Neurosurgery for intractable @entity3119 and XXXX : critical issues.

@entity1 @entity308 @entity146 @entity73 @entity1314 @entity3119
Intractable @entity3119 and @entity308 cause tremendous suffering in those affected and in their families. The impaired ability to function of those affected imposes a heavy burden on society as a whole. Existing data suggest that lesion procedures offer benefit to a large proportion (ranging from about 35%-70%) of @entity1 with intractable @entity3119 and @entity308 . The literature also suggests that although serious long-term adverse events have occurred, these are relatively infrequent overall. Methodologic limitations of the earlier reports on any of these procedures were described previously in this article. The major academic centers conducting this work have since been obtaining systematic prospective data using modern assessment tools. Nevertheless, even with improved methodologies, more recent studies confront some remaining issues that have been difficult to overcome fully. First, the number of @entity1 who have received any one procedure has been relatively small, constraining statistical power. This limits the ability of researchers to enhance @entity1 selection based on clinical characteristics. This is important, because @entity1 with intractable @entity3119 and @entity308 referred for neurosurgery have high rates of comorbid Axis I diagnoses, @entity1314 , and @entity73 , which may have value in predicting response. Other features, such as age of onset, chronicity, and symptom subtypes, may be likewise useful. Another key factor in response may be postoperative management, which has varied most over time but also across @entity1 enrolled in trials. As noted previously, randomized controlled trials of neurosurgical treatment for intractable @entity146 have not been reported, although one has been proposed for gamma knife capsulotomy in intractable @entity3119 [23]. The development of deep brain stimulation has also made sham-controlled studies possible and also allows within- @entity1 designs to be considered. Bearing these problems in mind, the literature does provide important guidance on a number of key points, including approaches to referral, @entity1 selection, and the need for long-term prospective follow-up and postoperative management. Nevertheless, important gaps in knowledge remain in all these areas. Research is expected to narrow these gaps in a number of ways, including @entity1 selection, optimizing the procedures themselves, and understanding the mechanisms of therapeutic action. Neuroimaging studies will play a key role in achieving these aims (see the article by Rauch in this issue). So will cross-species translational research on the anatomy and physiology of the pathways implicated in the pathophysiology and response to treatment in these disorders. Future research in @entity146 neurosurgery must proceed cautiously. A recent editorial statement of the @entity3119 -DBS Collaborative Group [26] recommends a minimum set of standards for any multidisciplinary teams contemplating work in this domain. The rationale for those standards is found throughout this issue and is especially developed in the article by Fins. The need for safe and effective therapeutic options for @entity1 suffering with these severe illnesses is just as clear. The experience over the last several decades provides grounds for careful optimism that refined lesion procedures or reversible deep brain stimulation may relieve suffering and improve the lives of @entity1 with these devastating disorders.
