Reanimación cardiopulmonar en prono a propósito de un caso / Case report cardiopulmonary resuscitation in prone position

Prone position is necessary for some neurosurgical and othopedic procedures. Cardiopulmonary resuscitation (CPR) in prone position was first described by McNeil in 1989, since then several successful cases have been published. We report the case of a 72-year-old patient with history of stage IV breast cancer who presented acute spinal cord compression due to a vertebral fracture at T10 level. Surgical spinal cord decompression and posterior arthrodesis was performed. After three hours of surgery, cardiorespiratory arrest occur while patient was in prone position. Unestable spine and fixed head made turning the patient into supine position very difficult, consequently prone CPR manoeuvres were started with recovery of spontaneous circulation. In case of cardiorespiratory arrest in prone position, the intense fixation and the extent of the surgical incision make the change to supine a time-consuming and technically complex procedure. If cardiorespiratory arrest occurs in the prone position, CPR in the prone position might be reasonable.

La posición de decúbito prono es necesaria para la realización de algunos procedimientos neuroquirúrgicos y traumatológicos. La reanimación cardiopulmonar (RCP) en prono fue descrita por primera vez por McNeil en 1989, desde entonces se han publicado varios casos de RCP en prono con buen resultado. Presentamos el caso de una paciente de 72 años con antecedentes de carcinoma de mama estadio IV que presenta síndrome de compresión medular por fractura patológica a nivel de T10. Se decide realizar descompresión medular y artrodesis por vía posterior. A las 3 horas de la cirugía se produjo parada cardiorrespiratoria en prono. Dada la inestabilidad espinal y la fijación de la paciente, el cambio a supino era complejo por lo que se iniciaron maniobras de RCP en prono con posterior recuperación de circulación espontánea. En caso de parda cardiorrespiratoria en prono, la intensa fijación y la extensión de la incisión quirúrgica hace que el cambio a supino consuma tiempo y sea técnicamente complejo. Si la PCR ocurre en prono, está justificado iniciar las maniobras de RCP en esta posición.

Modified simple decompression in the treatment of cubital tunnel syndrome: avoiding ulnar nerve subluxation / Descompressão simples modificada no tratamento da síndrome do túnel cubital: evitando subluxação do nervo ulnar

ABSTRACT Objective In this study, we propose a modification to the simple decompression technique that contains the ulnar nerve in the cubital fossa, thus preventing subluxation during forearm flexion movements. Methods Five consecutive patients with leprosy-associated cubital tunnel syndrome underwent surgery with the modified technique between July 2011 and October 2012. Results The most common symptoms were neuropathic pain and sensory changes (both 60%). On the McGowan scale, three patients maintained their preoperative score and two patients improved by two points, while on the Louisiana State University Health Sciences Center scale, two patients maintained the same scores, two improved by two points, and one improved by one point. Four patients were able to discontinue corticosteroid use. The mean follow-up time was 25.6 months (range 2-48 months). There were no recurrences or subluxations in the long-term. Conclusion This alternative technique resulted in excellent functional results, as well as successful withdrawal from corticosteroids. Furthermore, it resulted in no ulnar nerve subluxations.

RESUMO Objetivo Neste manuscrito apresentamos uma modificação da técnica de descompressão simples do nervo ulnar no túnel cubital que impede a subluxação do nervo em movimentos de flexão do antebraço. Métodos Foram incluídos cinco pacientes consecutivos acometidos por síndrome do túnel cubital (Hanseníase) submetidos à cirurgia entre 2011 e 2012. Resultados Os sintomas mais comuns foram dor neuropática e alterações sensitivas (60%). No pós-operatório, três pacientes mantiveram o mesmo escore e dois melhoraram dois pontos na escala de McGowan, enquanto na escala Louisiana State University Health Sciences Center, dois pacientes mantiveram o mesmo escore, dois melhoraram dois pontos e um melhorou um ponto. Os corticosteróides foram descontinuados em quatro pacientes. O tempo médio de seguimento foi 25,6 meses (variação 2-48 meses). Não foram observadas recorrência ou subluxação no longo prazo. Conclusões A técnica alternativa apresentou excelentes resultados funcionais e foi bem sucedida na retirada dos corticosteróides. Ademais, subluxações do nervo ulnar não foram observadas.

Results of Total Hip Arthroplasty after Core Decompression with Tantalum Rod for Osteonecrosis of the Femoral Head

BACKGROUND: Early stage osteonecrosis of the femoral head (ONFH) has many treatment options including core decompression with implantation of a tantalum rod. The purpose of this study was to evaluate clinical and radiological outcomes and potential complications during conversion total hip arthroplasty (THA) in such patients. METHODS: Six male patients (8 hips) underwent THA subsequent to removing a tantalum rod (group I) from April 2010 to November 2011. We retrospectively reviewed the medical records of these patients. We enrolled 12 age- and sex-matched patients (16 hips) during the same period, who had undergone primary THA without a previous operation as the control group (group II). All patients were followed for at least 3 years. We checked the Harris hip score (HHS), operative time, and volume of blood loss. Radiological results, including inclination, anteversion of the acetabular cup, presence of periprosthetic osteolysis, and subsidence of femoral stem were checked at the last follow-up. RESULTS: The mean preoperative HHS values were 56.5 (range, 50 to 62) and 59.1 (range, 42 to 70) in groups I and II, respectively. The HHS improved to 96.0 (range, 93 to 100) and 97.6 (range, 93 to 100), respectively, at the 3-year follow-up (p = 0.172). Mean operation time was 98.8 minutes (range, 70 to 120 minutes) in group I and 77.5 minutes (range, 60 to 115 minutes) in group II (p = 0.006). Total blood loss volumes were 1,193.8 mL (range, 960 to 1,360 mL) and 944.1 mL (range, 640 to 1,280 mL) in groups I and II, respectively (p = 0.004). No significant differences in inclination or anteversion of acetabular cup and no evidence of osteolysis or subsidence of the femoral stem were reported in either group in radiological follow-up results. However, one case of squeaking occurred in group I during the follow-up. CONCLUSIONS: The two groups showed no clinical or radiological differences except extended operative time and increased blood loss. However, the incidence of squeaking (1 of 8 hips) was higher, as compared to the control group or previously reported values.

Evaluation of Outcome of Posterior Decompression and Instrumented Fusion in Lumbar and Lumbosacral Tuberculosis

BACKGROUND: For surgical treatment of lumbar and lumbosacral tuberculosis, the anterior approach has been the most popular approach because it allows direct access to the infected tissue, thereby providing good decompression. However, anterior fixation is not strong, and graft failure and loss of correction are frequent complications. The posterior approach allows circumferential decompression of neural elements along with three-column fixation attained via pedicle screws by the same approach. The purpose of this study was to evaluate the outcome (functional, neurological, and radiological) in patients with lumbar and lumbosacral tuberculosis operated through the posterior approach. METHODS: Twenty-eight patients were diagnosed with tuberculosis of the lumbar and lumbosacral region from August 2012 to August 2013. Of these, 13 patients had progressive neurological deterioration or increasing back pain despite conservative measures and underwent posterior decompression and pedicle screw fixation with posterolateral fusion. Antitubercular therapy was given till signs of radiological healing were evident (9 to 16 months). Functional outcome (visual analogue scale [VAS] score for back pain), neurological recovery (Frankel grading), and radiological improvement were evaluated preoperatively, immediately postoperatively and 3 months, 6 months, and 1 year postoperatively. RESULTS: The mean VAS score for back pain improved from 7.89 (range, 9 to 7) preoperatively to 2.2 (range, 3 to 1) at 1-year follow-up. Frankel grading was grade B in 3, grade C in 7, and grade D in 3 patients preoperatively, which improved to grade D in 7 and grade E in 6 patients at the last follow-up. Radiological healing was evident in the form of reappearance of trabeculae formation, resolution of pus, fatty marrow replacement, and bony fusion in all patients. The mean correction of segmental kyphosis was 9.85° postoperatively. The mean loss of correction at final follow-up was 3.15°. CONCLUSIONS: Posterior decompression with instrumented fusion is a safe and effective approach for management of patients with lumbar and lumbosacral tuberculosis.

Surgical Outcome Predictor in Degenerative Lumbar Spinal Disease Based on Health Related Quality of Life Using Euro-Quality 5 Dimensions Analysis

PURPOSE: We aim to introduce the predictive value of a quantitatively described formula model in a multicenter prospective analysis using the EuroQol-5 dimensions (EQ-5D) health scale to anticipate postoperative improvement in patients with degenerative lumbar spine disease (DLSD). MATERIALS AND METHODS: Quality of life was evaluated in 376 patients from 17 tertiary hospitals before and after spinal decompression and fusion surgery. The five items of the EQ-5D, mobility (M), self-care (S), usual activities (A), pain/discomfort (P), and anxiety/depression (D), were checked as level 1, 2, or 3, with 3 being the worst. A minimal significant change in the calculated EQ-5D (cEQ-5D) was set as 0.05. Logistic regression analysis was performed to predict the highest successful outcome (cEQ-5D improvement after operation >0.05) with the given sets of 5 items of the EQ-5D. RESULTS: In the cEQ-5D analysis, among patients with a formula score of S+A+2×P+D≤8, 18/68 (27%) showed significant improvement in the cEQ-5D at 1 year postoperatively (p<0.05). However, in patients with a formula score of ≥9, 265/308 (86%) demonstrated significant improvements in the cEQ-5D at 1 year postoperatively (p<0.05). CONCLUSION: We suggest that S+A+2×P+D≥9 in the EQ-5D can quantitatively describe the better surgical outcome predictors for DLSD. With a definite DLSD lesion confirmed by an imaging study, patients who meet the formula scores of 9 or over and have refractory symptoms to non-operative treatment could be better surgical candidates resulting in satisfactory surgical outcomes of over 86%, than those who scored 8 or lower.

Semi-Circumferential Decompression: Microsurgical Total en-bloc Ligamentum Flavectomy to Treat Lumbar Spinal Stenosis with Grade I Degenerative Spondylolisthesis

BACKGROUND: To describe and assess clinical outcomes of the semi-circumferential decompression technique for microsurgical en-bloc total ligamentum flavectomy with preservation of the facet joint to treat the patients who have a lumbar spinal stenosis with degenerative spondylolisthesis. METHODS: We retrospectively analyzed the clinical and radiologic outcomes of 19 patients who have a spinal stenosis with Meyerding grade I degenerative spondylolisthesis. They were treated using the "semi-circumferential decompression" method. We evaluated improvements in back and radiating pain using a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). We also evaluated occurrence of spinal instability on radiological exam using percentage slip and slip angle. RESULTS: The mean VAS score for back pain decreased significantly from 6.3 to 4.3, although some patients had residual back pain. The mean VAS for radiating pain decreased significantly from 8.3 to 2.5. The ODI score improved significantly from 25.3 preoperatively to 10.8 postoperatively. No significant change in percentage slip was observed (10% preoperatively vs. 12.2% at the last follow-up). The dynamic percentage slip (gap in percentage slip between flexion and extension X-ray exams) did not change significantly (5.2% vs. 5.8%). Slip angle and dynamic slip angle did not change (3.2° and 8.2° vs. 3.6° and 9.2°, respectively). CONCLUSIONS: The results suggested that semi-circumferential decompression is a clinically recommendable procedure that can improve pain. This procedure does not cause spinal instability when treating patients who have a spinal stenosis with degenerative spondylolisthesis.

Factors Affecting Survival in Patients Undergoing Palliative Spine Surgery for Metastatic Lung and Hepatocellular Cancer: Dose the Type of Surgery Influence the Surgical Results for Metastatic Spine Disease?

BACKGROUND: Surgical treatment for metastatic spine disease has been becoming more prominent with the help of technological advances and a few favorable reports on the surgery. In cases of this peculiar condition, it is necessary to establish the role of surgery and analyze the factors affecting survival. METHODS: From January 2011 to April 2015, 119 patients were surgically treated for metastatic spine lesions. To reduce the bias along the heterogeneous cancers, the primary cancer was confined to either the lung (n = 25) or the liver (n = 18). Forty-three patients (male, 32; female, 11; mean age, 57.5 years) who had undergone palliative surgery were enrolled in this study. Posterior decompression and fusion was performed in 30 patients (P group), and anteroposterior (AP) reconstruction was performed in 13 patients (AP group) for palliative surgery. Pre- and postoperative (3 months) pain (visual analogue scale, VAS), performance status (Karnofsky performance score), neurologic status (American Spinal Injury Association [ASIA] grade), and spinal instability neoplastic score (SINS) were compared. The survival period and related hazard factors were also assessed by Kaplan-Meier and Cox regression analysis. RESULTS: Most patients experienced improvements in pain and performance status (12.3% +/- 17.2%) at 3 months postoperatively. In terms of neurologic recovery, 9 patients (20.9%) graded ASIA D experienced neurological improvement to ASIA E while the remainder was status quo. In an analysis according to operation type, there was no significant difference in patient demographics. At 12 months postoperatively, cumulative survival rates were 31.5% and 38.7% for the P group and the AP group, respectively (p > 0.05). Survival was not affected by the pre- and postoperative pain scale, Tokuhashi score, neurologic status, SINS, or operation type. Preoperative Karnofsky performance score (hazard ratio, 0.93; 95% confidence interval [CI], 0.89 to 0.96) and improvement of performance status after surgery (hazard ratio, 0.95; 95% CI, 0.92 to 0.97) significantly affected survival after operation. CONCLUSIONS: There was no significant difference in surgical outcomes and survival rates between posterior and AP surgery for metastatic lesions resulting from lung and hepatocellular cancer. Preoperative Karnofsky score and improvement of performance status had a significant impact on the survival rate following surgical treatment for these metastatic spine lesions.

Perdas auditivas em paralisia facial periférica após cirurgia de descompressão / Hearing loss in peripheral facial palsy after decompression surgery

A paralisia facial pode resultar de uma variedade de etiologias, sendo a mais comum a idiopática. A avaliação e o tratamento são particularmente complexos. O tratamento da paralisia facial aguda pode envolver cirurgia de descompressão do nervo facial. Qualquer estrutura perto do trajeto do nervo facial está em risco durante a cirurgia de descompressão via transmastoidea. OBJETIVO: Estudo retrospectivo que irá avaliar a perda auditiva após descompressão via transmastoidea e a evolução do grau de paralisia nos casos idiopáticos dos últimos 15 anos. MATERIAL E MÉTODO: Foram selecionados prontuários de 33 pacientes submetidos à descompressão do nervo facial via transmastoidea nos últimos 15 anos e avaliou-se a perda auditiva e a paralisia facial. RESULTADOS: Observou-se alta porcentagem (61%) dos pacientes com algum grau de perda auditiva após o procedimento e, em todos os casos, houve melhora da paralisia. CONCLUSÃO: O procedimento cirúrgico não é isento de riscos. Indicações, riscos e benefícios devem ser esclarecidos aos pacientes por meio de consentimento informado.

Facial paralysis can result from a variety of etiologies; the most common is the idiopathic type. Evaluation and treatment are particularly complex. The treatment of acute facial paralysis may require facial nerve decompression surgery. Any structure near the path of the facial nerve is at risk during transmastoid decompression surgery. AIM: This is a retrospective study, carried out in order to evaluate hearing loss after transmastoid decompression and how idiopathic cases evolved in terms of their degree of paralysis in the last 15 years. MATERIALS AND METHODS: We selected the charts from 33 patients submitted to transmastoid facial nerve decompression in the past 15 years and we assessed their hearing loss and facial paralysis. RESULTS: There was a high percentage (61%) of patients with some degree of hearing loss after the procedure and in all cases there was improvement in the paralysis. DISCUSSION: The values obtained are similar to those reported in the literature. One possible explanation for this hearing loss is the vibration transmission by drilling near the ossicular chain. CONCLUSION: The surgical procedure is not risk free; indications, risks and benefits should be explained to patients through an informed consent form.

Ocular decompression retinopathy after trabeculectomy with mitomycin-C for angle recession glaucoma.

A 45-year-old male presented with intractable glaucoma following 360-degree angle recession after blunt trauma. He underwent an uncomplicated trabeculectomy with mitomycin-C (MMC). Adequate precautions were taken to reduce the chances of sudden lowering of intraocular pressure (IOP). He did not have any intraoperative shallowing of the anterior chamber or postoperative hypotony, but still developed ocular decompression retinopathy. On detailed review of the previously reported cases we discovered that besides a large IOP drop after surgery, either the preoperative rise of IOP in all these cases was over a relatively short period or the course of their glaucomatous process was likely to have exposed them to intermittent spikes of high IOP. To our knowledge this factor has not been previously postulated in the pathophysiology of ocular decompression retinopathy. We illustrate this with a rare case of ocular decompression retinopathy after trabeculectomy with MMC for post-traumatic angle recession glaucoma.

Decompressive craniotomy: prognostic factors and complications in 89 patients / Craniotomia descompressiva: análise de fatores prognósticos e complicações em 89 pacientes

Decompressive craniotomy (DC) is applied to treat post-traumatic intracranial hypertension (ICH). The purpose of this study is to identify prognostic factors and complications of unilateral DC. Eighty-nine patients submited to unilateral DC were retrospectively analyzed over a period of 30 months. Qui square independent test and Fisher test were used to identify prognostic factors. The majority of patients were male (87 percent). Traffic accidents had occurred in 47 percent of the cases. 64 percent of the patients had suffered severe head injury, while pupillary abnormalities were already present in 34 percent. Brain swelling plus acute subdural hematoma were the most common tomographic findings (64 percent). Complications occurred in 34.8 percent of the patients: subdural effusions in 10 (11.2 percent), hydrocephalus in 7 (7.9 percent) and infection in 14 (15.7 percent). The admittance Glasgow coma scale was a statistically significant predictor of outcome ( p=0.0309).

A craniotomia descompressiva (CD) é técnica utilizada para tratamento da hipertensão intracraniana (HIC) pós-traumática. O objetivo do estudo foi determinar fatores prognósticos e complicações nos pacientes submetidos a esta técnica. Realizou-se estudo retrospectivo de 89 pacientes submetidos à CD unilateral para tratamento da HIC pós-traumática durante 30 meses. Utilizou-se testes do Qui-quadrado de independência e teste exato de Fisher para análise de fatores independentes de prognóstico. A maioria dos pacientes era do sexo masculino (87 por cento). A causa mais comum foi o acidente de trânsito (47 por cento). A maioria apresentava traumatismo cranioencefálico grave (64 por cento), 34 por cento já apresentavam anisocoria. O achado tomográfico mais comum foi a associação entre tumefação cerebral e hematoma subdural agudo (64 por cento). Em 34,8 por cento dos pacientes houve complicações inerentes à técnica: coleção subdural (11,2 por cento), hidrocefalia (7,9 por cento) e infecção (15,7 por cento). A escala de coma de Glasgow à admissão correlacionou-se estatisticamente como fator prognóstico (p=0,0309).

Brain-stem auditory evoked responses during microvascular decompression for trigeminal neuralgia: predicting post-operative hearing loss.

CONTEXT: The importance of brainstem auditory evoked potential monitoring in reducing hearing loss during microvascular decompression for trigeminal neuralgia is now accepted. However the extent of the changes in the pattern of these potentials and the safe limits to which these changes are relevant in reducing postoperative hearing loss have not been established. AIMS: The aim of this study is to quantify these changes and relate these to the postoperative hearing loss. SETTINGS AND DESIGN: This study was done at the Walton Centre for neurology and neurosurgery, Liverpool, United Kingdom. The study was designed to give a measure of the change in the wave pattern following microvascular decompression and relate it to postoperative hearing loss. MATERIALS AND METHODS: Seventy-five patients undergoing microvascular decompression for trigeminal neuralgia had preoperative and postoperative hearing assessments and intraoperative brainstem auditory evoked potential monitoring. STATISTICAL ANALYSIS USED: Chi-square tests. RESULTS: It was found that the wave V latency was increased by more than 0.9 ms in nine patients, eight of whom suffered significant postoperative hearing loss as demonstrated by audiometry. It was also seen that progressive decrease in amplitude of wave V showed progressive hearing loss with 25% loss when amplitude fell by 50 and 100% loss when wave V was lost completely. However most of the patients did not have a clinically manifest hearing loss. CONCLUSIONS: A per-operative increase in the latency of wave V greater than 0.9 ms and a fall of amplitude of wave V of more than 50% indicates a risk to hearing.

Craniotomia descompressiva para tratamento precoce da hipertensão intracraniana traumática / Decompressive craniotomy for the early treatment of traumatic intracranial hypertension

O papel da craniotomia descompressiva (CD) no tratamento da hipertensão intracraniana (HIC) refratária ainda não está estabelecido na literatura. Atualmente é recomendada como opção, pois há deficiência de trabalhos classe I ou II que suportem seu emprego. Trabalhos recentes têm avaliado a eficácia da CD quando aplicada precocemente no tratamento da HIC pós traumática. No presente trabalho analisam-se 21 pacientes nos quais a CD foi realizada precocemente. A maioria dos pacientes apresentava traumatismo cranioencefálico grave (Escala de coma glasgow <9) e tomografia de crânio evidenciando tumefação cerebral (brain swelling) ou hematoma subdural agudo. A principal complicação inerente à técnica foi a hidrocefalia (28,5 por cento). Boa reabilitação social ocorreu em 11 pacientes (52,5 por cento). Parece que a CD, quando realizada precocemente, é eficaz no tratamento da HIC refratária, ressaltando-se ainda a necessidade de estudos classe I e II que suportem esta opinião.

Transient Paraparesis After Laminectomy in a Patient with Multi-Level Ossification of the Spinal Ligament

Acute neurologic deterioration is not a rare event in the surgical decompression for thoracic spinal stenosis. We report a case of transient paraparesis after decompressive laminectomy in a 50-yr-old male patient with multi-level thoracic ossification of the ligamentum flavum and cervical ossification of the posterior longitudinal ligament. Decompressive laminectomy from T9 to T11 was performed without gross neurological improvement. Two weeks after the first operation, laminoplasty from C4 to C6 and additional decompressive laminectomies of T3, T4, T6, and T8 were performed. Paraparesis developed 3 hr after the second operation, which recovered spontaneously 5 hr thereafter. CT and MRI were immediately performed, but there were no corresponding lesions. Vascular compromise of the borderlines of the arterial supply by microthrombi might be responsible for the paraparesis.

Incidência de dor acromioclavicular após descompresssäo subacromial artroscópica / Incidence of acromioclavicular pain after arthroscopic subacromial decompression

A acromioplastia artroscópica, atualmente, é o método de escolha para o tratamento da síndrome do impacto (SI). Porém seria ela isenta de complicaçoes? No Grupo de Ombro do Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de Sao Paulo, os autores realizaram 177 acromioplastias artroscópicas. Desse grupo de pacientes, excluíram os casos em que havia qualquer outra lesao (ruptura completa do manguito rotador, SLAP lesion, os acromiale, etc.) ou associaçao de qualquer outro procedimento cirúrgico, prévio ou associado (como ressecçao artroscópica da extremidade distal da clavícula, sutura de lesao do manguito rotador, etc.). Portanto, reavaliaram 43 casos em que haviam realizado exclusivamente a acromioplastia artroscópica. Porém, mantiveram nesse subgrupo os casos em que, além da acromioplastia artroscópica, realizaram também claviculoplastia ântero-inferior. Fizeram revisao desses 43 casos e constataram uma complicaçao ainda nao descrita, porém comentada, a dor na articulaçao acromioclavicular (A/C), que se desenvolve após a descompressao subacromial artroscópica. Encontraram 8 casos de dor A/C nao existente antes da artroscopia, dor essa que aparece nas primeiras semanas do período pós-operatório. Um paciente evoluiu bem sem qualquer tratamento; 3, satisfatoriamente com tratamento conservador (infiltraçoes com corticosteróides); 3 aguardam reoperaçao e 1 caso já foi submetido à ressecçao artroscópica da clávícula distal, desenvolvendo-se muito bem. Convém ressaltar que, desses 8 casos, 6 haviam sido submetidos a claviculoplastia ântero-inferior artroscópica. Os autores consideram que a claviculoplastia ântero-inferior artroscópica deva ser reavaliada, quando de acromioplastia artroscópica, pois dor A/C pós-operatória é freqüente e com alto índice de resultados insatisfatórios.

Descompressäo da bainha do nervo óptico / Optic nerve sheat decompression

Este trabalho relata nossa experiência com dez pacientes (onze olhos) submetidos à descompressäo da bainha do nervo optico. Cinco eram portadores de pseudotumor cerebral, quatro neuropatia óptica isquêmica anterior, forma progressiva, e um anomalia de Morning Glory com descolamento de retina. Descrevemos a técnica cirúrgica utilizada, as principais indicaçöes, os resultados e as complicaçöes deste procedimento cirúrgico.