Refractory neuropathic pain of the head and neck remains a major clinical challenge, particularly when mediated through the cervicotrigeminal complex (CTC), a unique anatomical hub integrating trigeminal and upper cervical nociceptive inputs. This narrative review synthesizes neuroanatomical, pathophysiological, and clinical evidence to provide a unifying framework for diagnosis and management. A structured search of PubMed, Scopus, and Web of Science identified English-language clinical and mechanistic studies addressing CTC-mediated pain, with case reports excluded unless mechanistically informative. We propose multidimensional refractoriness criteria that integrate pharmacological non-response, failed interventional strategies, and objective functional impairment. Current treatments span pharmacotherapy, peripheral interventions (nerve blocks, radiofrequency ablation), and neuromodulation at multiple network levels (occipital nerve stimulation, spinal cord stimulation, motor cortex stimulation, deep brain stimulation). Non-invasive approaches such as rTMS, tDCS, and vagus nerve stimulation are emerging but remain investigational. Advances in imaging and neurophysiological biomarkers now permit greater precision in detecting CTC dysfunction and tailoring therapy. By combining anatomical precision, mechanistic insight, and multidisciplinary strategies, this review proposes a clinically actionable definition of refractoriness and supports a stepwise, mechanism-based approach to therapy. CTC emerges as a targetable hub for diagnostic and therapeutic strategies in refractory head and neck pain.

Introduction: Disorders of consciousness (DoC) encompass a spectrum of clinical conditions with often indistinct boundaries, making accurate diagnosis and therapeutic decision-making particularly challenging. While advanced imaging techniques such as fMRI and PET reduce misdiagnosis risk, their limited availability in routine clinical settings underscores the need for alternative approaches. This study investigates whether the integration of qualitative and quantitative parameters derived from conventional MRI can improve diagnostic precision and support more accurate deep brain stimulation (DBS) candidate selection in DoC patients.Methods: Fifty consecutive DoC patients underwent comprehensive clinical, neurophysiological, and MRI assessment. Based on an integrated assessment of these findings, patients were classified as DBS candidates or non-candidates. MRI scans were qualitatively assessed for cortical and subcortical atrophy (including diffuse cortical, thalamic, and brainstem degeneration), ventricular enlargement, sulcal widening, leukoaraiosis, corpus callosum damage, gray-white matter border effacement, and extensive lesions (e.g., global ischemia or porencephalic cavities). Quantitative volumetric analysis was performed using the FreeSurfer pipeline.Results: Qualitative features such as leukoaraiosis, thalamic and cortical atrophy, ventricular enlargement, and corpus callosum lesions were significantly associated with DBS candidacy. Quantitative predictors included striatal volume, total gray matter, ventricular volume, CSF, and supratentorial volume. A combined model incorporating both qualitative and quantitative MRI data achieved high predictive accuracy (AUC = 0.88) for DBS candidacy.Conclusion: Integrating conventional MRI-based qualitative and quantitative assessments with clinical and neurophysiological evaluation may substantially improve DBS candidate selection in DoC patients, especially where functional imaging is unavailable. These findings support the development of practical MRI-based decision frameworks and call for multicenter validation. Despite increasing research on imaging and neuromodulation in DoC, studies directly comparing qualitative and quantitative structural MRI in the context of DBS candidacy remain scarce, highlighting a critical gap in the field.

Background: Parkinson’s disease (PD) is a progressive neurodegenerative disorder associated with systemic inflammation, immune dysregulation, and malnutrition, all of which may influence surgical outcomes. Subthalamic nucleus deep brain stimulation (STN DBS) is a widely used treatment for advanced PD, yet postoperative complications remain a concern. This study evaluates the predictive value of preoperative immunonutritional markers—including the Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score, Aggregate Index of Systemic Inflammation (AISI), Lymphocyte-to-Monocyte Ratio (LMR), and systemic inflammatory response syndrome (SIRS)—for the risk of extracranial complications following STN DBS. Methods: A retrospective cohort study was conducted on 138 PD patients who underwent STN DBS. Clinical and laboratory data were analyzed to assess the association between preoperative immunonutritional markers and postoperative complications, including infections, wound healing disturbances, and surgical revisions. Logistic regression and receiver operating characteristic (ROC) analysis were performed to evaluate the predictive power of these markers. Results: SIRS emerged as the strongest predictor of complications (aOR = 6.99, 95% CI = 1.844–26.509), emphasizing the critical role of systemic inflammation in surgical outcomes. HALP, AISI, and LMR also demonstrated significant predictive potential, with HALP (AUC = 0.69) and LMR (AUC = 0.73) being the most robust predictors of complications. While albumin alone was not a significant predictor, it correlated with inflammatory markers and comorbidities, underscoring its role in broader risk assessments. Conclusions: This study underscores the value of preoperative immunonutritional markers in predicting complications following STN DBS in PD patients. Incorporating these markers into clinical risk stratification may enhance preoperative planning and personalized postoperative care, ultimately improving surgical outcomes. These findings, while promising, warrant validation through prospective, multicenter studies to refine predictive models and enhance patient outcomes.

Background: Infratentorial chronic subdural hematoma (cSDH) is still a rather elusive neurosurgical entity, which, due to its proximity and likely compression of the cerebellum and brainstem, can lead to devastating consequences. To establish standardized treatment, more studies and reports regarding its therapy are needed. We report a case of a simultaneous unilateral supratentorial and bilateral infratentorial cSDH, with the latter causing hydrocephalus and successfully treated with a bilateral burr-hole trepanation of occipital bone and placement of subdural drains. Case Description: A 71-year-old man with gait disturbance, Glasgow Coma Scale 12, and a radiologically verified unilateral supratentorial and bilateral cSDH of the posterior fossa causing cerebellum, brainstem, and fourth ventricle compression with obstructive hydrocephalus, underwent surgical evacuation of infratentorial hematoma with a bilateral burr-hole trepanation. The postoperative course was uneventful, with a control head computed tomography scan showing the resolution of the hematoma and hydrocephalus. The patient was discharged with no newly acquired neurological deficits. Conclusion: Due to a limited number of reports and studies involving infratentorial cSDHs causing hydrocephalus, decision-making and optimal surgical treatment remain unclear. We recommend a timely surgical evacuation of the hematoma if the patient is symptomatic while avoiding placement of external ventricular drainage.

Background: Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic tumor, accounting for <1% of astrocytic tumors. Due to its rarity, etiology, natural history, and biologic behavior is not completely explained. We present a case of malignant transformation of a PXA to glioblastoma in pregnant patient 6 month after tumor biopsy. Case Description: A 28-year-old female patient was presented with a newly onset of headache, nausea, and right-sided hemiparesis at 21st week of pregnancy. Magnetic resonance imaging (MRI) revealed cystic mass in the left frontal region. Patient underwent biopsy to confirm pathohistological analysis; the tumor tissue corresponded to an anaplastic PXA. Two weeks after initial biopsy, open surgery along with gross total tumor removal was performed confirming pathohistological analysis. Six months later, after childbirth, and control MRI revealed a recurrent tumor mass: the patient underwent surgical resection and the tumor tissue corresponded to a glioblastoma. The patients were further treated with radiation and chemotherapy according to oncologist. Conclusion: Distinguishing between PXA patients who have a good prognosis and those at risk for early progression is very important for the PXA clinical management. Despite cellular pleomorphism, mitotic index and the extent of resection are shown to be the main predictors for recurrence-free survival and overall survival rates. The standard therapy management is not yet established. Our patient treatment was associated with a significant ethical dilemma. Respecting patient’s wishes to deliver a baby, nor radio or chemo treatments were done. Further studies are necessary to provide factors responsible for malignant transformation of PXA. In addition, in ethically sensitive situation, such as tumor in pregnant patient, good communication, respecting patient’s wishes, and a multidisciplinary teamwork is the key for better outcome.

Background: Epidural motor cortex stimulation (MCS) is an established neuromodulatory option for refractory neuropathic pain; however, structured data on long-term outcomes, stimulation dependency, and real-world device management remain limited, particularly in chronic neuropathic orofacial pain. Methods: This retrospective single-center cohort study included patients with refractory neuropathic orofacial pain treated with epidural MCS at a tertiary neurosurgical center. Clinical data were extracted from medical records and longitudinal follow-up documentation. Pain intensity was assessed using a unified 0–10 numerical rating scale (NRS/VAS) at baseline, best achieved response, and last follow-up. Responder status was defined at the last follow-up (≥50% pain reduction from baseline). Secondary outcomes included stimulation dependency during OFF periods, reprogramming burden, device-related events, and safety. Results: Ten patients (6 women, 4 men; mean age 61.5 ± 8.6 years) were followed for a mean of 7.6 ± 6.3 years (range 2–22 years), with 70% exceeding five years of follow-up. Baseline pain intensity (8.8 ± 0.4) decreased to 4.6 ± 0.8 at the best achieved response and remained lower at last follow-up (5.6 ± 0.9). At the last follow-up, eight patients (80%) were classified as partial responders (30–49% pain reduction), while two (20%) were classified as non-responders. Clinically relevant worsening during stimulator OFF periods occurred in 70% of patients. Reprogramming was required in all patients, and 60% underwent battery replacement. No clinically significant stimulation-related adverse effects were observed. Conclusions: Epidural MCS was associated with sustained pain reduction over extended follow-up. These findings support the interpretation of MCS as a chronic neuromodulatory therapy requiring ongoing stimulation, individualized programming, and long-term device management, contributing clinically relevant long-term evidence to the evolving role of neuromodulation in refractory chronic neuropathic pain.