Current status and progress of percutaneous spinal endoscopy in the treatment of degenerative lumbar spinal stenosis / 中国骨伤

Percutaneous endoscopic spine decompression(PSED) in recent years in the treatment of degenerative lumbar spinal stenosis(DLSS) achieved excellent results.Compared with traditional open surgery, which is characterized by large trauma, much bleeding, longer bed stay and slow recovery, the rapid development of PSED technology has greatly reduced the surgical trauma, postoperative recovery time and complications of DLSS patients. PSED core as the target therapy, with minimal trauma at the same time to achieve satisfactory decompression effect for lumbar spinal stenosis. Depending on the level, location, and degree of lumbar spinal stenosis, it is important to determine the ideal treatment. However, in practice, PSED has insufficient understanding of the treatment of different pathological types of lumbar spinal stenosis, such as indication selection, surgical approach selection, advantages and limitations of various approaches, and endoscopic vertebral fusion.At present, with the deepening of PSED research and the improvement of endoscopic instruments, great progress has been made in the treatment of DLSS.In this paper, the research progress in the treatment of DLSS by PSED in recent years will be described from four aspects, namely, the grasp of indications, the selection of approaches, the advantages and disadvantages of endoscopic approaches, and endoscope-assisted vertebral fusion, in order to provide certain guidance for the clinical treatment of DLSS by PSED.

Osteonecrosis bilateral de rodilla tratada con descompresión y concentrado de aspirado de médula ósea / Bilateral knee osteonecrosis with decompression and bone marrow concentrate

Descripta por Ahlbäck en 1968, la osteonecrosis de rodilla es una patología con un gran potencial de morbilidad. Está dividida en tres grandes grupos: primaria/espontánea, postoperatoria y secundaria/atraumática. Esta última podría estar directamente relacionada con el consumo prolongado de corticoides. Su tratamiento constituye un desafío para el cirujano ortopedista. Va a depender del estadio de la enfermedad y del colapso articular, y se intentará siempre preservar la superficie articular nativa. Dentro de las distintas opciones terapéuticas, las terapias biológicas constituyen una herramienta potencialmente valiosa como complemento al tratamiento quirúrgico, y muestran resultados clínicos esperanzadores. Presentamos el caso de una paciente con una osteonecrosis de rodilla bilateral, secundaria al consumo crónico de corticoides, tratada con una artroscopía bilateral asociada a perforaciones subcondrales descompresivas y aplicación subcondral de concentrado de médula ósea (CMO), con evolución satisfactoria de los síntomas a los treinta meses de seguimiento en la rodilla derecha, mientras que en la rodilla izquierda presentó una evolución tórpida de los síntomas a partir de los veinticuatro meses, por lo que está en plan de reemplazo articular.

Described by Ahlbäck in 1968, osteonecrosis of the knee is a pathology with great potential for morbidity. It is divided into three large groups: primary/spontaneous, postoperative, and secondary/atraumatic. The latter might be directly related to prolonged consumption of steroids. Its treatment is a challenge for the orthopedist. It will depend on the disease stage and articular collapse, always trying to preserve the native articular surface. Within the different therapeutic options, biological therapies are a potentially valuable tool as a complement to surgical treatment, showing encouraging clinical results. We present the case of a female patient with bilateral osteonecrosis of the knee, secondary to chronic consumption of steroids, treated with bilateral arthroscopy associated with decompressive subchondral perforations and subchondral application of bone marrow concentrate (BMC), with a satisfactory evolution of symptoms after thirty months of follow-up in the right knee. However, the left knee showed a torpid evolution of symptoms after twenty-four months of follow-up, so she is on a joint replacement plan

Túnel carpiano con anestesia local versus WALANT / Carpal tunnel with local anesthesia versus WALANT

Objetivo: Las cirugías con WALANT han ganado gran popularidad hoy en día. La ventaja principal que ofrece esta técnica es la de prescindir del torniquete y así eliminar las molestias que este genera. Nuestra hipótesis es que la descompresión del túnel carpiano con anestesia local y manguito neumático, realizada por un cirujano experimentado, en un tiempo quirúrgico corto, permite obtener similares resultados que con la cirugía con WALANT. materiales y métodos:Se diseñó un estudio de cohortes prospectivo comparativo clínico. Se incluyeron 23 pacientes (30 manos) con síndrome del túnel carpiano. Se asignó a los pacientes en forma aleatorizada, a 2 grupos: grupo 1, operados con anestesia local y grupo 2, operados con WALANT. Se realizó un análisis estadístico. Resultados:Todas las variables mostraron diferencias estadísticamente significativas respecto a los valores preoperatorios para los dos grupos. Respecto a la relación entre los dos grupos, los resultados funcionales de dolor y grado de satisfacción posoperatorios no mostraron diferencias con significancia estadística. Conclusiones: En nuestro estudio, la descompresión del túnel carpiano con anestesia local y torniquete y la realizada con WALANT arrojaron similares resultados. En cirujanos con experiencia posiblemente la anestesia local con torniquete sea suficiente para realizar el procedimiento, y así evitar las bajas, pero complejas complicaciones de la epinefrina. Nivel de Evidencia: II

Objective: Surgeries with the WALANT technique have recently become popular. The main advantage of this technique is that it avoids using the tourniquet and eliminates the discomfort it generates. We hypothesize that carpal tunnel decompression with local anesthesia and a pneumatic tourniquet, performed by an experienced surgeon in a short surgical time, allows us to obtain similar outcomes to the WALANT technique surgery. Materials and methods: We designed a prospective clinical comparative cohort study. We included twenty-three patients (30 hands) with carpal tunnel syndrome. Two groups of patients were randomized. Group 1 consisted of patients operated on with local anesthesia, and Group 2 included those operated on with the WALANT technique. We carried out a statistical analysis. Results: All the variables showed statistically significant differences concerning the preoperative values for the two groups. Regarding the relationship between those two groups, the functional outcomes of pain and degree of postoperative satisfaction did not show statistically significant differences. Conclusions: In our study, carpal tunnel decompression performed with local anesthesia with a tourniquet and those achieved with the WALANT technique had similar outcomes. In the hands of experienced surgeons, local anesthesia with a tourniquet may be sufficient to perform the procedure, thus avoiding the few but complex complications of epinephrine. Level of Evidence: II

Queratoquiste odontogénico: características diagnósticas y tratamiento quirúrgico conservador / Odontogenic keratocyst: diagnostic characteristics and coservative surgical treatment

El queratoquiste es una lesión odontogénica benigna de comportamiento agresivo, que deriva probablemente de la lámina dental. Se localiza frecuentemente en la parte posterior del hueso mandibular en la zona del tercer molar, ángulo mandibular y puede progresar hacia la rama y el cuerpo, presentando una asociación directa con órganos dentales retenidos. Existe una amplia variedad de técnicas para el tratamiento de esta lesión, como pueden ser descompresión, marsupialización, enucleación y la resección en bloque, así como también la combinación de estas con métodos coadyuvantes. El interés en esta lesión radica por su elevado índice de recidiva que se estima en un 20-30% en la población en general, sin embargo, en la actualidad se ha optado por el uso de tratamientos conservadores como la marsupialización y la descompresión que han demostrado una mayor efectividad y menor recidiva. Es por esto que tras el tratamiento de las lesiones es importante dar un seguimiento a largo plazo. El objetivo de la publicación es presentar el reporte de un caso clínico de un paciente masculino de 21 años con un diagnóstico de queratoquiste odontogénico tratado con una técnica de descompresión durante cinco meses para su posterior enucleación quirúrgica.Se ha comprobado que el tratamiento de descompresión seguido de enucleación y acompañado de métodos coadyuvantes resulta un manejo terapéutico adecuado para los queratoquistes por demostrar su menor tasa de recidiva y su comportamiento noble con estructuras vitales vecinas. Sin embargo, en todos los casos se debe realizar un seguimiento periódico para prevenir la recurrencia de la lesión.

Introduction: Keratocyst is a benign odontogenic lesion with aggressive behavior, probably derived from the dental lamina. It is frequently located in the posterior part of the mandibular bone in the area of the third molar, mandibular angle and can progress towards the ramus and the body, presenting a direct association with retained dental organs. There is a wide variety of techniques for the treatment of this lesion, such as decompression, marsupialization, enucleation, and en bloc resection, as well as the combination of these with adjuvant methods. The interest in this lesion stems from its high recurrence rate, which is estimated to be 20-30% in the general population, however, at present the use of conservative treatments such as marsupialization and decompression has been chosen. demonstrated greater effectiveness and less recurrence. This is why after treating the lesions it is important to give a long-term follow-up.The objective of the publication is to present the report of a clinical case of a 21-year-old male patient with a diagnosis of odontogenic keratocyst treated with a decompression technique for five months for subsequent surgical enucleation.Conclusion: It has been proven that decompression treatment followed by enucleation and accompanied by adjuvant methods is an adequate therapeutic management for keratocysts as it demonstrates its lower rate of recurrence and its noble behavior with neighboring vital structures. However, in all cases, regular monitoring should be carried out to prevent recurrence of the lesion

Características de orbitopatía asociada al tiroides y tasa de requerimiento de cirugía / Thyroid-associated orbitopathy characteristics and surgery requirement rate

RESUMO Objetivo: Conheça as características demográficas e clínicas da Órbita Associada da Tiroide (OAT), bem como a taxa de exigência da cirurgia orbital em pacientes do Centro Médico Nacional do Oeste. Métodos. Estudo observacional, transversal, descritivo e retrospetivo realizado analisando os registos de pacientes diagnosticados com OAT tratados num centro de cuidados de terceiro nível de janeiro de 2005 a julho de 2016. Os resultados. Um total de 236 órbitas de 118 pacientes foram avaliados, com uma idade média de 47,3 (13,2 anos, 74,6% eram do sexo feminino e 25,4% masculinos. 4,2% dos doentes foram tratados com hipotiroidismo, 94,1% com hipertireoidismo e 1,7% com goiter tóxico difuso. 44,9% dos doentes estudados com restrição de movimento ocular,10,2% com queratopatia de exposição e 51,7% com hipertensão intraocular. 34,7% dos doentes avaliados no serviço necessitaram de descompressão orbital, 16,1% de cirurgia palpebral e 8,5% de correção do hatrabisma. Na gestão conservadora destes doentes, 48,3% exigiam o uso de lubrificantes tópicos dos olhos, enquanto 52,5% dos pacientes necessitavam do uso de hipotensivos oculares em número variável. As conclusões. A OAT foi associada principalmente ao hipertiroidismo, sendo mais comum em pacientes do sexo feminino entre os 40 e os 59 anos; mais de 50% dos pacientes necessitaram do uso de hipotensivos oculares. Da mesma forma, a gestão cirúrgica foi realizada em mais de 50% dos pacientes, sendo a descompressão orbital a intervenção mais frequente.

ABSTRACT Objective. To know the demographic and clinical characteristics of Thyroid Associated Orbitopathy (TAO), as well as the requirement rate of orbital surgery in patients of the Orbit Service in the National Medical Center of the West, IMSS. Methods. Observational, cross-cutting, descriptive and retrospective study carried out analyzing the records of patients diagnosed with TAO and treated at a third-level care center from January 2005 to July 2016. Results. A total of 236 orbits of 118 patients were valued, with an average age of 47.3 ± 13.2 years, 74.6% were female and 25.4% male. 4.2% of patients were treated with hypothyroidism, 94.1% with hyperthyroidism and 1.7% with diffuse toxic goiter. 44.9% of patients studied had eye movement restriction,10.2% exposure keratopathy and 51.7% intraocular hypertension. 34.7% of patients valued in the service required orbital decompression, 16.1% palpebral surgery and 8.5% strabism correction. In the conservative management of these patients 48.3% required the use of topical eye lubricants, while 52.5% required the use of eye hypotensives in variable numbers. Conclusions. TAO was mainly associated with hyperthyroidism, being more common in female patients between the age of 40 and 59; more than 50% of patients required the use of eye hypotensives. Likewise, surgical management was performed in more than 50% of patients, with orbital decompression being the most frequent intervention.

Clinical observation of arthroscopic single channel treatment of carpal tunnel syndrome with self-made instruments / 中国骨伤

OBJECTIVE@#To investigate the efficacy of self-made arthroscopic single channel in the treatment of carpal tunnel syndrome.@*METHODS@#Sixty patients with primary carpal tunnel syndrome treated from January 2014 to December 2019 were divided into arthroscopic group and traditional open operation group. There were 30 cases in arthroscopic group, including 12 males and 18 females, aged (47.5±4.5) years and the course of disease was (6.6±4.2) months. There were 30 cases in the traditional operation group, including 10 males and 20 females, aged (48.5±3.5) years, and the course of disease was (5.6±4.4) months. Both groups were unilateral. According to the anatomy of wrist joint and the characteristics of transverse carpal ligament and arthroscopy, the instruments including cannula, inner heart and hook knife were designed. The patients in two groups were treated with decompression of transverse carpal ligament using arthroscopy combined with self-made instruments and traditional open sergery. The incision length, operation time, intraoperative bleeding, hospitalization cost, hospitalization time and recovery time of the two groups were observed and compared. Boston Carpal Tunnel Questionnaire (BCTQ) score was used to evaluate the clinical efficacy of arthroscopy combined with self made instruments in the treatment of carpal tunnel syndrome.@*RESULTS@#Compared with the traditional group, the arthroscopic group had significant advantages in incision length, operation time, intraoperative bleeding and hospital stay, but the total cost of hospitalization was increased. The Boston score was significantly higher in the arthroscopic group than that in the traditional group at 1 month after operation, but not at 3 and 6 months after operation.@*CONCLUSION@#Arthroscopy combined with self-made instruments in the treatment of carpal tunnel syndrome is more reliable, minimally invasive and simplified than open surgery, but the patients should be clearly diagnosed and appropriately selected before operation to achieve satisfactory clinical effect.

Advances in tissue state recognition in spinal surgery: a review / 医学前沿

Spinal disease is an important cause of cervical discomfort, low back pain, radiating pain in the limbs, and neurogenic intermittent claudication, and its incidence is increasing annually. From the etiological viewpoint, these symptoms are directly caused by the compression of the spinal cord, nerve roots, and blood vessels and are most effectively treated with surgery. Spinal surgeries are primarily performed using two different techniques: spinal canal decompression and internal fixation. In the past, tactile sensation was the primary method used by surgeons to understand the state of the tissue within the operating area. However, this method has several disadvantages because of its subjectivity. Therefore, it has become the focus of spinal surgery research so as to strengthen the objectivity of tissue state recognition, improve the accuracy of safe area location, and avoid surgical injury to tissues. Aside from traditional imaging methods, surgical sensing techniques based on force, bioelectrical impedance, and other methods have been gradually developed and tested in the clinical setting. This article reviews the progress of different tissue state recognition methods in spinal surgery and summarizes their advantages and disadvantages.

Latest Progresses in Surgical Treatment of Median Arcuate Ligament Syndrome / 中国医学科学院学报

Median arcuate ligament syndrome(MALS)is compression of the celiac trunk by the median arcuate ligament.Median arcuate ligament release is the corner stone for the surgical treatment of MALS.Open surgery,laparoscopic surgery,and robot-assisted surgery have been developed,among which laparoscopic surgery has been proposed as the preferred approach in view of its minimal trauma and short hospital stay.Auxiliary celiac plexus neurolysis could further alleviate the patient's discomfort.Moreover,vascular reconstitution is of vital importance in the case of persistent stenosis in the celiac artery despite of median arcuate ligament decompression.Vascular reconstruction has satisfactory long-term patency rate,while endovascular treatment is less invasive.This article aims to summarize the consensuses and advances and shed light on the surgical treatment of MALS.

Tratamento cirúrgico da forma arterial da síndrome do desfiladeiro torácico associado à costela cervical / Surgical treatment of cervical rib-associated arterial thoracic outlet syndrome

Resumo A forma arterial da síndrome do desfiladeiro torácico é rara e está associada a uma anomalia anatômica, geralmente uma costela cervical. Suas manifestações são muito variadas. Este artigo tem como proposta relatar dois casos de apresentações clínicas distintas: microembolização e aneurisma. Em ambos, uma costela cervical estava presente. O diagnóstico foi realizado através da história, do exame físico, das manobras posturais e das radiografias. A angiotomografia computadorizada proporcionou o detalhe anatômico necessário para o planejamento operatório. O tratamento cirúrgico foi realizado pela abordagem supraclavicular, com sucesso em ambos casos.

Abstract The arterial form of thoracic outlet syndrome is rare and is associated with anatomic anomalies, generally a cervical rib. It has a varied range of manifestations. The aim of this article is to describe two cases with different clinical presentations: microembolization and aneurysm. A cervical rib was present in both cases. Diagnosis was made on the basis of history, physical examination, postural maneuvers, and X-rays. Computed tomography angiography provided the anatomic detail necessary to plan surgery. Surgical treatment was performed via supraclavicular access, successfully, in both cases.

Diagnosis, treatment and etiology analysis of nerve compression by bone fragment after lumbar spine surgery / 中国骨伤

OBJECTIVE@#To explore the diagnosis, treatment, cause and prevention of nerve compression by bone fragment after lumbar spine surgery.@*METHODS@#The clinical data of 23 patients with nerve compression by bone fragment after lumbar spine surgery from February 2012 to March 2019 were collected retrospectively, including 9 males and 14 females, aged 42 to 81 years with an average of (62.60±5.70) years. The surgical methods included lumbar interbody fusion in 20 cases and spinal endoscopy in 3 cases. All 23 patients experienced radiating pain on the decompression side or the contralateral limb after operation. The time of occurrence was from immediately after operation to 2 weeks after operation, with an average of (3.2±1.7) days. All patients underwent postoperative examination of lumbar spine CT or MRI to confirm residual ectopic bone fragments, and at the same time, bilateral lower extremity color Doppler ultrasound excluded thrombosis. Sources of ectopic bone fragments:14 cases of residual bone fragments caused by intervertebral fusion bone graft loss or fenestration fusion, 6 cases of fractured upper articular process head, and 3 cases of upper articular process bone remaining during spinal endoscopic surgery.@*RESULTS@#The patient's hospital stay was 10 to 37 (23.4±6.2) days. All patients were followed up for 6 to 25 (13.6±3.4) months. Three patients underwent posterior open nerve root exploration for removing bone fragments on the same day or the second day after surgery, and the symptoms were relieved. Twenty patients underwent conservative treatment firstly, and 13 patients were discharged after pain relieved by conservative treatment, 7 patients failed conservative treatment, the 2 cases of failed 7 cases had undergone nerve root block surgery during conservative treatment. Two patients underwent spinal endoscopy nerve root exploration and bone mass removal, and five patients underwent posterior open nerve root exploration and bone fragmentation removal. All postoperative pain symptoms were relieved. Preoperative CT, MRI and intraoperative bone fragment removal confirmed the shape and location of the bone fragments. The most likely source of bone fragments was the loss of intervertebral fusion bone grafts or residual bone fragments resulting from fenestration fusion (14 cases), fractured upper articular process head (6 cases), and upper articular process bones remaining in endoscopic surgery (3 cases). According to the Macnab criteria in evaluating clinical outcome, 20 cases got excellent results and 3 good.@*CONCLUSION@#After the lumbar spine surgery, the nerve compression by bone fragments is treated with appropriate treatments, and good clinical results can be obtained. Timely removal of residual bone fragments during operation and careful exploration of nerve roots before closing incision can avoid such complications.

Treatment of senile lumbar spinal stenosis by unilateral approach and bilateral decompression with large channel endoscopy / 中国骨伤

OBJECTIVE@#To evaluate clinical effect of unilateral approach and bilateral decompression via large channel endoscopic system for the treatment of lumbar spinal stenosis.@*METHODS@#The clinical data of 32 patients with lumbar spinal tenosis treated by unilateral approach and bilateral decompression via large channel endoscopy from February 2018 to February 2019 were retrospectively analyzed. There were 18 males and 14 females, aged 65 to 84 years old with an average of (70.6± 8.4) years. The course of disease was from 1 to 12 years. All 32 cases were accompanied by numbness or pain in the lower limbs, of which 28 cases were accompanied by intermittent claudication. Narrow segments were L@*RESULTS@#All the patients were followed up for 12-24 (17.68±2.43) months and all operations were successfully completed with the operation time of 70-160(85.64±11.94) min. Spinal dural tear occurred in 1 case during the operation, and sensory disturbance in the other side of lower limb in a short period of time occurred in 2 cases, all improved after corresponding treatment. Postoperative imaging showed that the spinal canal was significantly enlarged and the nerve root was fully released. Before operation and 3 days, 3 months, 1 year after operation, VAS scores of low back pain were 4.62 ±1.41, 2.73 ±1.35, 1.21 ±1.17, 1.11 ±0.34, respectively;VAS scores of leg pain were 6.83 ± 1.71, 3.10±1.50, 1.08±0.19, 0.89±0.24, respectively. VAS scores of low back pain and leg pain each time point after operation were obvious improved (@*CONCLUSION@#It is a safe and effective way to treat lumbar spinal stenosis with unilateral approach and bilateral decompression via large channel endoscopic system. It has the advantages of sufficient decompression, less trauma, fast recovery, high safety and low incidence of postoperative complications. It can minimize the damage to the stable structure of the lumbar spine and is an ideal minimally invasive operation for the treatment of lumbar spinal stenosis.

Comunicación Buco Sinusal a causa de un Quiste Odontogénico Residual / Oroantral fistula caused by a residual odontogenic cyst

Los quistes odontogénicos se dividen en dos grupos principales de acuerdo a la patogénesis de la entidad. Uno de esos grupos incluye a los quistes radiculares de origen inflamatorio. Nuestra situación es una paciente de sexo femenino que a causa de un molar superior con tratamiento endodóntico la patología quística invadió la cavidad sinusal comprometiendo las estructuras vecinas y al realizar la exodoncia se generó una comunicación bucosinusal con infección de esa entidad patológica. El diagnostico de certeza se confirmó a través de la biopsia previa, y se la intervino bajo anestesia general para la extirpación total de la patología quística (AU)

Descompresión lumbar en pacientes con enfermedad de Parkinson: serie de casos tratados con cirugía mínimamente invasiva / Lumbar decompression in patients with Parkinson's disease: series of cases treated with minimally invasive surgery

Introducción: La enfermedad de Parkinson afecta principalmente a personas >65 años. El cuadro degenerativo lumbar en el contexto de un canal estrecho sumado a la alteración neuromuscular y la mala calidad ósea, favorece al desequilibrio sagital y coronal. Los pacientes que necesitan cirugía tienen altas tasas de revisión y reoperación con técnicas instrumentadas y no ins-trumentadas. El objetivo de este estudio fue evaluar la técnica quirúrgica de descompresión mínimamente invasiva en pacientes con enfermedad de Parkinson y dolor radicular o claudicación neurogénica en los miembros inferiores. materiales y métodos: Se evaluó a pacientes con diagnóstico de canal lumbar estrecho y enfermedad de Parkinson tratados quirúrgicamente. El procedimiento se indicó por síntomas de canal estrecho o estenosis foraminal de causa degenerativa. Todos fueron tratados con una cirugía descompresiva a través de una hemilaminectomía mínimamente invasiva mediante retracción tubular y asistencia con microscopia. Resultados: De enero de 2015 a diciembre de 2017, se trató a 6 pacientes con enfermedad de Parkinson y canal lumbar estrecho. Se descomprimieron 12 niveles en total, todos estuvieron internados <24 h. No se necesitaron transfusiones, no hubo complicaciones asociadas, el tiempo promedio de cirugía fue de 120 minutos. El seguimiento mínimo fue de 12 meses, los síntomas no reaparecieron. Conclusiones: La elevada tasa de complicaciones en pacientes operados con enfermedad de Parkinson y la disminución de las complicaciones en este estudio sugieren que la cirugía mínimamente invasiva de columna lumbar debería ser una alternativa quirúrgica en estos pacientes. Nivel de Evidencia: IV

Introduction: Parkinson's disease mainly affects patients aged 65 and older. The degenerative condition at the lumbar spine in the context of a narrow canal added to the neuromuscular disorder and poor bone quality favors sagittal and coronal imbalance. Patients who need surgery have high rates of revision and reoperation with instrumented and non-instrumented techniques. The objective of this study was to evaluate the minimally invasive surgical decompression technique in patients with Parkinson's disease and radicular pain or neurogenic claudication in the lower limbs. Materials and Methods: Surgically treated patients with a diagnosis of lumbar spinal stenosis and Parkinson's disease were evaluated. The indication for the procedure was due to symptoms of the lumbar or foraminal stenosis of degenerative cause. All the patients were treated with decompressive surgery through a minimally invasive hemilaminectomy using tubular retraction and assistance with microscopy. Results: From January 2015 to December 2017, 6 patients with Parkinson's disease and lumbar spinal stenosis were treated. A total of 12 segments were decompressed, all patients were hospitalized for less than 24 hours. They did not require a transfusion nor suffered associated complications, with an average surgery time of 120 minutes. All with a minimum follow-up of 12 months and no relapse of the symptoms. Conclusion: The high rate of surgical complications in patients with Parkinson's disease, in contrast to the low rate of complications in the present study, suggests that minimally invasive surgery of the lumbar spine should be a surgical alternative in these patients. Level of Evidence: IV

Técnica de "slalom" quirúrgico en estenosis de canal lumbar multinivel. Serie de casos tratados de manera simultánea con descompresión endoscópica y tubular con asistencia microscópica bilateral / Slalom Technique as a treatment in multilevel lumbar spinal stenosis. Series of cases treated simultaneously with endoscopic and tubular decompression with microscopic assistance

Introducción: La laminectomía unilateral para descompresión bilateral por abordaje único ha tomado relevancia en pacientes con estenosis multinivel. Cuando se realiza en más de un nivel por un abordaje único, de manera alterna y de forma cruzada, al abordaje anterior es conocida como técnica de "slalom". Elobjetivode este artículo es presentar una serie de casos tratados con la técnica de "slalom" con asistencia endoscópica y microscópica bilateral, simultánea, en pacientes con estenosis de canal lumbar multinivel.materiales y métodos: Análisis retrospectivo de pacientes tratados de forma simultánea, entre enero de 2017 y enero de 2018, todos operados por el mismo equipo quirúrgico con separadores tubulares, y asistencia endoscópica y micros-cópica simultánea.Resultados: Se incluyó a 4 hombres, con una edad promedio de 73.5 años y patología lumbar multinivel. Se descomprimieron 10 segmentos (2,5 media de niveles por paciente), con un tiempo quirúrgico promedio de 107 minutos. No hubo complicaciones asociadas y los pacientes recibieron el alta hospitalaria el día de la cirugía.Conclusiones:La técnica de "slalom" mínimamente invasiva resulta ser un procedimiento muy eficaz para resolver síntomas de estenosis multinivel asociada a una técnica combinada bilateral con dos equipos quirúrgicos para el tratamiento de este tipo de pacientes. Nivel de Evidencia: IV

Introduction: Unilateral laminectomy for bilateral decompression (ULBD) by single approach has become relevant in patients with multilevel stenosis, when it is performed at more than one level with single approach, alternately and crosswise to the previous approach is known as a slalom technique.The objective of the following work is to present a series of cases treated with the slalom technique with bilateral endoscopic and microscopic assistance, simultaneous in patients with multilevel lumbar canal stenosis. Materials and Methods: Retrospective analysis of patients treated simultaneously between the months of January 2017 to January 2018, all operated by the same surgical team with tubular separators and simultaneous endoscopic and microscopic assistance. Results: Four patients, all male, with an average age of 73.5 years with multilevel lumbar pathology, were included. In total 10 segments were decompressed (2.5 average level for patients), with an average surgery of 107 minutes. No associated complications, with hospital discharge within the day of surgery. Conclusions: The minimally invasive Slalom technique turns out to be a very effective procedure to resolve symptoms of multilevel stenosis associated with a bilateral combined technique with two surgical teams, resulting in a viable option for the treatment of this type of patient. Level of Evidence: IV

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES: To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS: Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS: Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS: IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Lumbar degenerative spondylolisthesis II: treatment and controversies / Espondilolistesis degenerativa lumbar II: tratamiento y controversias

Abstract: There are various approaches and surgical techniques with the objective of nerve root decompression, restrict mobility, and fusion of the listhesis. Among the techniques, posterior interbody fusion combines direct and indirect root decompression with the fusion between vertebral bodies, placing an autologous bone graft between transverse apophysis and vertebral bodies. Transforaminal lumbar and posterior interbody fusion, on the same way, look to decompress and fuse but with a different approach to the spine. The anterior approach for interbody fusion provides a better fusion rate. Lateral lumbar interbody fusion is considered less invasive, with an anterolateral transpsoas approach. The lumbar fusion technique in degenerative spondylolisthesis must be individualized. Non-fusion decompression is considered a less invasive procedure. Various studies suggest that decompression has better results when fusion is added. Surgery had several potential benefits and greater improvement in those patients who fail conservative management. An optimal technique is not conclusively identified.

Resumen: El tratamiento de la espondilolistesis degenerativa lumbar es específico para cada etapa de la enfermedad y el manejo quirúrgico no debe de ser la primera elección en la mayoría de los casos. El manejo conservador está basado en el uso de antiinflamatorios no esteroideos, control de peso y rehabilitación. En caso de falla después de cuatro a seis semanas, el siguiente paso es la infiltración facetaria. En caso de dolor persistente, alteraciones neurológicas o claudicación neurogénica el siguiente paso es la cirugía. Existen varios abordajes y técnicas quirúrgicas con el objetivo de descomprimir las raíces nerviosas, restringir la movilidad y fusionar la listesis. Entre las técnicas quirúrgicas, la fusión posterior combina la descompresión directa e indirecta con artrodesis entre los cuerpos vertebrales, colocando injerto entre las apófisis transversas y los cuerpos vertebrales. La artrodesis intersomática transforaminal y posterior buscan de la misma manera la descompresión y fusión, pero con un abordaje distinto. El abordaje anterior para artrodesis intersomática provee la mejor tasa de fusión. La artrodesis intersomática lateral se considera un procedimiento menos invasivo, con un abordaje anterolateral transpsoas. La técnica de artrodesis lumbar en la espondilolistesis debe ser individualizada. La descompresión sin artrodesis se considera un procedimiento menos invasivo; varios estudios sugieren que la descompresión tiene mejores resultados cuando se agrega una artrodesis. La cirugía tiene múltiples beneficios posibles en pacientes en quienes el tratamiento conservador ha fallado. No se ha identificado una técnica óptima de tratamiento.

Solução de Carnoy no tratamento de ceratocisto / Carnoy's solution in treatment of keratocyst

Introdução: O objetivo do trabalho é relatar um caso de ceratocisto associado à impactação dentária, o qual foi tratado com descompressão, seguido de enucleação da lesão e utilização de solução de Carnoy. Relato de caso: Paciente do sexo masculino, 14 anos, encaminhado para avaliação de lesão encontrada após exame imaginológico de rotina. O mesmo demonstrou extensa lesão radiolúcida localizada na região de ângulo e ramo da mandíbula, com presença do elemento 48 intralesional próximo a basilar. Foi realizado biópsia incisional e instalação de dispositivo de descompressão no mesmo tempo cirúrgico, o qual o resultado histopatológico foi de ceratocisto. Após 6 meses com o dispositivo, observou-se diminuição da lesão e melhora no posicionamento do dente incluso. Frente a boa resposta à descompressão, decidiu-se pela enucleação total da lesão, exodontia dos dentes 47 e 48, curetagem rigorosa e tereapia adjuvante com aplicação da solução de Carnoy. O paciente evoluiu bem, neoformação óssea na área operada e encontra-se em acompanhamento há 6 meses, sem sinais de recidiva. Considerações finais: O uso da descompressão cirúrgica em lesões císticas mandibulares minimiza os danos as estruturas circunvizinhas, riscos de fratura patológica e lesão nervosa. Em função das altas taxas de recidiva, a terapia adjuvante após a enucleção é imprescindível para essa lesão, sendo a aplicação da solução de Carnoy uma das técnicas com melhores resultados. Dessa forma, para aumentar a taxa de sucesso e minimizar as sequelas, o planejamento cirúrgico dos ceratocistos mandibulares extensos deve ser feito de forma criteriosa e cuidadosa... (AU)

Introduction: The objective of this study is to report a case of keratocyst associated with dental impaction, which was treated with decompression, followed by enucleation lesion and Carnoy solution. Case report: Male patient, 14 years old, referred for evaluation of lesion found after routine imaging. He showed extensive radiolucent lesion located in the region of the angle and branch of the mandible, with the presence of the intralesional element 48 near the basilar. An incisional biopsy was performed and a decompression device was installed during surgical time and the histopathological result was keratocyst. After 6 months of observation a reduction of the lesion and improvement in the positioning of the tooth even were noticed. Given the good response to decompression, it was decided to complete the enucleation of the lesion, extraction of teeth 47 and 48, rigorous curettage and adjuvant therapy with Carnoy's solution. Followed up for 6 months, patient evolved well creating a new bone formation in the operated area with no signs of relapse. Final considerations: The use of surgical decompression in cystic mandibular lesions minimizes damage to surrounding structures, pathological fracture risks, and nerve damage. Because of the high rates of recurrence, keratocysts require adjuvant therapy after enucleation and Carnoy's solution is one of the best performing techniques. Thus, to increase success rate and minimize sequelae, the surgical planning of extensive mandibular keratocysts should be done carefully and judiciously... (AU)

Terapia con células madre en la osteonecrosis de la cabeza femoral / Stem Cell Therapy in Osteonecrosis of the Femoral Head

RESUMEN Objetivos: Describir el efecto terapéutico del uso de células madre en el manejo de la osteonecrosis de la cabeza femoral. Métodos: Se realizó una búsqueda en las distintas bases de datos como Pubmed/MEDLINE, BVS y Cochrane de los últimos 10 años, incluyéndose estudios relevantes de metaanálisis, ensayos clínicos y revisiones. Además, se revisó la página electrónica oficial de la Organización Mundial de la Salud para referencias adicionales. Las palabras de búsqueda fueron: "("Stem Cells" OR "Stem Cell Transplantation"[Mesh] OR "Mesenchymal Stem Cell Transplantation"[Mesh] OR Hematopoietic Stem Cell Transplantation"[Mesh] OR Cell-and Tissue-Based Therapy"[Mesh] "Multipotent Stem Cells"[Mesh] OR "Embryonic Stem Cells"[Mesh]) AND ("Osteonecrosis"[Mesh] OR "Femur Head Necrosis"[Mesh] "osteonecrosis of the femoral head" OR "Femoral head"). Incluimos un total de 7 estudios. 2 metaanálisis, 2 artículos de revisión, 2 ensayos clínicos controlados y aleatorizados y un estudio de evidencia. Resultados: Todos los estudios evidenciaron que la terapia con células madre en el manejo de la osteonecrosis de la cabeza femoral es segura y efectiva. El tratamiento combinado de descompresión central más implantación de células madre mostró mayor efectividad. Conclusiones: La terapia con células madre es una opción terapéutica para tratar la osteonecrosis de la cabeza femoral, sobre todo en etapas tempranas. La combinación de descompresión central más la infiltración de células madre en la zona necrótica produce mejoría de la sintomatología y contiene el progreso de la enfermedad(AU)

ABSTRACT Objectives: To describe the therapeutic effect of the stem cell use in managing osteonecrosis of the femoral head. Methods: A search was carried out in the different databases as Pubmed / MEDLINE, BVS and Cochrane for the last 10 years, including relevant meta-analysis studies, clinical trials and reviews. In addition, the official website of the World Health Organization was checked for additional references. The search words were: "(" Stem Cells "OR" Stem Cell Transplantation "[Mesh] OR" Mesenchymal Stem Cell Transplantation "[Mesh] OR Hematopoietic Stem Cell Transplantation" [Mesh] OR Cell-and Tissue-Based Therapy "[ Mesh] "Multipotent Stem Cells" [Mesh] OR "Embryonic Stem Cells" [Mesh]) AND ("Osteonecrosis" [Mesh] OR "Femur Head Necrosis" [Mesh] "osteonecrosis of the femoral head" OR "Femoral head"). We include a total of 7 studies, 2 meta-analyzes, 2 review articles, 2 controlled and randomized clinical trials, and one evidence study. Findings: All the studies showed that stem cell therapy in managing osteonecrosis of the femoral head is safe and effective. The combined treatment of central decompression plus stem cell implantation showed greater effectiveness. Conclusions: Stem cell therapy is a therapeutic option to treat osteonecrosis of the femoral head, especially in the early stages. The combination of central decompression plus the infiltration of stem cells in the necrotic area produces an improvement in the symptoms and contains the progress of the disease(AU)

Removal of odontogenic keratocyst in maxilla through the Le Fort i osteotomy / Eliminación de queratoquiste odontogénico en el maxilar mediante la osteotomía Le Fort

The odontogenic keratocyst is a lesion with specific clinical and histopathological aspects. The World Health Organization (WHO) in 2017 reclassified it from a tumor to a cyst. It is characterized as a cyst of epithelial development of the jaws, arising from the remains of the dental blade. It represents 3 % to 11 % of all odontogenic cysts and 7 to 11 % of cysts of the gnatic bones. It stands out for its aggressive nature and high relapsing potential. Most of the cases are diagnosed in individuals between 10 and 40 years old, with a mild preference for the masculine gender, occurring more in the mandible. Radiographically, it is radiolucent and well delimited, predominantly unilocular, and may cause displacement of adjacent teeth. The present study aims to report a clinical case of a female 25 years old patient, presenting an intra-osseous lesion in the maxilla (posterior, left side), asymptomatic, with a slight increase in intraoral buccal volume, containing the tooth 28, with a diagnostic hypothesis of Odontogenic Keratocyst. The patient was submitted to the surgical decompression treatment, with cystic fluid puncture, biopsy of the lesion and posterior anatomopathological examination. The enucleation of the tumor was performed using LeFort I osteotomy of maxilla and reconstruction with titanium mesh. There is radiographic evidence of bone repair and lesion reduction. The patient is in periodic follow-up of 4 years and does not present clinical and radiographic signs of relapse. Due to the aggressiveness of the odontogenic keratocyst, the relapse rate is high. The knowledge of the techniques recommended for the treatment of Odontogenic Keratocysts and the clinical and radiographic follow-up of the patient demonstrate a gradual decrease of the lumen of the lesion and suggest local bone neoformation, favoring the prognosis of the case.

El queratoquiste odontogénico es una lesión con aspectos clínicos e histopatológicos específicos. La Organización Mundial de la Salud (OMS) en 2017 lo reclasificó de un tumor a un quiste. Se caracteriza como un quiste de desarrollo epitelial de las mandíbulas, que surge de los restos de la lámina dental. Representa del 3 % al 11 % de todos los quistes odontogénicos y del 7 al 11 % de los quistes de los huesos gnáticos. Se destaca por su naturaleza agresiva y su alto potencial de recaídas. La mayoría de los casos se diagnostican en individuos de entre 10 y 40 años, con una leve preferencia por el sexo masculino, que ocurre más en la mandíbula. Radiográficamente, es radiotransparente y bien delimitado, predominantemente unilocular, y puede causar el desplazamiento de los dientes adyacentes. El presente estudio tiene como objetivo reportar el caso clínico de una paciente de 25 años, que presenta una lesión intraósea en el maxilar (posterior, lado izquierdo), asintomática, con un ligero aumento en el volumen bucal intraoral, que contiene el diente 28, con una hipótesis diagnóstica de queratoquiste odontogénico. El paciente fue sometido al tratamiento quirúrgico de descompresión, con punción de líquido quístico, biopsia de la lesión y examen anatomopatológico posterior. La enucleación del tumor se realizó con osteotomía LeFort I de maxilar y reconstrucción con malla de titanio. Existe evidencia radiográfica de reparación ósea y reducción de la lesión. El paciente se encuentra en seguimiento periódico de 4 años y no presenta signos clínicos ni radiográficos de recaída. Debido a la agresividad del queratoquiste odontogénico, la tasa de recaída es alta. El conocimiento de las técnicas recomendadas para el tratamiento de los queratoquistes odontogénicos, y el seguimiento clínico y radiográfico del paciente, demuestran una disminución gradual del lumen de la lesión y sugieren neoformación ósea local, favoreciendo el pronóstico del caso.