Initial Conservative Treatment Research Articles

Djenkolism: Acute Kidney Injury Unresponsive to Conservative Therapy - A Case Report

Djenkol beans (Archidendron jiringa), a popular food in Southeast Asia, can cause djenkolism—a condition leading to acute kidney injury due to the presence of djenkol acid. This case report details a 26-year-old male who presented with three days of anuria following the consumption of half a kilogram of djenkol beans. Upon admission, he exhibited severe abdominal pain, costovertebral tenderness, and elevated renal markers, leading to a diagnosis of obstructive uropathy caused by djenkolic acid crystals. Initial conservative treatment was ineffective, prompting the need for emergency ureteroscopy and placement of bilateral JJ stents to relieve the obstruction. Post-procedure, the patient experienced significant improvement, with a marked increase in urine output; post-obstructive diuresis in the first 24 hours, and resolution of abdominal pain, alongside improved renal function. This case underscores the importance of recognizing djenkolism as a potential cause of acute kidney injury, and advocating for timely diagnosis and intervention to mitigate kidney damage. Public awareness regarding the risks associated with djenkol consumption is also essential. Keywords: Djenkolism, Obstructive Uropathy, Post-Obstructive Diuresis, Acute Kidney Injury

Pediatric uveitis

ABSTRACT Up to 10% of uveitis cases occur in children, with notable implications due to the risk of chronicity and vision loss. It can result from infections, autoimmune and autoinflammatory diseases, trauma, or masquerade syndromes. Primary care providers are vital in early detection, symptom management, and timely specialist referral. Depending on the etiology, symptoms may include redness, pain, photophobia, vision changes, and sometimes more severe vision loss or intense pain. Conservative initial treatment may include pain relievers and corticosteroid eye drops. Specialist care involves a thorough ocular examination and diagnostic tests to identify the underlying cause. Treatment aims to control inflammation and preserve vision, often necessitating long-term medication, with compliance being crucial. In low-resource settings, telemedicine and generic drugs may be useful to manage costs. Preventative strategies focus on prenatal care to avoid congenital infections, and distinguishing uveitis from conditions like conjunctivitis is essential for proper treatment. Multidisciplinary care ensures comprehensive management of the child’s health. In summary, early intervention and a collaborative approach among healthcare providers are key to mitigating the impact of uveitis on a child’s life.

Long-term outcome of adult traumatic atlantoaxial rotatory fixation: a case series

BackgroundThis case series presents five cases of adult atlantoaxial rotatory subluxation (AARS) following traumatic events, focusing on treatment strategies and long-term outcomes.Case presentationThis paper includes four Iranian male patients and one Iranian female patient with ages ranging from 25 to 46 years old. Each case involved unique presentations and management approaches. Initial conservative treatments, including skull traction and orthoses, were attempted, but surgical intervention became necessary due to inadequate response. Surgical fixation significantly improved functional status and alleviated symptoms in all patients, leading to long-term relief. Radiological assessments demonstrated successful outcomes post-surgery.ConclusionsThis study underscores the importance of considering both conservative and surgical options in managing adult atlantoaxial rotatory subluxation to achieve optimal outcomes.

Case Report: A 31-Year-Old Man with Relapsing Complicated Diverticulitis after Initial Conservative Treatment

BACKGROUND: There is controversy regarding the surgical approach for severe complications of diverticular disease. The classical approach has been a Hartmann’s procedure, but laparoscopic lavage and drainage has been suggested as an alternative. We present a patient who initially responded to conservative management of complicated diverticulitis, but had a recurrence that was managed surgically. CASE PRESENTATION: A 31-year-old man presented with Hinchey Stage I diverticulitis and was discharged from the hospital after medical management. Six days later, he returned to the hospital with radiographic evidence of a pericolonic abscess. The patient was taken to the operating room for laparoscopic drainage with placement of a drain in the abscess cavity. He required reoperation with sigmoid colon resection, primary anastomosis, and diverting ileostomy. DISCUSSION: Despite requiring reoperation, the authors believe that initial conservative management possibly prevented progression to generalized feculent peritonitis. If this had occurred, the patient may have required Hartmann’s procedure, which is associated with more complications than primary anastomosis with protective ileostomy. CONCLUSION: The patient had recurrence of complicated diverticular disease that was initially managed conservatively and then with laparoscopic drainage, followed by primary anastomosis with protective ileostomy. Given individual patient factors, the authors believe that he was managed optimally. There is currently controversy between the use of laparoscopic lavage and drainage versus Hartmann’s procedure for the management of complicated colonic diverticular disease and more investigation is required on the subject.

Treatment Outcomes of Intralesional Steroid Injection for Refractory Vocal Process Granuloma.

Vocal process granuloma (VPG) is a chronic condition resulting from a mucoperichondrial injury of vocal process. Initial conservative treatment typically involves vocal hygiene education and antireflux medication. Treatment challenges arise with refractory cases. Outcomes of second-line treatments such as surgical excision and botulinum toxin injections remain inconsistent. Thus, we propose this study to investigate the effectiveness of intralesional steroid injections for refractory VPG. We conducted a retrospective review of 23 patients with VPG who showed no improvement after 3 months of proton pump inhibitors. These patients underwent one to three courses of monthly in-office intralesional steroid injections as a second-line therapy. Treatment outcomes were evaluated by measuring the size of the VPG relative to the length of the vocal folds before and after the final injection procedure. Results showed a significant reduction in VPG size from baseline of 27.74 ± 15.06 to 5.48 ± 8.95 (p < .001). 15 out of 23 patients were responsive (size reduction ≥ 75%) to intralesional steroid injection. Alcohol consumption and longer symptom duration were associated with a poor response (size reduction <75%), whereas prior intubation was associated with better response. For refractory VPG not responding to conservative treatment, intralesional steroid injection appears to be a promising alternative option without significant adverse effects.

Course-based intra-articular injection of medical chitosan mitigates excessive deposition of triacylglycerides in the synovial tissue of the knee osteoarthritis.

This study aimed to investigate the clinical efficacy of intra-articular injections of medical chitosan for treating knee osteoarthritis (KOA) and measure the lipid metabolism profiles of the synovial tissue. Sixty patients with KOA undergoing conservative treatment were recruited and randomized into two groups: one without pharmacological intervention (OA group) and the other receiving course-based intra-articular medical chitosan injections (CSI group). Quantitative lipidomic profile of synovial tissue was analyzed. Functional scores, including Kellgren-Lawrence rating (K-L), Visual Analog Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scoring, and American Knee Society (AKS) scoring were conducted. Survival from the initial conservative treatment to final knee arthroplasty was significantly longer in the CSI group compared to the OA group. Except for the presurgery VAS score, no statistically significant differences were observed in the other scores, including K-L, initial VAS, WOMAC, and AKS. However, the CSI group experienced more reductions in AKS-Knee subscores compared to the OA group. Compared to the CSI group, the OA group exhibited a significant upregulation in most differential lipids, particularly triacylglycerides (TAGs, 77%). The OA group had notably higher levels of long-chain unsaturated fatty acids. Intra-articular injection of medical chitosan significantly prolongs the survival period before knee arthroplasty and reduces the deposition of TAGs metabolites.

Challenging diagnosis and repair of an extensive cyclodialysis cleft

Introduction: This report describes a challenging case involving the diagnosis and surgical repair of an extensive cyclodialysis cleft (CDC) in a young, phakic patient. Patient and Clinical Findings: A 25-year-old man presented with ocular pain, visual impairment, eyelid hematoma, subconjunctival hemorrhage, and Berlin edema after blunt trauma to the right eye. Initial conservative treatment with medications was converted to surgery due to hypotony-induced maculopathy. Diagnosis, Intervention, and Outcomes: Ultrasound biomicroscopy (UBM) and gonioscopy revealed extensive supraciliary and suprachoroidal fluid and a CDC whose dimensions were inconclusive. However, consequent intraoperative UBM provided precise real-time anatomical evidence of an extensive CDC extending 8 clock hours and mandating closure with a direct cycloplexy approach. Layered scleral dissection and direct suturing of the ciliary body to the sclera were performed with 8-0 nylon sutures, resulting in CDC resolution, supraciliary and suprachoroidal fluid absorption, visual acuity improvement, and intraocular pressure stabilization. Conclusions: This case highlights the innovative use of intraoperative UBM as a critical tool, offering real-time guidance in managing an extensive CDC. The successful closure and improved visual outcomes in this case further validate the efficacy of direct cycloplexy for extensive CDCs.

The use of surgical sealant to repair intubation-related tracheal injury.

This case study describes the management of a tracheal injury following emergency intubation in a 56-year-old man. After collapsing from heavy alcohol ingestion, intubation was performed using a bougie, leading to a punctate tracheal wound. Initial conservative treatment with antibiotics was followed by bronchoscopy, revealing a tracheal laceration. Rigid bronchoscopy was then performed, and the wound was closed using BioGlue® surgical sealant. The patient made a full recovery, with follow-up bronchoscopy confirming complete healing. This case highlights the effectiveness of BioGlue® as a minimally invasive alternative for tracheal wound closure, reducing the need for more complex interventions.

Recommendations for the Prevention and Management of Deep Brain Stimulation Infections Based on 26-Year Single-Center Experience

Introduction: Infections related to deep brain stimulation (DBS) can lead to discontinuation of the treatment and increased morbidity. Various measures of reducing infection rates have been proposed in the literature, but scientific consensus is lacking. The aim of this study was to report a 26-year single center experience of DBS infections and provide recommendations for the prevention and management of them. Methods: The retrospective analysis consisted of 978 DBS surgeries performed at Oulu University Hospital (OUH) from 1997 to 2022. This included 342 primary or reimplantations of DBS electrodes and 559 primary or reimplantations of implantable pulse generator (IPG). Infections within approximately 1 year after the surgery without secondary cause were considered surgical-site infections (SSIs). χ2 test was used to compare infection rates before and after 2013, when the systematic implementation of infection prevention measures was started. Results: A total of 35 DBS implants were found to be infected. The number of SSIs was 30, of which 29 were originally operated in OUH leading to a center-specific infection rate of 3.1%. Of the SSIs, 17.2% occurred after IPG replacement. Staphylococcus aureus was found in 75.0% of cultures and 32.1% were mixed infections. The treatment of SSIs included aggressive surgical revision combined with cefuroxime and vancomycin antibiotics, as most patients in the initial conservative treatment group eventually required surgical revision. A statistically significant difference in infection rates before and after the implementation of preventative measures was not observed (risk ratio 2.20, 95% confidence interval 0.94–5.75, p = 0.051), despite over two-fold difference in the incidence of SSIs. Conclusion: Our findings show that the rates of surgical infections are low in modern DBS, but due to their serious consequences, preventative measures should be implemented. We highlight that mixed infections should be accounted for in the antibiotic selection. Furthermore, our treatment recommendation includes aggressive surgical revision combined with antibiotic treatment.

Functional outcomes and center of rotation restoration in total hip arthroplasty after acetabular fracture: A review of 367 hips

BackgroundTotal hip arthroplasty (THA) after acetabular fracture is typically performed months or years later for posttraumatic arthritis after initial conservative treatment. But THA can be performed earlier after open reduction and internal fixation (ORIF) of the fracture. The aim of this study was to determine which strategy is best. The primary outcome measure was the radiological restoration of the hip's center of rotation (COR). The secondary outcome measures were the incidence of complications and the hip's functional scores. Materials and methodsA multicenter cohort was analyzed by splitting patients into three groups: group A (THA within 3weeks of fracture); group B (THA deferred after early ORIF); group C (THA more than 3weeks after fracture, without ORIF). Group B was separated into two subgroups: B- (THA less than 1year after ORIF) and B+ (THA more than 1year after ORIF). The demographics, surgical techniques, COR superior and lateral migration coefficient and functional scores (HHS, HOOS-PS and FJS) were recorded. The functional scores were gathered using PROMs. ResultsIn all, 367 patients were included: 108 in group A, 69 in group B-, 113 in group B+ and 77 in group C. The mean follow-up was 5.8years [3.4 months-35years]. The mean age of the patients was 69.2years [SD 15; 26-101], 52years [SD 16; 19-83], 49years [SD 16; 16-85] and 58.1years [SD 17; 13-94], respectively (p<0.01). The mean ASA score was 2.13 [SD 0.70], 1.84 [SD 0.65], 1.67 [SD 0.63] and 1.79 [SD 0.60], respectively (p<0.01). A complex Letournel fracture was present in 63 patients (61%), 46 patients (71%), 48 patients (49%) and 38 patients (62%), respectively (p<0.01). A reinforcement cage was implanted in 38 patients (69%), 16 patients (62%), 5 patients (12%) and 19 patients (66%), respectively (p<0.01). Cement was used in 45 patients (45%), 23 patients (35%), 19 patients (18%) and 21 patients (32%), respectively (p<0.01). A graft was needed in 46 patients (46%), 35 patients (53%), 17 patients (16%) and 21 patients (48%), respectively (p<0.01). Posterior ORIF was done in 40 patients (46%), 32 patients (55%), 64 patients (61%) and 9 patients (82%), respectively (p<0.01). The COR lateral migration coefficient was significantly higher in group C with a mean of +0.17 (SD 0.85) [-0.27 to +6] compared to the other groups (p=0.02). The COR superior migration coefficient was comparable between groups, with a mean of +0.77 (SD 2.26) [-0.99 to 27], p>0.05. There were complications in 10 patients (9.2%), 6 patients (8.7%), 6 patients (5.3%) and 3 patients (3.9%), respectively, with no significant difference between groups. The PROMs were completed by 51% of patients. At the final review, the mean HHS was 79.2 (SD 21.8) and the mean HOOS-PS was 77.7 (SD 20.1) in the entire cohort, p>0.05. The mean FJS by group was 55.9 (30.2), 47.7 (SD 36.4), 66.1 (SD 30.4) and 65.8 (SD 30.3), respectively (p=0.02). Discussion and conclusionThe B strategy (B+) yielded good outcomes in terms of function and COR restoration. When using this strategy, anterior ORIF preserves the native hip for a subsequent THA through a posterior approach. Strategy C also produces good functional outcomes but shifts the COR laterally. This study confirms the poor results of strategy A in previous publications. When the prognosis is poor, immediate mobilization after anterior ORIF followed by THA within 1year appears to be a good strategy (group B-). Level of evidenceIV, observational study.

Treatment of benign maxillomandibular osteolytic lesions larger than 4 cm: A systematic review

ObjectiveThis systematic review aimed to assess the different treatments of benign maxillo-mandibular radiolucent bone lesions over 4 cm to propose a management algorithm. Study DesignA literature search was conducted using MEDLINE/PubMed, Scopus, Google Scholar, Virtual Health Library databases, and gray literature. Randomized or non-randomized clinical trials and case series with 10 or more patients with a minimum follow up of 1 year, published in French or English until August 2023, were included. The risk of bias was assessed for all papers included. ResultsOf 1433 records identified, 22 were included in this review, reporting data from 1364 lesions. Ameloblastoma was the most common lesion (51.22%) and mandible was the most common site (81.21%). Initial conservative treatment was prevalent (71.04%). Recurrence was higher after conservative (13.8%) than after radical treatments (6.5%). Multilocularity, cortical perforation, dental element preservation were linked to a higher recurrence risk. ConclusionThis study has shown importance of understanding specific characteristics and recurrence risk in benign maxillomandibular osteolytic lesions. Multidisciplinary team approval, personalized approach based on lesion type and patient are crucial. The presence of at least one risk factor could lead to therapeutic decision. Despite limitations, the study informed lesion management and provided precise recommendations.

Predictive factors for recurrent acute appendicitis after conservative treatment

Introduction Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. Aim This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. Methods This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. Results In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1–17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37–4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18–3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. Conclusion This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Radiofrequency Ablation of the Thoracic Descending Branch of the Posterior Rami: An Effective Intervention for Facet Joint Pain. A Case Report

BACKGROUND: Thoracic spine pain is believed to have a comparable prevalence to that of neck pain and low back pain in the general population. Recent discoveries in thoracic spine neuroanatomy have shown that the descending branch of the posterior ramus innervates the thoracic facet joint capsule. We present a case in which thermal radiofrequency ablation of the descending branch was used to significantly relieve pain in a patient with thoracic facet joint pain. CASE REPORT: A 57-year-old woman presented with a 4-month history of severe midthoracic back pain. The patient had failed initial conservative treatment including oral pain medications and physical therapy for 3 months. She ultimately elected for 2 bilateral diagnostic blocks of the T4-T6 descending branches and subsequent radiofrequency ablation; this treatment resulted in complete pain relief and functional improvement. CONCLUSIONS: Thoracic spine descending branch thermal radiofrequency ablation may be a treatment option for thoracic facet joint pain. KEY WORDS: Back pain, thoracic facet joint, descending branch, radiofrequency ablation, posterior ramus, thoracic spine, back, pain

460 Frame Navigation Guided Percutaneous Balloon Compression for Intractable Trigeminal Neuralgia Secondary to Multiple Sclerosis

INTRODUCTION: Patients with multiple sclerosis (MS) are more likely to develop trigeminal neuralgia (TN) compared to the regular population, due to scarring of the nerve and the development of a demyelination plaque. Despite treatment, approximately 10% of MS patients treated for TN experience symptom recurrence, including the development of MS-like symptoms such as optic neuritis and bilateral facial pain. METHODS: A computed tomography (CT) scan was performed preoperatively on two patients diagnosed with multiple sclerosis (MS) who experienced secondary trigeminal neuralgia (TN). The acquired images were then introduced into a navigation system for intraoperative navigation. The preliminary CT images were registered using the navigation system and the bony landmarks were set. Fluoroscopy-guided cannulation was performed under general anesthesia to complete the procedure. RESULTS: Two patients diagnosed with multiple sclerosis (MS) who experienced refractory trigeminal neuralgia (TN) underwent percutaneous balloon compression. The patients were 38 and 56 years old and complained of facial pain in the V1-V2 and V3 distribution. Initial conservative treatment and one dosage of Gamma Knife Radiosurgery (GKR) resulted in symptom control for a few weeks. However, both patients had an acute recurrence of pain; thus, percutaneous retrogasserian balloon compression was performed. During follow-up, the patients reported a 70% decrease in pain after the procedure, with minimal recurrence of shooting episodes. CONCLUSIONS: The management of trigeminal neuralgia secondary to drug-resistant multiple sclerosis presents a persistent challenge. The percutaneous technique for retrogasserian balloon compression may offer a solution for some patients, but it can be technically challenging. Microvascular decompression remains a debated approach for this population, given the complexity of the pathogenesis, target identification, and the potential absence of neurovascular conflict, while stereotactic radiosurgery may be a promising alternative.

Conservative versus stent treatment for spontaneous isolated superior mesenteric artery dissection after the failure of initial 3 days' conservative treatment: A 10-year follow-up study.

To compare the safety and effectiveness of conservative and stent treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) patients after the failure of initial 3days' conservative treatment. All newly diagnosed SISMAD patients between 2013 and 2017 were retrospectively reviewed. After the failure of 3days' conservative treatment, all patients were recommended for stent treatment, but some patients refused to choose it. Their demographic, radiologic, and clinical data were compared. 57 patients were not improved after initial 3days' conservative treatment. Among them, 19 patients were chose to receive stent placement and 38 patients were continually treated with conservative treatment. The median follow-up time was 92.0 (range 62.7-120.4) months. There were no bowel ischemia and arterial rupture. No significant difference was observed in clinical complete recovery (Conservative 31/38 vs Stent 12/19, p =.19) and hospitalization time (Conservative 8.3 ± 1.7days vs Stent 7.2 ± 1.5days, p =.59) between conservative and stent treatment groups. Significant statistical differences were found in radiological complete remodeling (6/38 vs 16/19, p < .01) and hospitalization expense (8662 ± 2886 China Yuan vs 32,935 ± 11,767 China Yuan, p < .01) between these two groups. Although undergoing the failure of initial 3days' conservative treatment, continue conservative treatment still is safe and effective for SISMAD patients. Stent placement could be chosen as an alternative treatment, especially for patients potentially with bowel ischemia or arterial rupture.

Conservative versus surgical treatment of Gartland type II supracondylar humeral fractures in children.

The purpose of the study was to compare the efficacy of conservative and surgical treatments for Gartland type II supracondylar humerus fractures in children. We assessed 142 patients with type II supracondylar humerus fractures treated in our hospital from February 2018 to February 2019. The patients were divided into two groups: initial conservative treatment (Group A) and initial surgical treatment (Group B). Clinical outcomes were measured by the Flynn scoring system. Variables were analyzed using a statistical approach between those groups. All patients were followed up for 6-12 months. The rate of loss reduction was 19.8% in patients treated conservatively, and the incidence of pin infections was 7.1% in patients treated surgically. Although there were no statistical differences between the three groups in fracture healing time and Flynn score, the conservative treatment was superior to surgical treatment in functional recovery times. At the last follow-up, all fractures had healed without iatrogenic vascular or nerve injury, Volkmann's contracture, or cubit varus deformity. Conservative treatment is safe and effective for the treatment of Gartland type II supracondylar fracture and represents a faster recovery time of elbow range of motion as compared with surgical treatment. Type IIB had a 41.3% risk of secondary displacement versus 5.3% for IIA, but we still prefer closed reduction. However, closed reduction of Garland type II must be followed accurately in the first 2 weeks to identify patients with loss of reduction. The patients who loss reduction can be treated with percutaneous pinning, and the clinical effect was consistent with immediate surgical treatment. Level of evidence: level III.

Post-mastectomy reirradiation for ipsilateral T3N0M0 breast tumor relapse: apopulation-based study.

Post-mastectomy radiotherapy is commonly recommended for T3N0M0 breast cancer, particularly in the presence of adverse prognostic factors. However, for T3N0M0 ipsilateral recurrences following breast-conserving surgery and adjuvant radiotherapy, the situation is distinct. Recurrence alone signifies anegative prognostic factor. Moreover, tumor relapses within previously irradiated areas exhibit enhanced radioresistance, and reirradiation of the chest wall carries an escalated risk of radiation-induced toxicity. This study aimed to assess the impact of post-mastectomy reirradiation (PM-reRT) on patient outcomes in cases of ipsilateral T3N0M0 breast tumor recurrence, using data from the SEER database. We identified all patients who underwent treatment for primary non-metastatic breast cancer with breast-conserving surgery followed by adjuvant radiotherapy in the SEER database; among them, those who later experienced alocalized T3N0M0 breast tumor recurrence and underwent total mastectomy were included. The study's goal was to compare overall survival (OS) and cancer-specific survival (CSS) between patients who underwent only mastectomy versus those who had mastectomy followed by adjuvant PM-reRT for their ipsilateral T3N0M0 breast tumor relapse. From 2000 to 2020, the SEER database recorded 44patients with an ipsilateral T3N0M0 breast tumor recurrence after initial conservative treatment, managed with total mastectomy. No statistically significant differences in OS or CSS were observed between patients undergoing mastectomy (MT) alone versus those receiving MT combined with PM-reRT (p = 0.68 and p = 0.86, respectively). Five-year OS rates for the MT and MT + PM-reRT cohorts were 49.5% [95% CI: 29.9-81.8] and 41.7% [10.0-100.0], respectively, while 5‑year CSS rates were 51.6% [12.0-99.5] and 58.3% [15.2-100.0], respectively. For patients undergoing total mastectomy after an ipsilateral T3N0M0 breast tumor recurrence, subsequent to initial breast cancer treatment involving breast-conserving surgery and adjuvant radiotherapy, chest wall reirradiation does not enhance survival outcomes. As such, it should not be routinely performed.

Frame navigation guided percutaneous balloon compression for intractable trigeminal neuralgia secondary to multiple sclerosis

BackgroundPatients with multiple sclerosis (MS) are more likely to develop trigeminal neuralgia (TN) compared to the regular population, due to scarring of the nerve and development of a demyelination plaque. Despite treatment, approximately 10% of MS patients treated for TN experience symptom recurrence, including the development of MS-like symptoms such as optic neuritis and bilateral facial pain. MethodsA computed tomography (CT) scan was performed preoperatively on two patients diagnosed with multiple sclerosis (MS) who experienced secondary trigeminal neuralgia (TN). A precise reference frame was strapped firmly to the patient's forehead during the intraoperative procedure. Preliminary CT images were registered using the navigation system and the bony landmarks were set. Case descriptionTwo patients diagnosed with multiple sclerosis (MS) who experienced refractory trigeminal neuralgia (TN) underwent percutaneous balloon compression. Initial conservative treatment and one dosage of Gamma Knife Radiosurgery (GKR) resulted in symptom control for a few weeks. Both patients had an acute recurrence of pain; thus, percutaneous retrogasserian balloon compression was performed. During follow-up, the patients reported a 70% decrease in pain after the procedure, with minimal recurrence of shooting episodes. ConclusionManagement of trigeminal neuralgia secondary to drug-resistant multiple sclerosis presents a persistent challenge. The percutaneous technique for retrogasserian balloon compression may offer a solution for some patients, but it presents unique challenges for neurosurgeons. Given the complexity of the pathogenesis, target identification, and the potential absence of neurovascular conflict, microvascular decompression remains a debated approach for this patient population. While stereotactic radiosurgery may be a promising alternative.

The death of a neurotrauma trial lessons learned from the prematurely halted randomized evaluation of surgery in elderly with traumatic acute subdural hematoma (RESET-ASDH) trial

IntroductionAcute subdural hematoma (ASDH) due to traumatic brain injury (TBI) constitutes an increasing global health problem, especially in the elderly population. Treatment decisions on surgical versus conservative management pose a neurosurgical dilemma. Large practice variation exists between countries, hospitals, and individual neurosurgeons, illustrating the presence of ‘clinical equipoise’. The RESET-ASDH trial aimed to address this dilemma but was terminated prematurely due to insufficient patient recruitment. Research questionWhat factors may have contributed to the premature discontinuation of the RESET-ASDH trial? Materials and methodsThe RESET-ASDH was a multicenter randomized controlled trial (RCT) comparing functional outcome at 1 year after early surgery or an initial conservative treatment in elderly patients (≥65 years) with a traumatic ASDH. Logs of registry data, medical-ethical approval timelines and COVID-19 related research documents were analyzed. Furthermore, non-structured interviews with involved clinical research personnel were conducted. ResultsThe concept of clinical equipoise was broadly misinterpreted by neurosurgeons as individual uncertainty, hampering patient recruitment. Also, the elderly target population complicated the inclusion process as elderly and their informal caregivers were hesitant to participate in our acute surgical trial. Moreover, the COVID-19 pandemic added additional hurdles like delayed medical-ethical approval, a decline in eligible patients and repeated trial halts during the peaks of the pandemic. Discussion and conclusionThe premature termination of the RESET-ASDH study may have been related to the trial’s methodology and target population with an additional impact of COVID-19. Future acute neurosurgical trials in elderly may consider these challenges to prevent premature trial termination.

Efficacy of initial conservative treatment options for temporomandibular disorders: A network meta-analysis of randomized clinical trials.

This network meta-analysis (NMA) of randomized controlled trials (RCTs) aimed to identify effective initial conservative treatment strategies for patients with temporomandibular joint disorders (TMD). RCTs comparing treatment options for TMD published between January 2000 and July 2021 were retrieved from the databases of PubMed and Embase via a comprehensive electronic search. Patients diagnosed with myalgia (muscle pain) or arthralgia (joint pain) according to pain-related Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) were eligible for inclusion. Twelve treatment options and a placebo were included in the mutual comparisons. The risk of bias was assessed using Risk of Bias 2.0. Forest plots of direct comparisons between individual studies were created using MetaInsight. NMA was performed using R statistical software (netmeta). Twenty-four RCTs involving 1336 patients assessing pain and 12 RCTs involving 614 patients assessing maximal mouth opening were identified. Low-level laser therapy (standard mean difference [SMD]: -2.12, 95% confidence interval [CI]: -3.18, -1.06), self-exercise (SMD: -1.51, 95% CI: -2.82, -0.2), and stabilization splints (SMD: -1.16, 95% CI: -2.02, -0.29) were effective in improving pain; however, the certainty of evidence was very low. Self-exercise (SMD: 0.71, 95% CI: -0.58, 2.01), stabilization splints (SMD: 0.65, 95% CI: -0.09, 1.39), and low-level laser therapy (SMD: 0.63, 95% CI: -0.34, 1.6) were effective in improving maximal mouth opening; however, the certainty of evidence was very low. Stabilization splints, self-exercise, and low-level laser therapy may be effective in the initial treatment of TMD.