Descripción de un caso y revisión de la bibliografía / Transoral decompression of the brain stem in a basilar impression secondary to rheumatoid arthritis. Description of a case and survey of the literature

Introducción. La subluxación vertical o traslocación odontoidea que produce una impresión basilar con compresión del tronco cerebral es un fenómeno evolutivo último de la artritis reumatoidea; la aparición de síntomas medulares y de pares bajos es un signo específico de dicha alteración. En esta situación, los objetivos quirúrgicos establecidos son la descompresión de las estructuras nerviosas afectadas seguida de una estabilización craneocervical. El objeto de este artículo es dar a conocer la mejoría del déficit neurológico tras una cirugía transoral descompresiva (odontoidectomía), sin asociar ningún sistema de fijación interna en una paciente con artritis reumatoide de larga evolución y compresión anterior del tronco cerebral por impresión basilar y panus reumatoideo. Tras revisar la literatura, no existe, excepto algún caso clínico aislado, ningún artículo donde se describa la evolución postoperatoria de la descompresión quirúrgica por vía anterior del tronco cerebral en pacientes con subluxación odontoidea reumatoidea, sin asociar ningún sistema de estabilización interna. Caso clínico. Mujer de 65 años de edad, diagnosticada de artritis reumatoide a los 25 años, que ingresa con síntomas de compresión bulbomedular secundarios a una subluxación vertical de odontoides. Se le practicó una descompresión transoral del tronco cerebral(odontoidectomía y extirpación de pannus sin fijación posterior), con una evolución postoperatoria sorprendentemente favorable. Realizó una vida independiente a los 15 meses de la descompresión quirúrgica. Conclusiones. La mejoría neurológica de nuestra enferma tras la odontoidectomía descompresiva sugiere que la compresión mecánica de la odontoides impactada en el tronco cerebral fue el factor etiológico predominante de los síntomas bulbomedulares, mientras que su estabilización clínica puede explicarse por un mecanismo de autofusión espontánea de las masas laterales del atlas con los cóndilos occipitales y con el axis. Finalmente, consideramos que, en casos seleccionados de pacientes reumatoideos con subluxación atloaxoidea, impactación de odontoides en foramen magno y clínica compresiva bulbomedular, la descompresión transoral del tronco cerebral mediante odontoidectomía es el procedimiento quirúrgico inicial de elección, con el que se consigue una mejoría neurológica y una estabilización clínica. En cualquier caso, es preciso un seguimiento postoperatorio neurológico y radiológico estricto ante la posibilidad futura de una fijación craneocervical (AU)

Introduction. The vertical subluxation or translocation of the odontoid process producing a basilar impression with compression of the brain stem is a late phenomenon in the course of rheumatoid arthritis; the appearance of symptoms in the spinal cord and the lower pairs of spinal nerves is a specific sign of this disorder. In this situation, the standard surgical aims are the decompression of the affected nerve structures followed by craniocervical stabilisation. The objective of this paper is to report on the improvement of the neurological deficit after decompressive transoral surgery (odontoidectomy), without associating any internal fixation system, in a female patient with a long history of rheumatoid arthritis and anterior compression of the brain stem caused by basilar impression and rheumatoid pannus. A survey of the literature showed that, with the odd isolated clinical case, there are no papers which describe the post-operative development of surgical decompression of the brain stem carried out through an anterior approach in patients with rheumatoid subluxation of the odontoid process, without associating any internal stabilisation system. Case report. Female aged 65, diagnosed as suffering from rheumatoid arthritis at the age of 25, who was admitted with symptoms of compression of the medulla oblongata secondary to a vertical subluxation of the odontoid process. She was submitted to transoral decompression of the brain stem (odontoidectomy and removal of pannus without posterior fixation), and made surprisingly favourable post-operative progress. At 15 months after the surgical decompression she led an independent life. Conclusions. The neurological improvement of our patient after the decompressive odontoidectomy suggests that the mechanical compression of the odontoid process with impaction of the brain stem was the predominant aetiological factor causing the symptoms in the medulla oblongata. Her clinical stabilisation, on the other hand, can be explained by a mechanism involving the spontaneous autofusion of the lateral masses of the atlas with the occipital condyle and with the axis. Lastly, we consider that, in certain cases of rheumatoid patients with atlantoaxial subluxation, impaction of the odontoid process in the foramen magnum and clinical features involving compression of the medulla oblongata, transoral decompression of the brain stem through an odontoidectomy is the choice initial surgical procedure, since it affords neurological improvement and clinical stabilisation. In any case, a strict neurological and radiological post-operative followup is needed in view of a possible craniocervical fixation occurring in the future (AU)

[Transoral decompression of the brain stem in a basilar impression secondary to rheumatoid arthritis. Description of a case and survey of the literature]. / Descompresion transoral del tronco cerebral en una impresion basilar secundaria a artritis reumatoidea. Descripcion de un caso y revision de la bibliografia.

INTRODUCTION: The vertical subluxation or translocation of the odontoid process producing a basilar impression with compression of the brain stem is a late phenomenon in the course of rheumatoid arthritis; the appearance of symptoms in the spinal cord and the lower pairs of spinal nerves is a specific sign of this disorder. In this situation, the standard surgical aims are the decompression of the affected nerve structures followed by craniocervical stabilisation. The objective of this paper is to report on the improvement of the neurological deficit after decompressive transoral surgery (odontoidectomy), without associating any internal fixation system, in a female patient with a long history of rheumatoid arthritis and anterior compression of the brain stem caused by basilar impression and rheumatoid pannus. A survey of the literature showed that, with the odd isolated clinical case, there are no papers which describe the post operative development of surgical decompression of the brain stem carried out through an anterior approach in patients with rheumatoid subluxation of the odontoid process, without associating any internal stabilisation system. CASE REPORT: Female aged 65, diagnosed as suffering from rheumatoid arthritis at the age of 25, who was admitted with symptoms of compression of the medulla oblongata secondary to a vertical subluxation of the odontoid process. She was submitted to transoral decompression of the brain stem (odontoidectomy and removal of pannus without posterior fixation), and made surprisingly favourable post operative progress. At 15 months after the surgical decompression she led an independent life. CONCLUSIONS: The neurological improvement of our patient after the decompressive odontoidectomy suggests that the mechanical compression of the odontoid process with impaction of the brain stem was the predominant aetiological factor causing the symptoms in the medulla oblongata. Her clinical stabilisation, on the other hand, can be explained by a mechanism involving the spontaneous autofusion of the lateral masses of the atlas with the occipital condyle and with the axis. Lastly, we consider that, in certain cases of rheumatoid patients with atlantoaxial subluxation, impaction of the odontoid process in the foramen magnum and clinical features involving compression of the medulla oblongata, transoral decompression of the brain stem through an odontoidectomy is the choice initial surgical procedure, since it affords neurological improvement and clinical stabilisation. In any case, a strict neurological and radiological post operative follow up is needed in view of a possible craniocervical fixation occurring in the future.

[Palliative medicine before euthanasia]. / La medicina paliativa frente a la eutanasia.

Paliative Medicine offers many possibilities to reach a good control of the bothering symptoms of terminal patients and to the support of their families. We review the different causes of suffering, suicide and of request of euthanasia as the process of Medical Decision-Making in the care of the Dying. It is necessary to search for ways to reduce the suffering and to improve the quality of life that remains instead of how to finish it earlier.