It's not always postdural puncture headache: a case report and note to the astute anesthesiologist

Abstract Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

A review of the clinical significance of lumbar puncture in the diagnostic approach of Aneurysmal Subarachnoid Hemorrhage (SAH): A case report of CT-Negative and Lumbar Puncture–Positive SAH

@#Headaches are a common presentation in the emergency department (ED). Even though not all are potentially serious, some such as subarachnoid hemorrhage (SAH) can be more dangerous than others. SAH is a medical emergency with an almost 50% mortality rate. It is crucial not to miss the diagnosis of SAH, as a missed or delayed diagnosis can be severely detrimental. It classically presents as thunderclap headache, a severe, sudden-onset headache. There are various approaches in diagnosing or excluding SAH, which is classically done by performing a computed tomography (CT) scan followed by a lumbar puncture (LP). But with the improved sensitivity of more modern diagnostic tools, more physicians are in support of changing this classical teaching. The aim of this case report is to review the advantages and disadvantages of LP in diagnosing SAH, along with other diagnostic tools commonly used.

Spinal anesthesia using 29G pencil point needle: a large single center experience in non-obstetric patients / Anestesia espinal con aguja 29G punta de lápiz: experiencia unicentrica en pacientes no obstétricos

OBJECTIVES: Spinal anesthesia is a technique in which a local anesthetic is administered into the subarachnoid space. For this, different caliber and style needles are used, one of them, the pencil point needle, has reported a lower incidence of post-dural puncture headache (PDPH) and adverse events. However, failure rates vary, possible technical difficulty being one of the causes. In this context, the objective of this study was to evalúate the incidence of PDPH, the time in seconds to obtain cerebrospinal fluid (CSF) and the anesthetic success rate with the spinal technique using a 29G pencil point needle, for non-obstetric procedures. METHODS: Unique historical cohort (2016-2019) of 812 patients over 18 years old. Among the variables observed there were sociodemographic characteristics, number of lumbar puncture attempts, CSF collection time, patient position for the anesthetic procedure, type of surgery, anesthetic failure, and appearance of PDPH. Stata SE14.0 software was used for the statistical analysis of the information. Results: No cases of PDPH were observed. The average time for obtaining CSF was 86.1 seconds, with the factors associated with a higher time frame being the position in lateral decubitus and age. The anesthetic success rate was 99.2%. CONCLUSIÓN: The use of the 29G pencil point needle for subarachnoid anesthesia in patients for non-obstetric surgery, in the observed cohort, reported a success rate close to 100%. The time to obtain CSF can be slow compared to the use of larger gauge needles and varies with the position and age of the patient.

OBJETIVOS: La anestesia espinal es una técnica en la que se administra un anestésico local en el espacio subaracnoideo. Para ello se utilizan agujas de diferentes calibres y estilos, una de ellas, la aguja de punta de lápiz ha reportado menor incidencia de cefalea post punción dural (CPPD) y eventos adversos. Sin embargo, las tasas de falla varían, siendo la posible dificultad técnica una de las causas. En este contexto, el objetivo de este estudio fue evaluar la incidencia de CPPD, el tiempo en segundos para la obtención de líquido cefalorraquídeo (LCR) y la tasa de éxito anestésico con la técnica espinal con aguja punta lápiz 29G, para procedimientos no obstétricos. MÉTODOS: Cohorte histórica única (2016-2019) de 812 pacientes mayores de 18 años. Entre las variables observadas se encuentran las características sociodemográficas, número de intentos de punción lumbar, tiempo de recolección del LCR, posición del paciente para el procedimiento anestésico, tipo de cirugía, falla anestésica y aparición de CPPD. Para el análisis estadístico de la información se utilizó el software Stata SE14.0. RESULTADOS: No se observaron casos de CPPD. El tiempo medio de obtención del LCR fue de 86,1 segundos, siendo los factores asociados a un mayor tiempo la posición en decúbito lateral y la edad. La tasa de éxito anestésico fue del 99,2%. CONCLUSIONES: El uso de la aguja punta de lápiz 29G para anestesia subaracnoidea en pacientes para cirugía no obstétrica, en la cohorte observada, reportó una tasa de éxito cercana al 100%. El tiempo para obtener LCR puede ser lento en comparación con el uso de agujas de mayor calibre y varía según la posición y la edad del paciente.

Application of the theory of equal emphasis on muscle and bone in percutaneous vertebroplasty of lumbar osteoporotic compression fracture / 中国骨伤

OBJECTIVE@#To explore the clinical efficacy of percutaneous vertebroplasty(PVP) combined with nerve block in the treatment of lumbar osteoporotic vertebral compression fractures under the guidance of traditional chinese medicine "theory of equal emphasis on muscle and bone".@*METHODS@#Total of 115 patients with lumbar osteoporotic vertebral compression fractures were treated by percutaneous vertebroplasty from January 2015 to March 2022, including 51 males and 64 females, aged 25 to 86 (60.5±15.9) years. Among them, 48 cases were treated with PVP operation combined with erector spinae block and joint block of the injured vertebral articular eminence (intervention group), and 67 cases were treated with conventional PVP operation (control group). The visual analogue scale(VAS) and Oswestry disability index(ODI) before operation, 3 days, 1 month and 6 months after operation between two groups were evaluated. The operation time, number of punctures and intraoperative bleeding between two groups were compared.@*RESULTS@#The VAS and ODI scores of both groups improved significantly after operation compared with those before operation(P<0.05). Moreover, the VAS and ODI scores of 3 days and 1 month after operation of the intervention group improved more significantly than that of the control group(P<0.05). The difference of VAS and ODI scores before operation and 6 months after operation between two groups had no statistical significances(P>0.05). There was no statistically significant difference in the number of punctures and intraoperative bleeding between the two groups (P>0.05).@*CONCLUSION@#Based on the theory of "equal emphasis on muscles and bones", PVP combined with nerve block can effectively relieve paravertebral soft tissue spasm and other "muscle injuries", which can significantly improve short-term postoperative low back pain and lumbar spine mobility compared to conventional PVP treatment, and accelerate postoperative recovery, resulting in satisfactory clinical outcomes.

An MRI study of lateral vascular safety zones in oblique lumbar interbody fusion surgery / 中国修复重建外科杂志

OBJECTIVE@#To study the anatomical characteristics of blood vessels in the lateral segment of the vertebral body through the surgical approach of oblique lumbar interbody fusion (OLIF) using MRI imaging, and evaluate its potential vascular safety zone.@*METHODS@#The lumbar MRI data of 107 patients with low back and leg pain who met the selection criteria between October 2019 and November 2022 were retrospectively analyzed. The vascular emanation angles, vascular travel angles, and the length of vessels in the lateral segments of the left vertebral body of L 1-L 5, as well as the distance between the segmental vessels in different Moro junctions of the vertebral body and their distances from the edges of the vertebrae in the same sequence (bottom marked as I, top as S) were measured. The gap between the large abdominal vessels and the lateral vessels of the vertebral body was set as the lateral vascular safe zones of the lumbar spine, and the extent of the safe zones (namely the area between the vessels) was measured. The anterior 1/3 of the lumbar intervertebral disc was taken as the simulated puncture center, and the area with a diameter of 22 mm around it as the simulated channel area. The proportion of vessels in the channel was further counted. In addition, the proportions of segmental vessels at L 5 without a clear travel and with an emanation angel less than 90° were calculated.@*RESULTS@#Except for the differences in the vascular emanation angles between L 4 and L 5, the vascular travel angles between L 1, L 2 and L 4, L 5, and the length of vessels in the lateral segments of the vertebral body among L 1-L 4 were not significant ( P>0.05), the differences in the vascular emanation angles, vascular travel angles, and the length of vessels between the rest segments were all significant ( P<0.05). There was no significant difference in the distance between vessels of L 1, L 2 and L 2, L 3 at Moro Ⅰ-Ⅳ junctions ( P>0.05), in L 3, L 4 and L 4, L 5 at Ⅱ and Ⅲ junction ( P>0.05). There was no significant difference in the vascular distance of L 2, L 3 between Ⅱ, Ⅲ junction and Ⅲ, Ⅳ junction, and the vascular distance of L 3, L 4 between Ⅰ, Ⅱ junction and Ⅲ, Ⅳ junction ( P>0.05). The vascular distance of the other adjacent vertebral bodies was significant different between different Moro junctions ( P<0.05). Except that there was no significant difference in the distance between L 2I and L 3S at Ⅰ, Ⅱ junction, L 3I and L 4S at Ⅱ, Ⅲ junction, and L 2I and L 3S at Ⅲ, Ⅳ junction ( P>0.05), there was significant difference of the vascular distance between the bottom of one segment and the top of the next in the other segments ( P<0.05). Comparison between junctions: Except for the L 3S between Ⅰ, Ⅱ junction and Ⅱ, Ⅲ junction, and L 5S between Ⅰ, Ⅱ junction and Ⅱ, Ⅲ and Ⅲ, Ⅳ junctions had no significant difference ( P>0.05), there were significant differences in the distance between the other segmental vessels and the vertebral edge of the same sequence in different Moro junctions ( P<0.05). The overall proportion of vessels in the simulated channels was 40.19% (43/107), and the proportion of vessels in L 1 (41.12%, 44/107) and L 5 (18.69%, 20/107) was higher than that in the other segments. The proportion of vessels in the channel of Moro zone Ⅰ (46.73%, 50/107) and zone Ⅱ (32.71%, 35/107) was higher than that in the zone Ⅲ, while no segmental vessels in L 1 and L 2 were found in the channel of zone Ⅲ ( χ 2=74.950, P<0.001). Moreover, 26.17% (28/107) of the segmental vessels of lateral L 5 showed no movement, and 27.10% (29/107) vascular emanation angles of lateral L 5 were less than 90°.@*CONCLUSION@#L 1 and L 5 segmental vessels are most likely to be injured in Moro zones Ⅰ and Ⅱ, and the placement of OLIF channels in L 4, 5 at Ⅲ, Ⅳ junction should be avoided. It is usually safe to place fixation pins at the vertebral body edge on the cephalic side of the intervertebral space, but it is safer to place them on the caudal side in L 1, 2 (Ⅰ, Ⅱ junction), L 3, 4 (Ⅲ, Ⅳ junction), and L 4, 5 (Ⅱ, Ⅲ, Ⅳ junctions).

Clinical manifestation and treatment strategy of intervertebral space infection after radiofrequency ablation of lumbar nucleus pulposus / 中国骨伤

OBJECTIVE@#To study the clinical manifestations and treatment of intervertebral space infection after percutaneous lumbar radiofrequency ablation of nucleus pulposus.@*METHODS@#A retrospective analysis was performed of 496 patients who underwent percutaneous lumbar disc decompression using low-temperature plasma radiofrequency ablation nucleus pulposus from June 2009 to June 2019. Six patients had lumbar infection, and the infection rate was 1.21%. All patients were male, ranging in age from 20 to 61 years old. Three patients underwent single segment radiofrequency ablation, two patients underwent dual segments ablation;and one patient underwent three segment ablation, totaling 10 intervertebral discs. One patient was complicated with type 2 diabetes before operation. The interval between infection occurrence ranged from 21 to 65 days.@*RESULTS@#All 6 patients were followed up, and the duration ranged from 18 to 40 months, with an average of 24 months. Among them, 2 patients presented with symptoms of low back pain accompanied by fever, and imaging examination showed intervertebral space infection accompanied by abscess. In addition, 4 patients experienced low back pain but no fever, and MRI showed abnormal signals of the infected intervertebral endplate or vertebral body. One patient showed staphylococcus aureus in blood culture, while the remaining 5 patients showed negative bacterial culture. All the patients were treated with antibiotics after diagnosis. Four patients were treated with conservative management to control infection;1 patient was treated with debridement of posterior lumbar infection focus, and 1 patient was treated with debridement of posterior lumbar infection focus combined with interbody fusion and internal fixation.@*CONCLUSION@#The occurrence of intervertebral space infection during lumbar radiofrequency ablation nucleoplasty should be given sufficient attention. Strict aseptic technique, avoiding repeated multi segment puncture, realizing early detection and treatment, and selecting appropriate treatment methods according to the severity of infection is the guarantee of achieving curative effect.

An anatomical training model for cerebrospinal liquid collection and myelography in embalmed dog cadavers / Modelo anatômico para treinamento de colheita de líquido cerebroespinhal e mielografia em cadáveres de cães quimicamente preparados

In research and academic activities, guidelines are essential and imperative especially on the use of animals. Alternative methods that do not bring academic or scientific harm should also be sought. This study aimed to develop a training model for the collection of cerebrospinal fluid (CSF) and myelography in the cervical and lumbar regions in cadavers of embalmed dogs, using an alcoholic solution and curing salts for fixation and conservation. The dogs were divided into 4 grups of 8 animal each and stored between 2ºC and 6ºC, for 30, 60, 90, or 120 days. Durotomy was performed to implant two urethral catheters (one in the cranial direction and another in the caudal direction to the spinal cord access site), in the subduraracnoid space. This space was fixed via manual infusion of saline solution with a 20-mL syringe to simulate the presence of the CSF and the positive pressure, while the puncture was made. Four cadavers of each group were randomly selected for the CSF puncture from the atlantooccipital joint and in the lumbar region between L5 and L6, respectively, and four were used for CSF puncture training, in which radiographic contrast (myelography) was injected in the same locations. This model was cost-effective, did not utilize toxic products, and can preserve cadavers for up to 120 days. In this novel anatomical model, a maximum of 15 students can be trained on CSF puncture, allowing cervical and lumbar myelography and at least 30 perforations per cadaver.

É essencial e imperioso ter critério quanto ao uso de animais em pesquisa e atividades de ensino e, consequentemente, buscar métodos alternativos que não causem prejuízo acadêmico ou científico. Para que não ocorra deterioração dos tecidos, a fixação e conservação de peças anatômicas e cadáveres devem ser realizadas. Objetivou-se, com este estudo, desenvolver um modelo anatômico para treinamento de colheita de líquido cerebroespinhal (LCE) e mielografia, nas regiões cervical e lombar. Os cães foram divididos em quatro grupos contendo oito animais cada e armazenados entre 2ºC e 6ºC, por 30, 60, 90 ou 120 dias. Foi realizada durotomia para implantação de duas sondas uretrais, no espaço subaracnóide. A infusão manual de solução fisiológica com seringa de 20 mL foi utilizada para simular a presença do LCE e a pressão positiva, enquanto era feita a punção. Quatro cadáveres de cada grupo foram selecionados para a punção de LCE na articulação atlantooccipital e na região lombar entre L5 e L6, e quatro foram utilizados para o treinamento da punção de LCE e injeção de contraste radiográfico (mielografia). A técnica anatômica empregada possibilitou o desenvolvimento de um modelo visando ao ensino e pesquisa da radiologia em cadáveres de cães quimicamente preparados, a custo baixo e sem utilização de produtos tóxicos, mantidos sob refrigeração por 120 dias. Com isso, um máximo de 15 alunos podem ser treinados em punção do LCR, permitindo mielografia cervical e lombar com 30 perfurações por cadáver.

Características clínicas, métodos diagnósticos y evolución de la criptococosis extrameníngea en personas viviendo con VIH / Clinical features, diagnosis methods and evolution in non meningeal cryptococcosis in people living with VIH

La criptococosis es una micosis grave que se manifiesta, en el 90% de los casos, como una meningoencefalitis, especialmente en las personas con VIH. El objetivo de este estudio es describir los casos de criptococosis extrameníngea en personas viviendo con VIH y conocer cuántas de estas padecen compromiso meníngeo concomitante. Además, determinar la relación con el título de antígeno polisacárido capsular de Cryptococcus en suero. Se realizó un estudio retrospectivo, observacional y analítico. Se incluyeron personas viviendo con VIH cuyo diagnóstico inicial de criptococosis se había realizado a partir de muestras extrameníngeas en el período comprendido entre 2012 y 2019. Los pacientes se dividieron en dos grupos. Grupo 1, pacientes sin compromiso meníngeo; Grupo 2, aquellos que finalmente tenían compromiso del SNC. De un total de 531 criptococosis registradas en ese período, se incluyeron 113 pacientes (21%), de los cuales en 58 se comprobó el compromiso meníngeo. No se observaron diferencias significativas en cuanto a la mortalidad entre ambos grupos.Ninguno de los pacientes con antigenemia por LFA (antígeno capsular en suero por inmunocromatografía) positiva, pero con antigenemia por aglutinación de partículas de látex (AL) negativa, tuvo compromiso meníngeo. Se observó que títulos de antígeno para Cryptococcus en suero por AL mayor o igual a 1/100 se correlacionaron con un aumento de 30 veces en la posibilidad de padecer meningitis. En todos los casos se debe descartar el compromiso del SNC. La AL sigue siendo una prueba útil y complementaria, debido a que en los casos con AL negativa no se observó compromiso meníngeo

Cryptococcosis is a serious mycosis that manifests itself, in 90% of cases, as meningoencephalitis, especially in AIDS patients. The objective of this study is to describe the extra-meningeal cases of cryptococcosis in people living with HIV and to know how many of them suffer from concomitant meningeal involvement. Also, to determine its relationship with the Cryptococcus capsular polysaccharide antigen titer in serum.A retrospective, observational and analytical study was carried out. HIV-positive patients whose initial diagnosis had been made from extrameningeal samples in the period between 2012 and 2019 were included. The patients were divided into 2 groups. Group 1: patients without meningeal involvement; group 2: those who finally had CNS involvement.Of a total of 531 cryptococcosis registered in this period, 113 patients (21%) were included, of whom meningeal involvement was confirmed in 58. No significant differences were observed in terms of mortality in both groups.None of the patients with positive LFA antigenemia (Capsular antigen detection by lateral Flow assay) but negative latex particle agglutination (LA) antigenemia had meningeal involvement. LFA was found to be highly sensitive and allows early diagnosis, but it does not replace other diagnostic procedures.Serum Cryptococcus antigen titers for by LA greater than or equal to 1/100 were found to correlate with a 30-fold increase in the likelihood of meningitis.In all cases, CNS involvement must be ruled out. LA continues to be a useful and complementary test, because in cases with negative LA, no meningeal involvement was observed

Sepsis neonatal precoz: recomendaciones para su abordaje en la práctica clínica / Early neonatal sepsis: recommendations for approach in clinical practice / Sepse neonatal precoce: recomendações para sua abordagem na prática clínica

La sepsis neonatal precoz se define como la que se manifiesta en las primeras 72 horas de vida. Es una importante causa de morbilidad y mortalidad neonatal. Su incidencia es inversamente proporcional a la edad gestacional. Los microorganismos considerados como frecuentes son Streptoccocus del grupo B, Escherichia coli y Listeria monocytogenes. El diagnóstico de sepsis precoz se basa principalmente en la presencia de factores de riesgo como la corioamnionitis y la edad gestacional. Los signos clínicos son inespecíficos y los exámenes paraclínicos disponibles actualmente, como los reactantes de fase aguda (proteína C reactiva y procalcitonia) tienen escaso valor predictivo positivo. Se realizó una revisión bibliográfica de las últimas publicaciones disponibles sobre sepsis neonatal precoz en recién nacidos, en cuanto a su sospecha, confirmación diagnóstica y tratamiento. A partir de las últimas publicaciones se confeccionó una guía para el manejo clínico de los recién nacidos con sospecha de sepsis precoz.

Early neonatal sepsis is defined as that type of sepsis with an onset within the first 72 hours of life and that is a major cause of neonatal morbidity and mortality. Its incidence is inversely proportional to its gestational age. Frequent microorganisms are group B Streptococcus, Escherichia coli and Listeria monocytogenes. Early sepsis diagnosis is mainly based on the presence of risk factors such as chorioamnionitis and gestational age. Clinical signs are non-specific and currently available paraclinical tests such as acute phase reactants (C-reactive protein and procalcitonin) have little positive predictive value. A bibliographic review of the suspicion, diagnostic confirmation and treatment on Early Neonatal Sepsis in newborns in the latest papers and guidelines were prepared for the clinical treatment of newborns with suspected early sepsis.

A sepse neonatal precoce é definida como aquela que se manifesta nas primeiras 72 horas de vida e que é uma das principais causas de morbidade e mortalidade neonatal. Sua incidência é inversamente proporcional à idade gestacional. Os microrganismos considerados frequentes são o Streptococcus grupo B, Escherichia coli e Listeria monocytogenes. O diagnóstico de sepse precoce baseia-se principalmente na presença de fatores de risco como a coioamnionite e a idade gestacional. Os sinais clínicos são inespecíficos e os testes para-clínicos atualmente disponíveis, como reagentes de fase aguda (proteína C-reativa e procalcitonia) têm pouco valor preditivo positivo. Fizemos uma revisão bibliográfica das últimas publicações disponíveis sobre sepse neonatal precoce em recém-nascidos em termos de suspeita e confirmação diagnóstica e tratamento. Com base nas últimas publicações, elaboramos um guia para o manejo clínico de recém-nascidos com suspeita de sepse precoce.

Um cirurgião sob o olhar de Deus

Objetivo A síndrome de Terson (ST), também conhecida como hemorragia vítrea, é relatada em pacientes com hemorragia subaracnóide causada por um aneurisma rompido. Este estudo tem como objetivo avaliar a presença de hemorragia ocular nesses pacientes, buscando identificar aqueles que poderiam se beneficiar do tratamento específico para a recuperação do déficit visual. Métodos Estudo prospectivo de 53 pacientes com hemorragia subaracnóide espontânea (SSAH) por aneurisma rompido. Os pacientes foram avaliados quanto à hemorragia vítrea por fundoscopia indireta com 6 a 12 meses de seguimento. Resultados A idade dos pacientes variou de 17 a 79 anos (média de 45,9 ± 11,7); 39 pacientes eram do sexo feminino (73%) e 14 do sexo masculino (27%). Seis pacientes (11%) apresentaram ST e 83,3% apresentaram perda transitória de consciência durante a ictus. Conclusões Uma avaliação oftalmológica deve ser realizada rotineiramente em pacientes com hemorragia subaracnóide, especialmente naqueles com pior grau neurológico. Além disso, o prognóstico foi ruim em pacientes com ST.

Effect of bone cement distribution on the clinical outcome of unilateral transpedicular puncture for spinal osteoporotic fractures / 中国骨伤

OBJECTIVE@#To investigate the effects of different bone cement morphology distribution on the clinical efficacy of unilateral percutaneous vertebroplasty(PVP) for spinal osteoporotic fractures.@*METHODS@#The clinical data of 66 patients with osteoporotic vertebral compression fractures received unilateral PVP treatment from January 2019 to April 2020 were retrospectively analyzed. There were 16 males and 50 females, including 83 vertebral bodies, 45 thoracic vertebrae and 38 lumbar vertebrae, and 55 patients with single-segment, 6 double-segment, 4 three-segment and 1 four-segment. The age ranged from 60 to 93 years with an average of (76.83±8.65) years. The included patients were admitted to hospital 1 to 10 days after onset, and were diagnosed by anteroposterior and lateral X-rays, MRI and bone density examination before surgery. According to the shape of bone cement in postoperative X-ray, the patients were divided into O-shaped group (28 cases) and H-shaped group (38 cases). In O-shaped group, the bone cement presented agglomeration mass distribution in the affected vertebra in postoperative X-ray while the bone cement presented disseminated honeycomb distribution in the affected vertebrae in H-shaped group. Bone cement injection volume was collected in two groups. The intraoperative bone cement leakage and postoperative adjacent vertebral fractures were observed. The VAS of the two groups before operation and 1 day, 1 month, 6 months and 1 year after operation were compared;and ODI of the two groups 1 day, 6 months and 1 year after operation were compared. The kyphosis angle and anterior height of the affected vertebrae were measured before operation and 1 week, 1 year after operation.@*RESULTS@#All 66 patients completed 1-year follow-up, and all patients healed well at the puncture site after surgery. There were 1 case and 8 cases of bone cement leakage in O-shaped group and H-shaped group during surgery respectively (P<0.05), but no serious complications occurred. One case occurred adjacent vertebral fracture in both groups during one-year follow-up (P>0.05). There was no statistical significance in injection amount of bone cement between the two groups (P>0.05). The VAS scores of O-shaped group and H-shaped group were 7.89±0.79, 2.75±1.08, 0.46±0.58, 0.36±0.49 and 8.00±1.04, 2.58±1.15, 0.53±0.56, 0.42±0.50 before operation, 1 day, 6 months, 1 year after operation respectively, and there was no statistical significance(P>0.05), and the VAS scores were 0.96±0.58 and 1.18±0.83 at 1 month after operation respectively, with statistical significance(P<0.05). The ODI scores of O-shaped group and H-shaped group were 12.43±3.78, 10.00±2.46, 8.43±1.50 and 12.11±3.68, 9.53±2.35, 8.32±1.51 at 1 day, 6 months and 1 year after surgery respectively, and there was no statistical significance between the two groups(P>0.05). There were no statistical significance in kyphotic angles and anterior height before surgery and 1 week, 1 year after surgery between two groups (P>0.05).@*CONCLUSION@#No matter the distribution of bone cement is O-shape or H-shape, it can achieve good clinical effect, and the prognosis effect is equivalent. Therefore, when performing unilateral puncture PVP surgery, it is not necessary to deliberately increase the puncture angle of the puncture needle in order to achieve the full diffusion of the affected vertebrae, so as to reduce the risk of damaging important structures and bone cement leakage.

Principales técnicas quirúrgicas para el médico general / Main surgical techniques for the general practitioner

Existen múltiples técnicas y procedimientos quirúrgicos en la práctica clínica que todo médico general debería conocer y manejar ante una situación de urgencia que involucre la resolución inmediata. El no actuar en una situación emergente, ya sea por inexperiencia o desconocimiento puede poner en riesgo la vida del paciente. Entre estos procedimientos, podemos encontrar las suturas (y sus distintos tipos), la paracentesis, la apendicectomía (abierta y laparoscópica), la punción lumbar y la cesárea. Es por esto que se creó este artículo de educación médica utilizando un método explicativo de las principales técnicas quirúrgicas de forma resumida y concisa, basado en la literatura disponible, con el fin de servir como guía de bolsillo y revisión rápida para estudiantes, internos y médicos que deben enfrentarse a un procedimiento quirúrgico que no puede ser diferido.

There are multiple surgical techniques and procedures in the day to day clinical practice that every general practitioner should know how to do and handle in an emergency situation that requires immediate resolution. Failure to act in an emergent situation, either due to inexperience or ignorance, can put a patient's life at risk. Between these procedures there are sutures (and its variations), paracentesis, appendectomy (open and laparoscopic), lumbar puncture and cesarean delivery. That is why this medical education article was developed using an explicative method of the main surgical techniques in a summarized and concise way, based on the available literature, in order to serve as a pocket guide and quick review for students, interns and doctors who must face a surgical procedure that cannot be deferred.

Pituitary Apoplexy, Meningitis and Cerebral Infarction - A Perplexing Trifecta

Pituitary apoplexy (PA) is a clinical diagnosis comprising a sudden onset of headache, neurological deficits, endocrine disturbances, altered consciousness, visual loss, or ophthalmoplegia. However, clinically, the presentation of PA is extremely variable and occasionally fatal. While meningitis and cerebral infarcts are themselves serious diseases, they are rarely seen as manifestations of PA and are exceedingly rare when present together. We present the case of a 20-year-old male with a rapid progression of symptoms of meningitis, PA and stroke. The present article seeks to emphasize a rare manifestation of PA with an attempt to understand the intricacies of its evaluation and management.

Retiro de aguja intradural en la columna toracolumbar. Reporte de un caso / Spinal needle removal in the thoracolumbar spine. Case report

La presencia de elementos extraños dentro del canal raquídeo es infrecuente y no hay claro consenso respecto de su tratamiento. Las publicaciones sobre fragmentos de proyectil de arma de fuego intracanal recomiendan la exéresis de los fragmentos ante la posibilidad de migración, sobre todo, cuando están en una zona próxima al cono medular. Se debería proceder del mismo modo ante una aguja dentro del canal espinal. Presentamos a una paciente con dolor radicular invalidante provocado por un fragmento de aguja dentro del canal espinal luego de una cesárea. Nivel de Evidencia: IV

The presence of foreign elements within the spinal canal is rare and there is no clear consensus regarding its treatment. The publications on intracanal firearm projectile fragments recommend exeresis of the fragments due to the possibility of migration, especially when they are in an area close to the medullary cone. The same procedure should be applied to a needle inside the spinal canal. We present a patient with disabling radicular pain caused by a needle fragment within the spinal canal after cesarean section. Level of Evidence: IV

Uso de la ecografía en tiempo estático para la punción lumbar / Use of static-time ecography for lumbar puncture

La ecografía es una herramienta de gran ayuda en medicina, rápido, tecnología portátil y segura. Así por ejemplo realización de la punción lumbar (accesos vasculares y bloqueos regionales) para la obtención de líquido cefalorraquídeo por médicos de emergencia y anestesiólogos, etc. Como ventajas tenemos: disminución del número de punciones lumbares, satisfacción del paciente. Es una alternativa en pacientes con alta probabilidad de punción lumbar difícil como por ejemplo: pacientes obesos, pacientes con edema, con antecedentes de cirugía columna previa, escoliosis. En el presente artículo tiene como objetivo brindar información sobre la utilidad de la ecografía en la punción lumbar en adultos y la obtención del líquido cefalorraquídeo. Proponer una abordaje metódico para puncion lumbar y el bloqueo neuroaxial en tiempo estático por ecografía de la columna lumbar del adulto. Se realizó la búsqueda de la bibliografía de revistas académicas de medicina y anestesiología disponibles en base de datos confiables.

Ultrasound is a tool of great help in medicine, fast, portable and safe technology. Thus, for example, the performance of lumbar punctures (vascular accesses and regional blocks) to obtain cerebrospinal fluid by emergency physicians and anesthesiologists, etc. As advantages we have: decrease in the number of lumbar punctures, patient satisfaction. It is an alternative in patients with a high probability of difficult lumbar puncture such as: obese patients, patients with edema, with a history of previous spinal surgery, scoliosis. The aim of this article is to provide information on the usefulness of ultrasound in lumbar puncture in adults and obtaining cerebrospinal fluid. To propose a methodical approach for lumbar puncture and neuraxial block in static time by ultrasound of the lumbar spine in adults. A search was made of the bibliography of academic journals of medicine and anesthesiology available in reliable databases.

Normal pressure hydrocephalus: Diagnostic delay / Hidrocefalia de presión normal: demora en el diagnóstico

Abstract. Introduction: Normotensive hydrocephalus is a differential diagnosis in the evaluation of the dementia syndrome. The diagnostic protocols would allow detecting this pathology that has more effective treatment than other dementias. Objective: To describe a population with clinical suspicion of normal pressure hydrocephalus evaluated in a Colombian psychiatric hospital and discuss the possible reasons for its diagnostic and therapeutic delay. Materials and methods: We conducted a retrospective study of medical records to identify patients with suspected normal pressure hydrocephalus during a 5-year period. Results: Thirty-five patients with suspected normal pressure hydrocephalus underwent diagnostic lumbar puncture and five of them were considered candidates for a peritoneal-venous shunt, but none underwent this surgical procedure. After three to six months of the lumbar puncture, the gait pattern improved in 22.8% of the patients, cognition in 22.8%, and sphincter control in 11.4%. Improvement was not sustained in the long term (1 year) in any of them. Conclusion: This study suggests the poor implementation of the protocols for evaluating patients with cognitive deficits and delays in the diagnosis of normal pressure hydrocephalus. A small number of patients were identified as candidates for treatment. Normal pressure hydrocephalus is a potentially reversible clinical entity with the placement of a peritoneal ventricular shunt, but delays in diagnosis and treatment have deleterious consequences for patients and their families.

Resumen. Introducción. La hidrocefalia normotensiva es un diagnóstico diferencial en la evaluación del síndrome demencial. Los protocolos diagnósticos permitirían detectar esta condición, cuyo tratamiento es más efectivo que el de otras demencias. Objetivo. Describir una población con sospecha clínica de hidrocefalia normotensiva evaluada en un hospital psiquiátrico colombiano y discutir las posibles razones de la demora en el diagnóstico y en la terapia de esta condición clínica. Materiales y métodos. Se hizo un estudio retrospectivo de los registros médicos para detectar pacientes con sospecha de hidrocefalia normotensiva durante un período de cinco años. Resultados. A 35 pacientes con sospecha de hidrocefalia normotensiva se les hizo una punción lumbar diagnóstica. Cinco de ellos se consideraron candidatos para una derivación ventrículo-peritoneal, pero ninguno se sometió a este procedimiento quirúrgico. A los 3-6 meses de la punción lumbar, se observó una mejoría del patrón de la marcha en el 22,8 % de los pacientes, de la cognición en el 22,8 % y del control del esfínter en el 11,4 %. La mejoría no se mantuvo a largo plazo (un año) en ningún paciente. Conclusión. Se encontró una implementación deficiente de los protocolos de evaluación de los pacientes con déficit cognitivos y demoras en el diagnóstico de la hidrocefalia normotensiva, así como un número reducido de pacientes clasificados como candidatos para el tratamiento. La hidrocefalia normotensiva es una condición clínica potencialmente reversible con la colocación de una derivación ventrículo-peritoneal. Los retrasos en el diagnóstico y en el tratamiento tienen consecuencias perjudiciales para los pacientes y sus familias.

Cerebrospinal fluid analysis in 58 ruminants showing neurological disorders / Análise do líquido cefalorraquidiano em 58 ruminantes com distúrbios neurológicos

Ruminants may be affected by a wide variety of central nervous system (CNS) diseases. Cerebrospinal fluid (CSF) analysis forms the basis for ante mortem diagnostic evaluation of ruminants with clinical signs involving the CNS. Despite its importance as a tool to aid diagnosis, data regarding CSF examinations in spontaneous cases of CNS diseases in ruminants from Brazil are limited, and most reports involve experimental studies. Therefore, this study aimed to report the results of CSF analysis in 58 ruminants showing signs of neurological disorders. CSF samples for analysis were obtained from 32 cattle, 20 sheep, and 6 goats by cerebello-medullary cistern (n=54) or lumbosacral space (n=4) puncture. These ruminants showed neurological signs related to viral (n=13), mycotic (n=3), or bacterial (n=15) infections, and toxic (n=21), traumatic (n=4), or congenital disorders (n=2). CSF analysis from ruminants with viral infections presented lymphocytic pleocytosis, even though CSF showed no changes in several cases of rabies. Neutrophilic pleocytosis, cloudiness, presence of fibrin clots, and abnormal coloration were evident in the CSF of most cases of CNS bacterial infection, such as meningoencephalitis, meningitis, abscesses, myelitis, and a case of conidiobolomycosis. On the other hand, CSF was unchanged in most cases of toxic disorders, as botulism and hepatic encephalopathy. Elevated CSF density was observed in 60% of ruminants diagnosed with polioencephalomalacia. Our findings show that evaluation of CSF is a valuable diagnostic tool when used in association with epidemiological, clinical and pathological findings for diagnosis of CNS diseases in ruminants.(AU)

Os ruminantes podem ser afetados por uma grande variedade de doenças do sistema nervoso central (SNC). A análise do líquido cefalorraquidiano (LCR) constitui a base da avaliação diagnóstica ante mortem de ruminantes com sinais clínicos envolvendo o SNC. Apesar de sua importância como ferramenta para auxiliar no diagnóstico, os dados referentes aos exames do LCR em casos espontâneos de doenças do SNC em ruminantes no Brasil são limitados, e, a maioria dos relatos envolve estudos experimentais. Portanto, este trabalho teve como objetivo relatar os resultados da análise do LCR em 58 ruminantes com distúrbios neurológicos. Amostras do LCR foram obtidas de 32 bovinos, 20 ovinos e 6 caprinos por punção da cisterna cerebelo-medular (n=54) ou espaço lombossacro (n=4) para posterior análise. Esses ruminantes apresentaram sinais neurológicos relacionados a infecções virais (n=13), micóticas (n=3) ou bacterianas (n=15), e desordens tóxicas (n=21), traumáticas (n=4) ou congênitas (n=2) A análise do LCR de ruminantes com infecções virais apresentou pleocitose linfocítica, embora, em vários casos de raiva, o LCR não tenha apresentado alterações. Pleocitose neutrofílica, turbidez, presença de coágulos de fibrina e coloração anormal foram evidentes no LCR da maioria dos casos de infecções bacterianas do SNC, como meningoencefalites, meningites, abscessos, mielite e um caso de conidiobolomicose. Por outro lado, o LCR não foi alterado na maioria dos casos dos distúrbios tóxicos, como botulismo e encefalopatia hepática. A densidade elevada no LCR foi observada em 60% dos ruminantes diagnosticados com polioencefalomalácia. Nossos resultados mostram que a avaliação do LCR é uma valiosa ferramenta de diagnóstico, quando usada em associação com os achados epidemiológicos, clínicos e patológicos para o diagnóstico de doenças do SNC em ruminantes.(AU)

Post-dural puncture headache incidence after cerebrospinal fluid aspiration. A prospective observational study / Incidência de cefaleia pós-punção dural após aspiração do líquido cefalorraquidiano. Um estudo observacional prospectivo

Abstract Background: Post-dural puncture headache (PDPH) is an iatrogenic condition following lumbar puncture (LP). Incidence is variable and often associated with young females. Technical features of the procedure (i.e. needle gauge) have been investigated; however there is no investigation on the method of cerebrospinal fluid (CSF) collection. Objective: To investigate whether mild CSF aspiration is associated with increased PDPH in selected patients. Methods: 336 subjects were eligible to the study. Data on 237 patients from a tertiary neurology hospital who underwent diagnostic LP from February 2010 to December 2012 were analysed. Patient demographics, lumbar puncture method, CSF biochemical characteristics, opening pressures, and a follow-up inquire on PDPH occurrence were collected. CSF was collected either by allowing free flow or by mild aspiration. Results: The aspiration arm (n=163) was comprised of 55.8% females with mean age of 52(35‒69) years. Sex distribution was not different between the two arms (p=0.191). A significant larger amount of CSF was obtained in the aspiration arm (p=0.011). The incidence of PDPH in the aspiration arm was 16.5% versus 20.2% in the free flow arm, not statistically significant (p=0.489). No relevant associations emerged from the analyses in the subgroup aged <65 years. Conclusions: Aspiration of the CSF during LP was not associated with increased rates of PDPH compared to the standard method, particularly when larger amounts of CSF are required and ideal conditions are met. This is the first study looking into this matter, aiming to add safety to the procedure. Further randomized trials are required.

Resumo Introdução: Cefaleia pós-punção dural (CPPD) é uma condição iatrogênica após punção lombar (LP). Incidência é variável; frequentemente associada a mulheres jovens. Características técnicas do procedimento (ex: calibre da agulha) foram investigadas; no entanto, não há investigação sobre o método de coleta do líquido cefalorraquidiano (LCR). Objetivo: Avaliar se aspiração leve do LCR está associada ao aumento da CPPD em pacientes selecionados. Métodos: 336 indivíduos foram elegíveis para o estudo. Dados de 237 pacientes em um hospital neurológico terciário que foram submetidos à PL diagnóstica de fevereiro de 2010 a dezembro de 2012 foram analisados. Coletamos dados demográficos dos pacientes, método da PL, características bioquímicas do LCR, pressões de abertura e ocorrência da CPPD. Todos as PLs ocorreram em decúbito lateral. O LCR foi coletado permitindo livre fluxo ou aspiração leve. Resultados: O grupo aspiração (n=163) apresentava 55,8% de mulheres, idade média de 52(35‒69) anos. A distribuição por sexo não foi diferente entre os dois grupos (p=0,191). Uma quantidade maior de LCR foi obtida no grupo aspiração (p=0,011). A incidência de CPPD no grupo de aspiração foi de 16,5% versus 20,2% no fluxo livre, não estatisticamente significante (p=0,489). Nenhuma associação emergiu das análises no subgrupo com idades <65 anos. Conclusões: A aspiração do LCR durante PL não está associada ao aumento da CPPD em comparação com a método padrão, particularmente quando quantidades maiores de LCR são necessárias e condições ideais são satisfeitas. Este é o primeiro estudo a investigar o topico, visando aumentar a segurança do procedimento. Necessita-se futuros estudos randomizados.

Parálisis del nervio motor ocular externo luego de anestesia neuroaxial combinada epidural-espinal / Paralysis of the external oculomotor nerve after combined epidural-spinal neuroaxial anesthesia

Introducción: El abordaje del espacio subaracnoideo fue descrito por Quincke en el 1891. En la actualidad es práctica común para la realización de la anestesia neuroaxial subaracnoidea en las pacientes obstétricas. Las complicaciones descritas, asociadas a esto, son varias. Dentro de estas, la parálisis del nervio abducens o VI par no es frecuente y en ocasiones, no está relacionada a la punción ya que se produce días después del evento. Objetivo: Revisar la información relacionada con la complicación de parálisis del VI par. Presentación del caso: Paciente de 33 años de edad, femenina, de profesión médico, con antecedentes personales de migraña, historia de anestesia neuroaxial epidural sin complicaciones, que para la realización de una cesárea de segmento arciforme y salpinguectomia parcial bilateral, recibió una anestesia combinada peridural-espinal. El transoperatorio transcurre con estabilidad hemodinámica, hizo cefalea al tercer día del posoperatorio, que la atribuyó al antecedente de migraña y fue tratada sin evaluación por anestesiología con dipirona. A los 10 días de operada hace desviación de la mirada y diplopia, se diagnostica parálisis del VI par. Fue tratada por Neurología y se plantean varios diagnósticos diferenciales. Los estudios imagenológicos resultan negativos, se trató con vitaminas y se produjo remisión a las 6 semanas. Conclusiones: El diagnóstico de esta complicación es necesario ya que puede pasar inadvertida la relación con la anestesia y, por tanto, ser mal conducido su tratamiento(AU)

Introduction: The approach to the subarachnoid space was described by Quincke in 1891. It is now a common practice to perform subarachnoid neuroaxial anesthesia in obstetric patients. The complications described, associated with this, are several. Within these, the paralysis of the abducens nerve or sixth pair is not frequent and sometimes is not related to the puncture, since it occurs days after the event. Objective: To review the information related to the complication of paralysis of the sixth pair. Case presentation: A 33-year-old female patient, a physician, with a personal history of migraine, a history of epidural neuroaxial anesthesia without complications, who underwent combined epidural-spinal anesthesia for performing a cranial segment cesarean section and bilateral partial salpingectomy. The transoperative period runs with hemodynamic stability. There was headache three days after surgery, which was attributed to the migraine history and the patient was treated, without evaluation by anesthesiology, with dipyrone. At 10 days after surgery, the eyes are diverted and diplopia is manifested, paralysis of the sixth pair is diagnosed. She was treated by neurology and several differential diagnoses were proposed. Imaging studies are negative. She was treated with vitamins and remission occurred at six weeks. Conclusions: The diagnosis of this complication is necessary, since the relationship with anesthesia may go unnoticed and, therefore, its treatment may be poorly conducted(AU)