eleven patients implanted with a 16-contact spinal cord stimulation lead (Specify 5-6-5, Medtronic Inc) were assessed with a systematic exploration of 43 selected stimulation configurations to generate bilateral back paresthesia in addition to leg territory coverage., Results: The tripolar lead successfully generated paresthesia in both bilateral back and leg territories in 9 patients (81.8%). Success rates of multicolumn stimulation patterns were significantly higher than for longitudinal configurations for lombodorsal paresthesia coverage. Six months after implantation, significant pain relief was obtained compared with preoperative evaluation for global pain (Visual Analog Scale, 2.25 vs 8.2 preoperatively; P < .05), leg pain (Visual Analog Scale, 0.5 vs 7.6 preoperatively; P < .05), and back pain (Visual Analog Scale, 1.5 vs 7.8 preoperatively; P < .05)., Conclusion: These results suggest that multicolumn leads can reliably generate back pain coverage and favor pain relief outcomes. This may lead physicians to reconsider new indications for spinal cord stimulation. Expanding neurostimulation perspectives to intractable back pain syndromes could become realistic in the near future.

Background: The fiber-dissection technique provides unique 3-dimensional anatomic knowledge of the white matter., Objective: To better identify the frontostriatal pathways in the human brain, we used a fiber-dissection technique to reconstruct neural connections between the frontal cortex and the nucleus accumbens (NAcc), which is the most ventral extent of the striatum., Methods: Thirty previously frozen, formalin-fixed human brains were dissected under the operating microscope using a modified fiber-dissection technique, primarily reported by Klingler., Results: Our serial dissections of 30 human brain specimens clearly demonstrated that projection fibers form a connection between the NAcc and the frontal lobe. We evidenced this newly described subcortical tract as an accumbofrontal fasciculus. This focal projection was concentrated at the level of the ventromedial part of the NAcc and characterized by an elective and specific projection from the orbitomedial prefrontal cortex, particularly the gyrus rectus and the medial orbital gyrus situated between the H-shaped and the medial orbital sulcus., Conclusion: The accumbofrontal fasciculus is an elective and specific projection from the orbitoprefrontal cortex. This fasciculus is part of a corticostriatothalamocortical loop and a putative target for deep-brain stimulation in the treatment of obsessive-compulsive disorder and major depression. The analysis of in vivo diffusion tractography, used today as a standard in the investigation of many brain disorders, could potentially take advantage of complementary anatomic correlations and functional extrapolations, as described in this study.

In his book, De humani corporis fabrica, published in 1543, Andreas Vesalius refuted the existence of the rete mirabile in humans. At the same time, it was through dissection of sheep that he continued to demonstrate its existence in some animals, thereby proving that its absence in humans was not owing to erroneous dissection. Radically breaking with Galenic dogma, Vesalius would not accept the idea that some scientific expositions are resignedly accepted as true because dogmatic reasons rendered their being subjected to anatomic verification impossible. He epitomized the awakening of the critical spirit and the onset of modern anatomy. In this study, we aimed to comprehend the approach that led Andreas Vesalius to his denial that the rete mirabile existed in humans. We attempted to restore Vesalius's verification procedures through our dissection "à la Vesalius" of the rete mirabile in sheep. Was it not utterly imperative for him to dare to believe more of what is seen than what is written? In the same spirit, wishing to verify inherited ideas and to avoid meaningless phrases, we have taken it upon ourselves to translate the Latin commentaries to Figures 16 and 17 of the seventh book of the Fabrica.

Objective: This study was a randomized, multicenter Phase II trial comparing the effect of perioperative implantation of 5-fluorouracil-releasing microspheres followed by early radiotherapy (Arm A) and early radiotherapy alone (Arm B) in patients with gross total resection of high-grade glioma., Methods: Patients were randomized on clinical and radiological assumption of supratentorial high-grade glioma. All patients underwent surgery, and after resection and histological confirmation, patients randomized to Arm A received multiple injections of microsphere suspension (130 mg of 5-fluorouracil). Conventional fractionated radiotherapy (59.4 Gy) was initiated between the second and the seventh day after surgery for both arms., Results: A total of 95 patients were randomized. Seventy-seven patients were treated and analyzed in intention to treat for efficacy and safety. Overall survival was 15.2 months in Arm A and 13.5 months in Arm B. In the subpopulation of patients with complete resection, overall survival was 15.2 months in Arm A versus 12.3 months in Arm B. However, these differences were not significant. Safety was acceptable with prophylactic high doses of corticosteroids., Conclusion: It may be hypothesized that the implantation of 5-fluorouracil-loaded microspheres in the wall of the cavity resection did increase the overall survival, but the present study was not designed and sufficiently powered to demonstrate this.