Estudio comparativo de una asociación de diclofenac, betametasona y vitamina b12 (blokium b12®) con diclofenac (sin asociar) en el tratamiento de patología dolorosa de columna con compromiso neural / COMPARATIVE STUDY OF AN ASSOCIATION OF DICLOFENAC, BETAMETASONE AND VITAMIN B12 (BLOKIUM B12®) WITH DICLOFENAC (WITHOUT ASSOCIATION) IN THE TREATMENT OF PAINFUL SPINE PATHOLOGY WITH NEURAL COMMITMENT

El dolor lumbar bajo y el dolor cervical con o sin irradiación son causas muy comunes de consulta a los médicos generalistas en los países desarrollados. La discopatía aguda y el dolor por estenosis del canal espinal son los diagnósticos más frecuentes. La postura tradicional ha sido la de administrar antiinflamatorios no esteroideos (AINES) para estas lumbalgias o cervicalgias agudas. Cuando existe irradiación neural por compresión radicular es usual asociar al AINE un corticoide a baja dosis, así como un antineurítico, para lograr un mejor resultado. Con el objeto de documentar la utilidad de esta práctica habitual, efectuamos en 142 pacientes ambulatorios un estudio multicéntrico randomizado que compara la efectividad y la tolerancia de una asociación a dosis fija de diclofenac, betametasona y cianocobalamina administrada por vía oral versus la administración de diclofenac como monofármaco en el tratamiento de la patología dolorosa de la columna lumbar y cervical asociada a compresión neural. La asociación demostró ser más eficaz en controlar el dolor y mejorar la funcionalidad de los pacientes que la administración de diclofenac en forma aislada y se asoció a escasos efectos colaterales, principalmente digestivos

Low back pain and neck pain with or without radiation are very common causes of consultation with general practitioners in developed countries. Acute discopathy and pain due to spinal canal stenosis are the most frequent diagnoses. The traditional approach has been to administer non-steroidal antiinflammatory drugs (NSAIDs) for these acute low back or cervical pain. When there is neural radiation due to root compression, it is usual to associate a low-dose corticosteroid with the NSAID, as well as an antineuritic, to achieve a better result. In order to document the usefulness of this routine practice, we conducted a randomized multicenter study in 142 outpatients that compared the effectiveness and tolerance of a fixed-dose combination of diclofenac, betamethasone, and cyanocobalamin administered orally versus the administration of diclofenac as Monopharmaceutical in the treatment of painful pathology of the lumbar and cervical spine associated with neural compression. The association proved to be more effective in controlling pain and improving the functionality of patients than the administration of diclofenac in isolation and was associated with few side effects, mainly digestive

Estenosis lumbar degenerativa: conceptos básicos, evaluación clínica y manejo / Degenerative lumbar spinal stenosis: basic concepts, clinical evaluation, treatment

La estenorraquis lumbar es la disminución del volumen del canal raquídeo en la columna. Es la causa más frecuente de dolor lumbociático y lumbocrural en población mayor de 60 años. Existen múltiples causas. La más común es la degenerativa que consiste en una disminución del canal secundario a varios factores como protrusión del disco intervertebral, hipertrofia y abombamiento del ligamento amarillo, engrosamiento de la capsula articular y por osteofitos. Los síntomas principales son el dolor lumbar irradiado a extremidades inferiores tipo lumbociática o lumbocruralgia y la claudicación neural intermitente. Generalmente no hay déficit motor ni sensitivo. La resonancia magnética es el estudio de elección para el diagnóstico, pero debe complementarse con radiografías y con frecuencia con tac para una mejor valoración de la patología. El tratamiento inicial siempre es conservador, que incluye uso de antiinflamatorios, analgésicos, relajantes musculares, kinesioterapia e infiltraciones de columna (epidurales o radiculares). La mayoría de los pacientes responden satisfactoriamente a este manejo. El tratamiento quirúrgico está indicado a los pacientes que presentan un dolor intenso, que afecta su calidad de vida y que no mejora con el tratamiento conservador. Consiste en la descompresión quirúrgica de las raíces lumbares a través de laminectomía. En ocasiones se recomienda complementar la descompresión con artrodesis específicamente cuando la estenorraquis se asocia a otras condiciones como espondilolistesis degenerativa, escoliosis, desbalance sagital o coronal, inestabilidad segmentaria y en enfermedad del segmento adyacente.

Spinal lumbar stenosis is a narrowing of the spinal canal in the lumbar spine. Is the most frequent cause of sciatic pain or cruralgia in the elderly population over 60 years old. Exist many etiologies. The most common is degenerative caused by many factors including bulging disc, hypertrophy of flavum ligament as well as facet capsule thickening and by osteophytes formation. The main symptoms of spinal stenosis are radicular pain and neurogenic claudication. Lumbar flexion usually improves the symptom and deambulation often worsens the pain. Most of the time neurologic examination is normal. The gold standard study is mri but is necessary to complement with x rays and ct to obtain a better evaluation. Initial treatment is always conservative and consists in nsaid's, muscle relaxants, physical therapy and steroid spinal injections. Most of the patients respond well to this treatment. Surgical treatment is indicated when the patient has a severe pain, quality of life is miserable and conservative treatment fails. Decompression is the gold standard surgical treatment. The addition of an arthrodesis or spinal fusion is recommended in degenerative spondylolisthesis, scoliosis, sagital or coronal imbalance, deformity correction, recurrent spinal stenosis and in cases of adjacent level disease problem.

Uso da inteligência articial como armamento no diagnóstico e condução clínica da estenose de canal lombar / Use of Articial Intelligence in Diagnosis and Clinical Conduct of Lumbar Spinal Stenosis

A estenose do canal vertebral lombar (ECL) é uma patologia complexa, com alta incidência entre pessoas acima de 65 anos de idade. No entanto, o diagnóstico correto é, por vezes, difícil de ser confirmado. O uso de modelos de Inteligência Articial (IA) na medicina é, em geral, desconhecida para a maioria da comunidade médica, mas tem sido usada há décadas na assistência em UTI, os métodos de imagem e dispositivos de diagnóstico eletrônico (ECG). Através de uma revisão sistemática da literatura, com foco nos achados clínicos e radiológicos, juntamente com todas as modalidades de tratamento, foi possível identicar o ambiente completo de pacientes LSS, para responder a quatro questões: (a) "Com base no quadro clínico, o paciente tem um, cenário moderado ou grave?"; (b) "Com base nos dados radiológicos, o paciente pode ser classicado com um cenário leve,moderada ou grave?"; (c) "Qual é a probabilidade, com base na anamnese, do paciente ter ECL?"; (d) "Qual é o melhor tratamento a ser oferecido?".þ. Como auxílio de um software usando Sistema Especialista (Expert Sinta), uma linguagem de IA, alocamos todas as variáveis e seus valores para orientar o software responder às quatro perguntas. Foi possível identicar 657 artigos cientícos, no entanto apenas 63 poderia mencionar não apenas as variáveis, mas a sua probabilidade de ocorrência ou teve disponibilidade texto completo. Foi possível classicar a intensidade do quadro clínico e radiológico, criar um índice de probabilidade para LSS e oferecer o melhor tratamento. Recomendamos o uso, sob supervisão médica, em de Neurocirurgia ou clínicas ortopédicas como um conselheiro para os pacientes com ELA.

The lumbar spinal stenosis (LSS) is a complex pathology with high incidence among people above 65 years old. However, the correct diagnose is sometimes difcult to perform. The use of Articial Intelligence (AI) models in medicine is, in general, unfamiliar for the majority of medical community, but has been used for decades in assistance in ICUs, image methods and electronic diagnostic devices (EKG). Through a systematic literature review focused in the clinical and radiological ndings, in addition to all treatmentmodalities, we identied the complete environment of LSS patients, to answer four questions. (a) "Based on the clinical presentation, the patient has a mild, moderate or severe scenario?", (b) "Based on the radiological data, the patient can be classied having a mild, moderate or severe scenario?", (c) "What is the probability, based on the anamneses, the patient has LSS?", and (d) "What is the best treatment to be offered?".With the aid of a software using Expert System (Expert Sinta), a language of AI, we allocate all the variables and their values to orient the software to answer the four questions. It was possible to identify 657 scientic articles, however only 63 could mention not only the variables, but their occurrence probability or had full text availability. It was possible to classify the intensity the clinical and radiological scenario, create a probability index for LSS and offer the best treatment. We recommend the use, under medical supervision, in neurosurgery or orthopedic clinics as an adviser for patients with LSS.

Actualización en estenorraquis lumbar: diagnóstico, tratamiento y controversias / Spinal lumbar stenosis: An update

Spinal lumbar stenosis is a disease that occurs mainly between the 5th and 7th decade of life and can be congenital or acquired. The latter has many etiologies, but a degenerative cause is the most common. Stenosis is a narrowing of the spinal canal diameter caused by many factors such as bulging discs, hypertrophy of flavum ligament, facet capsule thickening and osteophyte formation. The classical symptom of the disease is sciatic pain, that improves with lumbar flexion and worsens with ambulation. Neurological examination is often normal and the most useful imaging test is magnetic resonance imaging (MRI). Conservative management consists in non-steroidal anti-inflammatory drugs, muscle relaxants, physical therapy and epidural - radicular infiltrations. Spinal infiltrations have a proven efficacy for pain management. A good result of this therapy predicts a favorable outcome after surgery. Surgical treatment consists in decompression with or without lumbar fusion. The addition of an arthrodesis is recommended for degenerative spondylolisthesis, correction of deformities, recurrent spinal stenosis with instability, sagittal or coronal imbalance and adjacent segment disease.

Degenerative lumbar stenosis: update / Estenose lombar degenerativa: atualização

We present a literature review of the diagnosis and treatment of acquired lumbar spinal stenosis (LS), with a brief description of new surgical techniques. LS is the most common cause of spinal surgery in individuals older than 65 years of age. Neurogenic claudication and radiculopathy result from compression of the cauda equina and lumbosacral nerve roots by degenerated spinal elements. Surgical decompression is a well established treatment for patients with refractory, or moderate to severe clinical symptoms. However, the variety of surgical options is vast. New techniques have been developed with the goal of increasing long term functional outcomes. In this article we review lumbar decompression and fusion as treatment options for LS but also present other recent developments. Prospective long term studies are necessary to know which procedures would result in optimal patient outcome.

Apresentamos uma revisão de literatura do diagnóstico e tratamento da estenose lombar (EL) adquirida, enfatizando as novas técnicas de manejo cirúrgico. A EL é a causa mais comum de cirurgia na coluna de pacientes com mais de 65 anos de idade. Claudicação neurogênica e radiculopatias são sintomas resultantes da compressão das raízes lombossacrais pelos elementos degenerados. A descompressão cirúrgica é um procedimento bem estabelecido para pacientes com sintomas severos ou refratários ao tratamento clínico. Contudo, as opções cirúrgicas são amplas. Novas técnicas de fusão e artrodese são úteis para melhorar os resultados funcionais. Neste artigo, varias alternativas cirúrgicas são apresentadas, incluindo as novas tecnologias na área. Evidências científicas mais contundentes com seguimento longo são necessárias para a incorporação destas práticas na atividade médica de rotina.

Estenorraquis lumbar: ¿tratamiento médico, pequeña o gran cirugía? / Lumbar Estenorraquis: medical treatment, small or great surgery?

Lumbar spinal stenosis is a disease that is not always symptomatic, with increasing incidence on the population as it ages. Initial treatment must be conservative, based on medicine, physiokinesiotherapy, while compensating general illnesses. A second stage would include the use of steroid injections, as in the epidural or foraminal space, or in the facet joints. If these treatments were to fail, it is possible to realize surgical treatment, previously analizing the most suitable surgery for each patient, with laminectomy at the forefront. It is necessary to keep in mind that "minimally invasive surgery" is usually best. Arthrodesis must always be performed during surgery, which must to be realized in case of previous or intra operative instability, degenerative scoliosis, or flat back, while its use in degenerative espondilolisthesis is still in discussion.

La evidencia de la homeopatía: casos clínicos incurables curados / The evidence of the homeopathy: clinical cases incurable cured

Se analizan en forma detallada las historias clínicas de dos pacientes declarados incurables por la gravedad de las lesiones orgánicas irreversibles que presentan. En ambos casos se pone especial énfasis en la obtención de un stándard de presentación que priorice la rigurosidad en el análisis tanto de la metodología, criterio de aplicación de la ley de similitud utilizado, descripción de los síntomas en que se basó la prescripción, y seguimiento prolongado del caso para evaluar fehacientemente la naturaleza junto a la presentación de la documentación que avale el diagnóstico preciso y los resultados del tratamiento indicado. Se trata de un caso de Estenosis Espinal Severa y otro de Esterilidad por Obstrucción Tubaria Bilateral Completa. El enfoque terapéutico en ambos casos fue diferente, en tanto que el primero se resolvió aplicando la estrategia clásica de similitud sintomática, en el segundo caso se recurrió a la prescripción del medicamento a través del conocimiento de las propiedades fisiopatológicas, de su tropismo y de los resultados de su aplicación clínica por parte del autor

Estenosis del canal espinal lumbar / Stenosis of the spinal lumbar chanel

Para la realización de este trabajo se revisaron 176 historias clínicas de pacientes con patología lumbar, de los cuales 47, tenían diagnóstico de estenosis del canal espinal lumbar. Los pacientes fueron tratados quirúrgicamente por el Servicio de Neurocirugía del Hospital Universitario de Caracas, durante los años 1988-1992. La causa que más frecuentemente motivó a los pacientes a consultar fué: lumbociatalgia: 36 casos (76,59); seguido por lumbalgia: 8 casos (17,02); paraparesia: 7 casos (14,89); parestesias: 4 casos (8,51); retención urinaria: 3 casos (6,38); claudicación neurogénica: 2 casos (4,25); y otras causas como lumbosacralgia y atrofia muscular: 1 caso cada uno (2,12). Los estudios imagenológicos realizados en los pacientes fueron: radiología simple: 31 casos (65,95), en donde se observaron cambios degenerativos de la columna lumbar, dados por osteofitos, disminución del interespacio, esclerosis de los platillos vertebrales y espondilolistesis. Mielografía 23 casos observándose disminución del diá anteroposterior (bloqueo parcial o total), amputación de raíces, disminución del diámetro transverso. Mielotomografía 18 casos evidenciándose disminución de los diámetros anteroposterior transverso, hipertrofia de facetas articulares, osteofitos. Resonancia magnética 6 casos visualizándose protrusión del disco invertebrado, hipertrofia del ligamento amarillo, disminución de la grasa peridural, del diámetro del foramen neural y cambios en la señal del disco invertebrado. La electromiografía fué el único test electrofisiológico realizado en 33 casos. Todos los pacientes se trataron médicamente en el preoperatorio, con AINES. El tratamiento quirúrgico practicado fué: laminectomía más foraminotomía: 26 casos; laminectomía multinivel: 7 casos; laminectomía en un sólo nivel: 6 casos; foraminotomía 3 casos. Algunos pacientes requirieron estabilización espinal, la cual se efectúo de la siguiente manera descompresiva más fusiones 2 casos, descompresiva más instrumentación espinal 3 casos. Entre los hallazgos intraoperatorios más frecuentes se tuvo: hipertrofia del ligamento amarillo 26 casos; hipertrofia de facetas articulares 13 casos; hernia discal 16 casos; espondilolistesis 7 casos; osteofitos 6 casos; LOE estradural 5 casos; hipertrofia de las láminas 2 casos, ausencia de grasa epidural 1 caso. Las complicaciones observadas, fueron escasas, de 47 pacientes 39 casos no presentaron complicaciones, fístula de LCR 2 casos; lesión de raíz nerviosa, disminución de la fuerza muscular, infección de la herida, deshiciencia de sutura y muerte 1 caso cada uno. De los 47 pacientes, 41 casos evolucionaron satisfactoriamente, 6 pacientes persistieron con sintomatología neurológica.

Surgical management of lumbar spinal stenosis in elderly

Eighteen elderly patients aged 75-84 years had lumber spine decompression for spinal stenosis. Presentation and management are discussed and clinical results reported. There was no age related complication. Excellent results were obtained in seventy% of the cases with complete relief of symptoms. The results are gratifying and quality of life is considerably improved without any significant postoperative complications. It is concluded that chronological age should not be considered as a contraindication to spinal surgery in the elderly