Locked-in syndrome after traumatic atlantoaxial subluxation: a case report / Síndrome do encarceramento decorrente de subluxação atlantoaxial traumática: relato de caso / Síndrome de enclaustramiento por subluxación atlantoaxoidea traumática: informe de caso

ABSTRACT Traumatic atlanto-axial subluxation is a rare and underdiagnosed condition due to its high rate - reported to be between 60 and 80% - of early mortality. Its diagnosis takes into account the trauma mechanism, precise analyses of the imaging tests and the clinical presentation of the patient. This article describes a rare presentation of atlanto-axial subluxation associated with craniocervical dislocation as a case of locked-in syndrome. Level of evidence V; Retrospective observational study - Case report.

RESUMO Subluxação atlantoaxial traumática é uma condição de diagnóstico raro e subestimado, devido a sua alta taxa - descrita entre 60% e 80% - de mortalidade precoce. Seu diagnóstico leva em conta o mecanismo do trauma, as análises precisas dos exames de imagem e a apresentação clínica do paciente. Este artigo relata um quadro raro de subluxação atlantoaxial associada à luxação craniocervical como um caso de síndrome do encarceramento. Nível de evidência V; Estudo observacional retrospectivo - Relato de caso.

RESUMEN La subluxación atlantoaxoidea traumática es una afección rara y subdiagnosticada debido a su alta tasa - descrita entre el 60 y el 80%-de mortalidad temprana. Su diagnóstico tiene en cuenta el mecanismo del traumatismo, los análisis de imagen precisos y la presentación clínica del paciente. Este artículo informa de una rara condición de subluxación atloaxoidea asociada a una dislocación craniocervical como un caso de síndrome de enclaustramiento. Nivel de evidencia V; Estudio observacional retrospectivo - Informe de caso.

Labiomandibular glossotomy approach for craniocervical pathologies - spine reconstruction / Acesso por glossotomia labiomandibular em patologias craniocervicais - reconstrução da coluna / Acceso por glosotomía labiomandibular en patologías craneocervicales - reconstrucción de la columna

ABSTRACT Objectives: Exposing the clivus and upper cervical spine should, ideally, provide an adequate surgical field in which the surgeon can safely decompress and stabilize the craniovertebral junction (CVJ). We present a series of four cases with a narrative review of the literature in which Median Labiomandibular Glossotomy was used to treat CVJ disorders, in order to highlight the importance and indications of this access. Methods: We performed a retrospective analysis of patients who underwent MLMG for several pathologies. The group comprised four patients (two men and two women). Five approaches were performed (one revision surgery). Results: The approach was suitable for all cases, clivus was achieved when necessary. Distally, C4 was exposed to obtain satisfactory osteosynthesis. Laterally, we had a good view of the tumor borders and control of the vertebral artery. Complications encountered were a superficial wound infection that was easily healed, a later pharyngeal wound dehiscence and pseudoarthrosis, all in the same patient. There are 3 main anterior surgical techniques for managing lesions of the clivus, foramen magnum or upper cervical vertebrae. We chose Median Labiomadibular Glossotomy (MLMG) as a primary option, which provided a direct view of the clivus, C3 - C4 caudally and a wider surgical field. The main advantages of the MLMG technique include direct access to spinal pathology, an avascular plane through the median pharyngeal raphe, and a wider surgical field in both the transverse and sagittal dimensions. Conclusion: This approach provides excellent exposure of the craniocervical junction and upper cervical spine. Level of evidence IV; Series of cases analyzed retrospectively.

RESUMO Objetivos: A exposição do clivo e da coluna cervical alta deve, de modo ideal, proporcionar um campo cirúrgico adequado, no qual o cirurgião possa descomprimir e estabilizar a junção craniovertebral (JCV) com segurança. Apresentamos uma série de quatro casos, com revisão narrativa da literatura, nos quais a glossotomia labiomandibular mediana foi utilizada para tratamento de afecções da JCV, com o objetivo de destacar a importância e as indicações desse acesso. Métodos: Foi realizada uma análise retrospectiva dos pacientes submetidos a GLMM para diversas patologias. O grupo foi composto por quatro pacientes (dois homens e duas mulheres). Cinco abordagens/procedimentos<??> foram realizados (uma cirurgia de revisão). Resultados: O método/via de acesso/técnica foi adequado para todos os casos e o clivo foi alcançado quando necessário. Distalmente, C4 foi exposta para obter a osteossíntese satisfatória. Lateralmente, obteve-se boa visão das margens tumorais e controle da artéria vertebral. As complicações encontradas foram infecção superficial da ferida, com fácil cicatrização, deiscência tardia da parede posterior da faringe e pseudoartrose, todas no mesmo paciente. Existem três técnicas cirúrgicas principais com acesso anterior para o tratamento de lesões do clivo, forame magno ou vértebras cervicais superiores. Escolhemos a glossotomia labiomadibular mediana (GLMM) como opção primária, que proporcionou uma visão direta do clivo, de C3-C4 caudalmente e campo cirúrgico mais amplo. As principais vantagens da GLMM incluem acesso direto à patologia espinhal, plano avascular através da parte mediana da rafe da faringe e um campo cirúrgico ampliado nas dimensões transversa e sagital. Conclusões: Esta abordagem proporciona excelente exposição da junção craniocervical e da coluna cervical alta. Nível de evidência IV; Série de casos analisados retrospectivamente.

RESUMEN Objetivos: La exposición del clivus y de la columna cervical alta debe, de modo ideal, proporcionar un campo quirúrgico adecuado, en que el cirujano pueda descomprimir y estabilizar de manera segura la unión craneovertebral (UCV). Presentamos una serie de cuatro casos con revisión narrativa de la literatura, en los que se utilizó la glosotomía labiomandibular mediana para el tratamiento de afecciones de la UCV, con el objetivo de destacar la importancia y las indicaciones de ese acceso. Métodos: Se realizó un análisis retrospectivo de los pacientes sometidos a GLMM para diversas patologías. El grupo fue compuesto por cuatro pacientes (dos hombres y dos mujeres). Fueron realizados cinco abordajes/procedimientos (una cirugía de revisión). Resultados: El método/vía de acceso/técnica fue adecuado para todos los casos y el clivus fue alcanzado cuando fue necesario. Distalmente, C4 fue expuesta para obtener la osteosíntesis satisfactoria. Lateralmente, se obtuvo buena visión de los márgenes tumorales y control de la arteria vertebral. Las complicaciones encontradas fueron infección superficial de la herida, con fácil cicatrización, dehiscencia tardía de la pared posterior de la faringe y pseudoartrosis, todas en el mismo paciente. Existen tres técnicas quirúrgicas principales con acceso anterior para el tratamiento de lesiones del clivus, foramen magno o vértebras cervicales superiores. Elegimos la glosotomía labiomandibular mediana (GLMM) como opción primaria, que proporcionó una visión directa del clivus, C3-C4 caudalmente y campo quirúrgico más amplio. Las principales ventajas de la GLMM incluyen acceso directo a la patología espinal, plano avascular a través de la parte mediana del rafe de la faringe y un campo quirúrgico ampliado en las dimensiones transversa y sagital. Conclusiones: Este abordaje proporciona excelente exposición de la unión craneocervical y de la columna cervical alta. Nivel de evidencia IV; Serie de casos analizados retrospectivamente.

Patterns of injury at an Ethiopian referral hospital: Using an institutional trauma registry to inform injury prevention and systems strengthening

Background: Data about injury patterns and clinical outcomes are essential to address the burden of injury in low- and middle-income countries. Institutional trauma registries (ITRs) are a key tool for collecting epidemiologic data about injury. This study uses ITR data to describe the demographics and patterns of injury of trauma patients in Addis Ababa, Ethiopia in order to identify opportunities for injury prevention, systems strengthening and further research. Methods: This is an analysis of prospectively collected data from a sustainable ITR at Menelik II Specialized Hospital, a public teaching hospital with trauma expertise. All patients presenting to the hospital with serious injuries requiring intervention or admission over a 13 month period were included. Univariable and bivariable analyses were performed for patient demographics and injury characteristics. Results: A total of 854 patients with serious injuries were treated during the study period. Median age was 33 years and 74% were male. The most common mechanisms of injury were road traffic injuries (RTI) (37%), falls (30%) and blunt assault (17%). Over half of RTI victims were pedestrians. Median delay in presentation was 2 h; 17% of patients presented over 6 h after injury. 58% of patients were referred from another hospital or a clinic, and referrals accounted for 84% of patients arriving by ambulance. Median emergency center length of stay was 2 h and 62% of patients were discharged from the emergency center. Conclusion: This study highlights the utility of institutional trauma registries in collecting crucial injury surveillance data. In Addis Ababa, road safety is an important target for injury prevention. Our findings suggest that the most severely injured patients may not be making it to the referral centers with the capacity to treat their injuries, thus efforts to improve prehospital care and triage are needed. African relevance: Injury is a public health priority in Africa. Institutional trauma registries play a crucial role in efforts to improve trauma care by describing injury epidemiology to identify targets for injury prevention and systems strengthening efforts. In our context, pedestrian safety is a key target for injury prevention. Improving prehospital care and developing referral networks are goals for systems strengthening

Aerobic exercise combined with huwentoxin-I upregulates phase-Ⅱ detoxification enzymes to alleviate obstructive jaundice-induced central nervous system injury in mice / 南方医科大学学报

OBJECTIVE@#To explore the effects of aerobic exercise combined with huwentoxin-I (HWTX-I)-mediated Keap1-Nrf2-ARE pathway on phase II detoxification enzymes HO-1 and NQO1 and their protective effects against obstructive jaundice (OJ)-induced central nervous system injury in mice.@*METHODS@#50 male KM mice were randomly divided into blank group (GO), model group (M), aerobic exercise group (T), HWTX-I group (H), and aerobic exercise combined with HWTX-I group (TH). Mouse models of OJ were established with surgical suture for 72 h in the mice in all the groups except for the blank control group. The mice received interventions by aerobic exercise and tail vein injection of HWTX-I (0.05 μg/g) and were assessed by behavioral observation, Clark's neurological function scores, enzyme-linked immunosorbent assay (ELISA), brain tissue Nissl staining, hippocampal tissue Western blotting, and liver tissue mRNA expression profiling and sequencing.@*RESULTS@#The mice in group M had obvious jaundice symptoms after the operation with significantly increased Clark's neurological score ( < 0.01). Compared with those in group M, the mice in group T, group H, and group TH showed significantly decreased serum levels of ALT, AST, TBIL, and TBA ( < 0.01) with increased contents of 5-HT and BDNF and decreased contents of S100B and NSE in the hippocampus ( < 0.01). Synergistic effects between aerobic exercise and HWTX-I were noted on the above parameters except for the liver function indicators. Interventions with aerobic exercise and HWTX-I, alone or in combination, obviously lessened pathologies in the brain tissue induced by OJ, and the combined treatment produced the strongest effect. The treatment also increased the expression levels of Nrf2, HO-1, and NQO1 mRNA and protein in brain tissues ( < 0.01 or 0.05) with a synergistic effect between aerobic exercise and HWTX-I. Illumina high-throughput sequencing showed that the differentially expressed factors participated mainly in such neural regulatory pathways as neuroactive ligand-receptor interaction, GABAergic synapses, dopaminergic synapses, synaptic vesicle circulation, and axon guidance, involving tissue cell neuronal signal transduction, apoptosis inhibition, immune response, and toxicity. Aerobic exercise and HWTX-I synergistically increased the accumulation of the signal pathways related with neuron damage repair and proliferation.@*CONCLUSIONS@#Aerobic exercise combined with HWTX-I can up-regulate the expression of phase Ⅱ detoxification enzymes HO-1 and NQO1 through the Keap1-Nrf2-ARE pathway to protect the central nervous system against OJ-induced damage in mice.

Disorders of Consciousness: Practical Management in an Emergency Room

Lowering of the level of consciousness is a very common presentation at the emergency room, often without any history that helps finding an etiology. This emergency requires quick empirical measures to reduce neuronal mortality, with additional protection against sequelae. According to the Advanced Cardiac Life Support (ACLS) guidelines, there are current emergency neurological support protocols, such as the Emergency Neurological Life Support (ENLS) created by the Neurocritical Care Society. The present paper shows how to approach unconscious patients, highlighting possible etiologies and proposed treatments.

Prevalencia y factores asociados a las lesiones en los nervios alveolar inferior y lingual después de la exodoncia de terceros molares inferiores: Estudio retrospectivo / Prevalence and associated factors of inferior alveolar and lingual nerves injuries after lower third molars extractions: Retrospective study / Prevalência e fatores associados às lesões nos nervos alveolar inferior e lingual após a exodontia de terceiros molares inferiores: Estudo retrospectivo

Dentro de los tratamientos realizados en cirugía oral, la extracción de los terceros molares es la más frecuente y puede ocasionar lesiones nerviosas. Objetivo: Determinar la prevalencia y los factores asociados a las lesiones en los nervios alveolar inferior y lingual después de la extracción de terceros molares inferiores. Materiales y métodos: la muestra fue de 609 prontuarios analizados durante los años 2011-2016 en el Hospital Carlos Andrade Marín de la ciudad de Quito, Ecuador. Fueron consideradas como variables: sexo, edad, posición y profundidad del tercer molar (Pell y Gregory), la inclinación (Winter) y la relación radiográfica con el canal mandibular (Rood y Shehab). Los datos obtenidos fueron pro-cesados utilizando la prueba estadística de Chi-cuadrado con un nivel de significancia de 5%. Resultados: Presentaron lesiones nerviosas el 2,46% de los pacientes atendidos, correspondiendo al 1,64% y 0,82% a los nervios alveolar inferior y lingual respectivamente. La lesión del nervio alveolar inferior está asociado al sexo femenino (p= 0.032) y con la clase III (p= 0.010), mientras que las lesiones del nervio lingual estaban asociadas a la clase I (p= 0.004) y tipo A (p= 0.001). Radio-gráficamente la lesión del nervio alveolar está asociada en el 46,67% con la interrupción de la línea del canal mandibular (p= 0.010). Conclusión: La prevalencia de las lesiones en los nervios alveolar inferior y lingual posterior a la exodoncia del tercer molar inferior en pacientes ecuatorianos es baja, cuidados preoperatorios son importantes para evitar complicaciones postquirúrgicas.

Among the treatments performed in oral surgery, the third molars extraction is the most frequent and may cause nerve in-juries. Objective: To determine the prevalence and associated factors of inferior alveolar and lingual nerves injuries after inferior third molars extractions. Materials and methods: the sample was composed by of 609 records attended during the years 2011-2016 in the Carlos Andrade Marín Hospital in the city of Quito, Ecuador. The following variables were as-sessed: sex, age, position and depth of the third molar (Pell & Gregory), inclination (Winter) and radiographic relationship with the mandibular canal (Rood & Shehab). Data obtained were processed througth the Chi-square test with a significance level of 5%. Results: of all patients attended, 2.46% presented nerves injuries, corresponding to 1.64% and 0.82% to the inferior alveolar and lingual nerves respectively. The inferior alveolar nerve injury is associated with the female sex (p = 0.032) and with the class III (p = 0.010), while the lingual nerve lesions were associated with class I (p = 0.004) and type A (p = 0.001). Radiographically, the alveolar nerve injury is associated in 46.67% with the interruption of the mandibular canal line (p = 0.010). Conclusion: The prevalence of injuries in the inferior alveolar and lingual nerves after lower third molar extractions in Ecuadorian patients is low; preoperative care is important to avoid postoperative complications.

Dentre os tratamentos realizados na cirurgia bucal, a extração dos terceiros molares é a mais frequente e pode causar lesões nervosas. Objetivo: Determinar a prevalência e os fatores associados às lesões nos nervos alveolar inferior e lingual após a extração de terceiros molares inferiores. Materiais e métodos: a amostra foi de 609 prontuários analisados durante os anos de 2011 a 2016 no Hospital Carlos Andrade Marín, na cidade de Quito, Equador. Foram consideradas as seguintes variáveis: sexo, idade, posição e profundidade do terceiro molar (Pell e Gregory), inclinação (Winter) e relação radiográfica com o canal mandibular (Rood e Shehab). Os dados obtidos foram processados pelo teste estatístico Qui-quadrado com nível de significância de 5%. Resultados: Apresentaram lesões nervosas 2,46% dos pacientes atendidos, correspondendo a 1,64% e 0,82% dos nervos alveolar inferior e lingual respectivamente. A lesão do nervo alveolar inferior está associada ao sexo feminino (p = 0.032) e à classe III (p = 0.010), enquanto as lesões do nervo lingual foram associadas à classe I (p = 0.004) e tipo A (p = 0.001). Radiograficamente, a lesão do nervo alveolar está associada em 46,67% com a interrupção da linha do canal mandibular (p = 0.010). Conclusão: A prevalência de lesões nos nervos alveolar inferior e lingual após a extração do terceiro molar inferior em pacientes equatorianos é baixa; cuidados pré-operatórios são importantes para evitar complicações pós-operatórias.

Unión cráneo-cervical - anatomía normal y correlación con imágenes / Cranio Cervical Junction - Anatomy and Imaging Correlation

La solicitud de estudios de imagen en pacientes con trauma cervical es muy frecuente en la práctica diaria. Esa patología es causa relativamente frecuente de discapacidad en pacientes jóvenes junto con el trauma encéfalo craneano. En un porcentaje no despreciable de los casos, las lesiones traumáticas comprometen la unión cráneo- cervical y en esos pacientes, la morbi-mortalidad es más significativa. La transición entre el cráneo y el raquis se basa en un conjunto de estructuras óseas relacionadas por articulaciones muy móviles y estabilizadas por un grupo de ligamentos y músculos que le brindan al mismo tiempo gran solidez. Para una correcta interpretación de los estudios de imagen de uso corriente en la clínica, es fundamental un sólido conocimiento anatómico de la unión cráneo-cervical y sus componentes. Es el objetivo de esta revisión, sistematizar la anatomía de la unión cráneo-cervical con especial énfasis en sus ligamentos, analizar la fisiología de sus movimientos y el concepto de estabilidad para luego realizar una correlación con tomografía computada multi-detector y resonancia magnética.

The request of imaging techniques in patients with cervical spine trauma is very common in clinical practice. Cervical trauma is a relatively common cause of disability in young patients. In a significant percentage of cases traumatic injuries compromise the cranio-cervical junction with more important morbidity and mortality in this group of patients. The transition between the skull and the spine is based on a set of bony structures, high mobility joints, and stabilization mechanism formed by a group of ligaments and muscles. A solid anatomical knowledge of the cranio-cervical junction and its components is essential for a correct interpretation of current high resolution imaging studies. The goal of this review is highlight the anatomy of the cranio-cervical junction with special emphasis on the ligaments, analyze the biomechanics of their movements and the concept of stability. At last but not leastwe will establish a correlation with multidetector computed tomography and high-resolutionmagnetic resonance imaging.

Multiple vertebral fractures at the "dr. manuel dufoo" spine clinic / Fraturas vertebrais múltiplas na clínica de coluna "dr. manuel dufoo" / Fracturas vertebrales múltiples en la clínica de columna "dr. manuel dufoo"

ABSTRACT Objective: To establish the frequency of presentation of multiple vertebral fractures and evaluate the relationship between the postsurgical condition and the initial neurological lesion, as well as to report the associated injuries in this group of patients. Methods: We conducted a review of patients with spinal trauma and a diagnosis of multiple vertebral fractures who were admitted to the "Dr. Manuel Dufoo Olvera" Spine Clinic of the Secretary of Health of Mexico City from January 1,2014 to June 30, 2017. The multiple fractures were classified as either contiguous or non-contiguous, according to the number of vertebral bodies and levels affected. The statistical analysis was conducted using formulas of descriptive statistics and the information was then tabulated and graphed to assess the relationship between the anatomical classification and the degree of neurological injury. Results: We observed 530 patients, of whom 47 met the criteria. Thirty-one (65.95%) of the cases corresponded to contiguous fractures and 16 cases (34.05%) to non-contiguous fractures. Fourteen patients (29.78%) with neurological integrity were classified as ASIA D, 20 patients (42.58%) with complete lesion as ASIA A, 7 seven patients (14.89%) as ASIA B, and 6 patients (12.76%) with partial injury as ASIA C. Conclusions: The correlation between the classification of vertebral injuries and the presence of neurological lesion did not show significant differences between contiguous and non-contiguous fractures. Level of Evidence II; Retrospective.

RESUMO Objetivos: Estabelecer a frequência de apresentação de múltiplas fraturas vertebrais e avaliar a relação de sua condição pós-cirúrgica e a lesão neurológica inicial, bem como relatar as lesões associadas neste grupo de pacientes. Métodos: Uma revisão dos casos com traumatismo espinhal e diagnóstico de fratura vertebral múltipla, que entraram no Spine Clinic " Dr Manuel Dufoo Olvera " Secretário da Cidade do México saúde da coluna vertebral, durante o período de 1 de janeiro de 2014 a 30 de Junho de 2017. A classificação divide fraturas múltiplas como contíguas e não contíguas, seguido pelo número de pessoas afetadas e os corpos de nível. A análise estatística foi realizada utilizando fórmulas statística descritivas, então tabuladas e as informações representadas graficamente. Para avaliar a relação entre a classificação anatômica e do grau de lesão neurológica. Resultados: 530 Pacientes foram observados, dos quais 47 apresentaram os critérios necessários. 31 pacientes (65,95%) do estudo foram classificados com fraturas adjacentes contíguas e 16 casos (34,05%) como não contíguas. 14 doentes (29,78%) foram classificados com integridade neurológica ÁSIA D, 20 doentes (42,58%) apresentaram lesão completa ÁSIA A, sete doentes (14,89%) na ASIA B e seis doentes. (12,76%) com lesão incompleta ÁSIA C. Conclusão: A correlação entre a classificação das lesões da coluna vertebral e a presença de lesão neurológica não mostraram diferenças significativas entre fraturas adjacentes e não adjacentes. Nível de Evidência II; Restrospectivo.

RESUMEN Objetivo: Establecer la frecuencia de presentación de las fracturas vertebrales múltiples y evaluar la relación de su condición postquirúrgica y la lesión neurológica inicial, así como relatar las lesiones asociadas en este grupo de pacientes. Métodos: Se realiza una revisión de los casos con traumatismo raquimedular y diagnóstico de fractura vertebral múltiple que ingresaron a la Clínica de Columna "Dr. Manuel Dufoo Olvera" de la Secretaría de Salud de Ciudad de México del 1° de enero de 2014 al 30 de junio del 2017. La clasificación divide las fracturas múltiples como contiguas y no contiguas, acorde al número de cuerpos afectados y el nivel.. El análisis estadístico se realizó utilizando fórmulas de estadística descriptiva, para después tabular y graficar la información, para evaluar la relación entre la clasificación anatómica y el grado de lesión neurológica. Resultados: Fueron observados 530 pacientes, de los cuales 47 presentaron los criterios necesarios. Treinta y un pacientes (65,95%) del estudio fueron clasificados con fracturas contiguas y 16 casos (34,05%) con no contiguas. Catorce pacientes (29,78%) fueron clasificados con integridad neurológica ASIA D, 20 pacientes (42,58%) presentaron lesión completa ASIA A, siete pacientes (14,89%) en ASIA B y seis pacientes (12,76%) con lesión incompleta ASIA C. Conclusiones: La correlación entre la clasificación de lesión de columna vertebral y la presencia de lesión neurológica no mostró diferencias significativas entre fracturas contiguas y no contiguas. Nivel de Evidencia II; Retrospectivo.

Síndrome de Brown Sequard em associação à síndrome de Horner / Brown Sequard Syndrome In Association With Horner Syndrome

O trauma raquimedular (TRM) é uma importante causa de incapacidade, sendo constatado uma incidência média de 21 pacientes por milhão de habitantes por ano por uma revisão sistemática realizada nas cinco regiões do pais em. Em Belo Horizonte essa incidência chegou a 26 pacientes por milhão por ano. Trata-se de AFC, 28 anos, que foi encaminhado com urgência para o Hospital João XXIII com história de agressão por arma branca (um facão) na região supra clavicular esquerda no dia 22/10. Ao exame neurológico o paciente encontrava-se consciente, orientado e com hemiplegia á esquerda. Anestesia tátil e vibratória á esquerda (lesão do trato corticoespinhal e fascículo grácil e cuneiforme) e preservada á direita, além de anestesia térmica/dolorosa contralateral a hemissecção (lesão do trato espinotalâmico), que configuram a síndrome de Brown Sequard completa. Foi realizada tomografia computadorizada da coluna que evidenciou fratura de lâmina de T1. A ferida lacerante foi suturada e paciente manteve quadro estável por 5 dias. Após 7 dias da admissão hospitalar constatou-se anisocoria com pupila miótica à esquerda e ptose de pálpebra também a esquerda, que configura a síndrome de Horner concomitantemente. Foi realizada punção lombar constatando liquor hemorrágico e com alta celularidade, iniciado antibioticoterapia com Meropenem e Vancomicina. Relata-se a correlação anátomoclínica de paciente vitima de TRM aberto, com síndromes associadas, de hemissecção medular e Horner. Ressalta-se a importância dos conhecimentos em neuroanatomia. (AU)

Spinal cord trauma is an important cause of disability, with an average incidence of 21 patients per million inhabitants per year by a systematic review in the five regions of Brazil. In Belo Horizonte, this incidence reached 26 patients per million per year. This is the AFC, 28 years old, who was referred urgently to the Hospital João XXIII with a history of white-collar aggression (a machete) in the left supraclavicular region on 22/10. At the neurological examination the patient was conscious, oriented and with left hemiplegia. Tactile and vibratory anesthesia to the left (lesion of the corticospinal tract and gracile and cuneiform fasciculus) and preserved to the right, in addition to thermal / painful anesthesia contralateral to the hemisection (lesion of the spinothalamic tract), which constitute the complete Brown Sequard syndrome. Computed tomography of the spine was performed, showing a T1 fracture. The lacerating wound was sutured and patient maintained stable frame for 5 days. After 7 days of hospital admission, anisocoria was observed with miotic pupil on the left and ptosis of the eyelid also on the left, which configures Horner syndrome concomitantly. A lumbar puncture was performed, confirming hemorrhagic and high cellularity, and antibiotic therapy with Meropenem and Vancomycin. The anatomic-clinical correlation of a patient with open MTR with associated syndromes of medullary and Horner hemisection is reported. The importance of knowledge in neuroanatomy is emphasized. (AU)

O uso da ETCC associado ao treino motor de membros inferiores na neurologia: revisão sistemática da literatura / The use of transcranial direct current stimulation combined with lower limb motor training in neurology: A systematic review of the literature

Introdução: A estimulação Transcraniana por corrente contínua (ETCC) é uma técnica neuromodulatória que pode alterar um padrão de excitabilidade mal adaptativo frente á uma lesão neurológica. Seu uso combinado com o treino motor vem sendo amplamente discutido na literatura. Objetivo: realizar uma revisão de estudos que utilizaram a ETCC combinada com treinos físicos de membros inferiores para melhora da marcha, equilíbrio e controle postural de pacientes neurológicos. Método: Foi realizada uma revisão bibliográfica nas bases de dados: Medline, Lilacs, Embase, Physiotherapy Evidence Database, Cochrane databases, Cinahl, Scielo e PubMed.Os artigos utilizados nesta revisão foram pontuados e qualificados através da escala Physiotherapy Evidence Database. Resultados:Foram incluídos no estudo 9 artigos combinando o uso da ETCC a treinos motores de membros inferiores. Conclusão: Os resultados dos estudos mostram que embora ainda não exista uma padronização dos parâmetros ideais de utilização da ETCC, sugerimos que seu uso combinado com treino motor pode potencializar os efeitos funcionais da terapia.

Background: Transcranial direct current stimulation (tDCS) is a neuromodulatory stimulation technique that can modulate a maladaptive excitation pattern against neurological injury. The combined use of this technique with physical rehabilitation has been widely discussed in the literature. Objective: To conduct a review of studies that employed the tDCS combined with lower limb training to improve gait, balance and postural control in neurological patients. Methods: A bibliographic review was performed in the databases: Medline, Lilacs, Embase, Physiotherapy Evidence Database, Cochrane databases, Cinahl, Scielo and PubMed.Selected articles were scored and qualified based on the Physiotherapy Evidence Database scale. Results: Nine studies involving the combination of tDCS and lower limb motor training for individuals with neurological problems were included. Conclusion: Despite being widely studied scientifically, no general consensus is yet found in the literature regarding the ideal tDCS administration parameters, we suggest that the combined use with motor training may potentiate the functional effects of therapy.

Complex regional pain syndrome: new concepts regarding diagnosis and treatment

Antecedentes: Los autores presentan una revisión crítica sobre el cuadro clínico, el diagnóstico, clasificación y tratamientodel síndrome de dolor regional complejo, discutiendo todos los métodos de tratamiento y haciendo hincapié en que la reabilitación debe ser empleada con el fin de obtener un mejor resultado. Aspecto psicológico debe ser discutido en el tratamiento y también se anima equipo multidisciplinario para participar en él.

Background: The authors presented a critical review about the clinical picture, diagnosis, classification and treatment ofcomplex regional pain syndrome, discussing all methods of treatment and emphasizing that the reabiltation must be employed in order to obtain a better result. Psychological aspect must be involved in the treatment and also multidisciplinary team is encouraged to take part on it.

Ação do exercício de subida em escada com sobrecarga na morfologia do músculo tibial anterior de ratos Wistars após axonotmese / Action of the climbing ladder exercise with overload in the morphology of the anterior tibial muscle of wistars rats after axonotmesis

Objetivo: avaliar histomorfometrica e morfologicamente o músculo tibial anterior de ratos submetidos à axonotmese e tratados com exercício. Métodos: foram randomizados 28 ratos Wistar nos grupos controle (GC), exercício (GE), lesão (GL) e lesão+exercício (GLE). No terceiro dia após compressão, GE e GLE realizaram exercício de subida em escada, com duas séries de dez repetições. Após 21 dias, o músculo tibial anterior foi processado para microscopia de luz. Resultados: Na análise morfológica GC apresentou morfologia com aspecto característico, GE hipertrofia muscular, GL alterações morfológicas, como fibras polimórficas e núcleos centrais, e GLE aspecto semelhante ao controle, porém com algumas alterações. Na área de secção transversa e menor diâmetro das fibras GC e GE apresentaram valores maiores, o inverso da análise de vasos sanguíneos. Para o tecido conjuntivo, GE apresentou-se menor que o GL. Conclusão: O protocolo de exercício promoveu melhora nos aspectos histomorfológicos, mas não reverteu totalmente os efeitos deletérios. (AU)

Objective: to evaluate morphologically the tibialis anterior muscle of rats submitted to axonotmosis and treated with exercise. Methods: 28 Wistar rats were used in groups control (CG), exercise (GE), injury (GL) and injury + exercise (GLE). On the third day after compression, GE and GLE performed climb exercise staircase, with two sets of ten repetitions. After 21 days, the muscle was processed for light microscopy. Results: In the morphological analysis GC presented with morphology characteristic appearance, GE muscle hypertrophy, GL morphological changes like polymorphic fibers and central nucleo, and GLE look similar to the control, but with some changes morphological. In the cross-sectional area and smaller diameter of the GC and GE fiber showed higher values, inversed analysis of blood vessels. For the connective tissue, GE was lower than the GL. Conclusion: Summing up, the exercise promoted improvement in morphological aspects, but not totally reversed the deleterious effects of denervation. (AU)

Management of a Complex Basilar Invagination Case with Multiple Revision Surgeries ­ Case Report

We describe a Basilar Invagination (BI) case with craniocervical instability and many previous failure surgeries and poor wound coverage. The patient had been submitted to a large posterior fossa craniectomy (which greatly limited the availability of an adequate area for bone fixation) and showed a poor quality of the surgical wound in the posterior craniocervical region. We performed an occipito-cervical fixation, using the bone overlying the torculla as a point of cranial fixation. Craniocervical realignment was achieved by the use of distractive maneuvers with occipital rods, followed by coverage of the hardware via a pedicled longitudinal trapeze myocutaneous flap. We used local ribs removed from the region where the myocutaneous flap was harvested as autologous bone grafts for craniocervical fusion. Post-operatively, the patient was placed in a halo-vest for three months. The patient improved substantially after the procedure, recovered some muscular strength and experienced total relief of her pain. We hereby discuss the surgical strategy used for treating this complex case in details, with illustrative pictures.

Descrevemos caso de paciente com diagnóstico de invaginação basilar e instabilidade crânio cervical com múltiplas cirurgias prévias e deiscência de ferida operatória. Devido a falha de osso na escama occipital, assim como da cobertura cutânea adequada, realizamos realinhamento craniocervical, com descompressão indireta anterior, fixação occipitocervical na região da tórcula e cobertura da pele com flap miocutâneo longitudinal pediculado de trapézio. As costelas removidas da região do retalho miocutâneo foram transferidas para serem usadas como enxerto autólogo de osso para fusão craniocervical. No pós-operatório, a paciente utilizou um halo-vest por 3 meses. No presente artigo, apresentamos nuances ilustrados de manobras para realinhamento craniocervical por via posterior na invaginação basilar, bem como estratégias para otimizar a artrodese e o fechamento cutâneo.

Isolation and Characterization of Human Chorionic Membranes Mesenchymal Stem Cells and Their Neural Differentiation

Mesenchymal stem cells (MSCs) can be obtained from a variety of human tissues. Placenta has become an attractive stem cell source for potential applications in regenerative medicine and tissue engineering. The aim of this study was to localize and characterize MSCs within human chorionic membranes (hCMSCs). For this purpose, immunofluorescence labeling with CD105 and CD90 were used to determine the distribution of MSCs in chorionic membranes tissue. A medium supplemented with a synthetic serum and various concentrations of neurotrophic factors and cytokines was used to induce hCMSCs to neural cells. The results showed that the CD90 positive cells were scattered in the chorionic membranes tissue, and the CD105 positive cells were mostly located around the small blood vessels. hCMSCs expressed typical mesenchymal markers (CD73, CD90, CD105, CD44 and CD166) but not hematopoietic markers (CD45, CD34) and HLA-DR. hCMSCs differentiated into adipocytes, osteocytes, chondrocytes, and neuronal cells, as revealed by morphological changes, cell staining, immunofluorescence analyses, and RT-PCR showing the tissue-specific gene presence for differentiated cell lineages after the treatment with induce medium. Human chorionic membranes may be the source of MSCs for treatment of nervous system injury.

Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction / Análise retrospectiva de série de casos com lesões traumáticas da junção craniocervical

ABSTRACT Objective To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction. Methods This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets. Results We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration. Conclusion Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries.

RESUMO Objetivo Avaliar a correlação entre o tratamento, as características das lesões e o resultado clínico em pacientes com lesões traumáticas na junção craniocervical. Métodos Estudo retrospectivo de pacientes maiores de 18 anos tratados de forma conservadora ou cirúrgica, entre 2010 e 2013. Resultados Foram analisados 37 pacientes, 73% eram do sexo masculino e a média de idade foi de 41,7 anos. Inicialmente 32% dos pacientes foram submetidos a tratamento cirúrgico, e 68% foram submetidos a tratamento conservador. Sete pacientes (29%) do grupo conservador foram submetidos posteriormente à cirurgia. No grupo cirúrgico, houve sete casos de fratura de odontóide tipo II, dois casos de fratura de elementos posteriores do áxis, um caso de luxação C1-C2, um caso de deslocamento occipito-cervical e um caso de fraturas de C1 e C2 e luxação facetária. Um paciente apresentava déficit neurológico, melhorando após o tratamento. Houve duas complicações pós-cirúrgicas, uma fístula liquórica e uma infecção de ferida operatória (reabordada). No grupo conservador, predominaram as fraturas do odontóide (oito) e dos elementos posteriores de C2 (cinco). Em dois casos, havia também fraturas em outros segmentos da coluna. Nenhum dos pacientes deste grupo apresentou deterioração neurológica. Conclusão As lesões da junção craniocervical são raras, sendo mais frequentes as fraturas do odontóide e dos elementos posteriores do áxis. Nossos resultados recomendam o tratamento cirúrgico precoce para os pacientes com fraturas do odontóide tipo II e lesões ligamentares, e tratamento conservador para os demais pacientes.

Alta hospitalar de clientes com lesão neurológica incapacitante: impreteríveis encaminhamentos para reabilitação / Hospital discharge of patients with disabling neurological injury: necessary referrals to rehabilitation

Resumo Trata-se de pesquisa de abordagem qualitativa realizada no segundo semestre de 2014, mediante entrevistas com 12 médicos e 13 enfermeiros gestores atuantes em Hospital de grande porte, referência na área de urgência e emergência para a Zona da Mata Mineira. Buscou identificar os critérios utilizados por médicos e enfermeiros para o preparo da alta de pessoas com lesão neurológica incapacitante e indicação para acesso a programa de reabilitação física. Para o tratamento dos dados, utilizou-se a técnica de Análise de Conteúdo, modalidade temática. Os resultados mostram que os gestores hospitalares ainda encontram dificuldades para proceder ao encaminhamento adequado dessas pessoas para serviços especializados de reabilitação, o que compromete a autonomia e independência para o autocuidado. Conclui-se que os gestores além de envolver cuidadores e familiares no preparo da alta de pessoas com lesão neurológica que resulta em incapacidades para o autocuidado, deveriam avaliar as condições de acessibilidade em seus domicílios e fazer encaminhamentos adequados para serviços de reabilitação disponíveis na comunidade, a despeito da pouca divulgação acerca dos fluxos da Rede de Cuidados da Pessoa com Deficiência.

Abstract The present qualitative study was conducted in the second semester of 2014 via interviews with 12 doctors and 13 nurses working as managers at a large hospital that serves as a reference center for urgent and emergent care in the Zona da Mata region of Minas Gerais State, Brazil. The study sought to identify the criteria that doctors and nurses use to discharge individuals with disabling neurological injury with instructions related to accessing physical rehabilitation programs. Thematic content analysis was used to examine data. The results show that the participating hospital managers still have difficulties providing adequate referrals to specialized rehabilitation services and that their patients’ autonomy and independence for self-care are impaired as a result. We concluded that in addition to involving relatives and other caregivers in the discharge of patients with a neurological injury that impairs their self-care abilities, managers should assess the accessibility of the patient’s home and make adequate referrals to rehabilitation services in the community in light of the poor dispersal of information about what is available within the Care for People with Disability Network.

Resultados del tratamiento kinésico en un paciente con diagnóstico de neuropraxia ­ axonotmesis del plexo braquial / Results of kinesic treatment in a patient with diagnosis of neuropraxia - brachial plexus axonotmesis

Se presenta el caso de un paciente de 71 años, de sexo masculino, con diagnóstico médico de neuropraxia-axonotmesis del plexo braquial como producto de una luxación de hombro. Presentaba el brazo izquierdo pléjico luego de la reducción. Ingresó al Servicio Universitario de Kinesiología y realizó 60 sesiones de tratamiento kinésico basado en electroestimulación muscular selectiva con corriente exponencial y rectangular, asociada a ejercicios de reeducación muscular. Mediante la electroestimulación se logró prevenir la atrofia muscular, lo cual permitió desarrollar posteriormente trofismo y fuerza muscular. El paciente recuperó las funciones musculares que le permitieron realizar sus actividades de la vida diaria de manera autónoma. Este caso pertenece a un ensayo clínico controlado aprobado por el Comité de Bioética de la Facultad de Medicina

Regenerative capacity and histomorphometric changes in rat sciatic nerve following experimental neurotmesis / Capacidad regenerativa y cambios histomorfométricos en el nervio ciático de ratas luego de una neurotmesis experimental

Through a wide range of cellular and molecular events, the peripheral nervous system is endowed with great regenerative capacity, responding immediately to injuries that occur along the length of the nerve. The aim of this study was to histomorphometrically assess the degree of maturity of the nervous tissue and possible microscopic changes in newly formed nerve segments 60 days after experimental neurotmesis of the sciatic nerve in rats. Control Group (CG) and an Injury Group (IG) were used. IG underwent neurotmesis of the sciatic nerve of the right foot, with immediate surgical repair using the tubulization technique. 60 days following experimental surgery, animals from both groups had their sciatic nerves collected for histomorphometric analysis. Statistical analysis was performed, using the Student t-test for independent samples, expressed as mean ± standard deviation, with 5% significance. In the event of injury, peripheral nerve tissue is mobilized in an intrinsic self-healing process. 60 days following of nerve regeneration in neurotmesis injury, the peripheral nerve presents a segment joining the newly formed neural stump. The new stump has a number of regenerated axons compatible with an intact nerve, but which still show great immaturity in the axonal structural layers of the nerve.

Mediante diversos procesos celulares y moleculares, el sistema nervioso periférico tiene una gran capacidad regenerativa, respondiendo inmediatamente a las lesiones ocurridas a lo largo de su extensión. El objetivo de este estudio fue evaluar histomorfométricamente el grado de madurez del tejido nervioso y los posibles cambios microscópicos en los segmentos nerviosos recién formados 60 días después de la neurotmesis experimental en el nervio ciático de ratas. Se utilizaron 9 ratas (Wistar) separadas en grupo control (GC, n= 4) y Grupo lesión (GL, n= 5). A los 60 días de vida, el grupo GL fue sometido a neurotmesis del nervio ciático de la miembro posterior derecho, con inmediata corección quirúrgica con la técnica de tubolización. Completados 60 días luego de la cirugía experimental, los animales de ambos grupos fueron anestesiados y sus nervios ciáticos seccionados para el análisis histomorfométrico. Se realizó un análisis estadístico utilizando la prueba t de Student para muestras independientes, expresado como media ± desviación estándar, con un 5% de significancia. A los 60 días de la lesión por neurotmesis, el nervio ciático del GL presentó alteraciones histomorfométricas significativas para las variables: número de vasa nevorum, densidad de fibras mielínicas, diámetro axonal y de fibras mielínicas, espesor de la vaina de mielina y razón G, con similitud solamente para los números absolutos de fibras mielínicas regeneradas. El nervio periférico durante su proceso regenerativo, pasa por grandes alteraciones estructurales, siguiendo una secuencia coordinada de acciones, que dependiendo de las condiciones del microambiente donde ocurre esta regeneración, podrá ser clave para el nivel de regenerecion nerviosa periférica.

Optical Biopsy of Peripheral Nerve Using Confocal Laser Endomicroscopy: A New Tool for Nerve Surgeons?

Peripheral nerve injuries remain a challenge for reconstructive surgeons with many patients obtaining suboptimal results. Understanding the level of injury is imperative for successful repair. Current methods for distinguishing healthy from damaged nerve are time consuming and possess limited efficacy. Confocal laser endomicroscopy (CLE) is an emerging optical biopsy technology that enables dynamic, high resolution, sub-surface imaging of live tissue. Porcine sciatic nerve was either left undamaged or briefly clamped to simulate injury. Diluted fluorescein was applied topically to the nerve. CLE imaging was performed by direct contact of the probe with nerve tissue. Images representative of both damaged and undamaged nerve fibers were collected and compared to routine H&E histology. Optical biopsy of undamaged nerve revealed bands of longitudinal nerve fibers, distinct from surrounding adipose and connective tissue. When damaged, these bands appear truncated and terminate in blebs of opacity. H&E staining revealed similar features in damaged nerve fibers. These results prompt development of a protocol for imaging peripheral nerves intraoperatively. To this end, improving surgeons' ability to understand the level of injury through real-time imaging will allow for faster and more informed operative decisions than the current standard permits.