Drezotomía en el tratamiento del dolor por desaferentización: revisión de resultados y análisis de factores predictores de éxito / DREZotomy in the treatment of deafferentation pain: review of results and analysis of predictive factors for success

Antecedentes y objetivos El tratamiento del dolor por desaferentización mediante drezotomía espinal es una opción terapéutica contrastada en la literatura. En los últimos años, la drezotomía ha visto relegado su empleo a un segundo plano debido a la eclosión de las terapias neuromoduladoras. Los objetivos de este estudio son demostrar que la drezotomía continúa siendo un tratamiento efectivo y seguro, y analizar aquellos factores predictores de éxito. Pacientes y métodos Se realizó un estudio retrospectivo de todos los pacientes tratados en nuestro servicio mediante drezotomía espinal desde 1998 hasta 2018. Se excluyeron los casos de drezotomía bulbar. Se emplearon la escala visual analógica (EVA) y la reducción de la medicación habitual como variables resultado, y se analizaron variables demográficas, clínicas y quirúrgicas como factores predictores de éxito. Resultados Un total de 27 pacientes (51,9% mujeres) de 53,7 años de edad media fueron tratados mediante drezotomía. La etiología principal del dolor fue por avulsión de plexo braquial (55,6%) seguida de causa tumoral (18,5%). El tiempo medio de evolución del dolor fue de 8,4 años con una intensidad media de 8,7 según la EVA, pese a que el 63% de los pacientes habían recibido tratamiento neuroestimulador previo. Durante el postoperatorio inmediato un 77,8% de los pacientes presentaron una reducción del 50% o más en la EVA. Tras un seguimiento medio de 22 meses posdrezotomía, permaneció una reducción de al menos el 50% en la EVA en el 59,3% de los pacientes (reducción media de 4,9 puntos) permitiendo una reducción del tratamiento analgésico habitual en el 70,4% de ellos. La drezotomía en la avulsión de plexo braquial presentó una tasa de éxito (93%) superior al resto de patologías (41,7%) de manera significativa (p = 0,001) (AU)

Background and objectives The treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success. Patients and methods A retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success. Results A total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥ 50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p = .001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits (AU)

DREZotomy in the treatment of deafferentation pain: review of results and analysis of predictive factors for success. / Drezotomía en el tratamiento del dolor por desaferentización: revisión de resultados y análisis de factores predictores de éxito.

BACKGROUND AND OBJECTIVES: The treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success. PATIENTS AND METHODS: A retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success. RESULTS: A total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p=.001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits. CONCLUSION: Dorsal root entry zone surgery is effective and safe for treating patients with deafferentation pain, especially after brachial plexus injury. It can be considered an alternative treatment after failed neurostimulation techniques for pain control. However, its indication should be considered as the first therapeutic option after medical therapy failure due to its good long-term results.

Hemifacial spasm caused by a cerebellopontine angle arachnoid cyst. Case report and literature review / Espasmo hemifacial causado por un quiste aracnoideo del ángulo pontocerebeloso. Caso clínico y revisión de la literatura

Arachnoid cysts involving the cerebellopontine angle are an unusual cause of hemifacial spasm. The case is reported of a 71-year old woman presenting with a right hemifacial spasm and an ipsilateral arachnoid cyst. Preoperative magnetic resonance imaging findings suggested a neurovascular compression caused by displacement of the facial-acoustic complex and the anterior inferior cerebellar artery by the cyst. Cyst excision and microvascular decompression of the facial nerve achieved permanent relief. The existing cases of arachnoid cysts causing hemifacial spasm are reviewed and the importance of a secondary neurovascular conflict identification and decompression in these cases is highlighted

Los quistes aracnoideos del ángulo pontocerebeloso son una causa inusual de espasmo hemifacial. Describimos el caso de una mujer de 71 años que presentaba un espasmo hemifacial derecho y un quiste aracnoideo ipsilateral. Los hallazgos de la resonancia magnética preoperatoria indicaban una compresión neurovascular provocada por el desplazamiento del complejo nervioso facial-acústico y de la arteria cerebelosa anteroinferior por el quiste. La extirpación del quiste y la descompresión microvascular del nervio facial consiguieron un alivio permanente del espasmo. Se revisan los casos conocidos de espasmo hemifacial secundario a un quiste aracnoideo y se resalta la importancia de identificar un conflicto neurovascular secundario y de realizar una descompresión en estos casos

Hemifacial spasm caused by a cerebellopontine angle arachnoid cyst. Case report and literature review.

Arachnoid cysts involving the cerebellopontine angle are an unusual cause of hemifacial spasm. The case is reported of a 71-year old woman presenting with a right hemifacial spasm and an ipsilateral arachnoid cyst. Preoperative magnetic resonance imaging findings suggested a neurovascular compression caused by displacement of the facial-acoustic complex and the anterior inferior cerebellar artery by the cyst. Cyst excision and microvascular decompression of the facial nerve achieved permanent relief. The existing cases of arachnoid cysts causing hemifacial spasm are reviewed and the importance of a secondary neurovascular conflict identification and decompression in these cases is highlighted.

Abordaje anterior y anterolateral en el tratamiento de la compresión medular metastásica a nivel torácico y lumbar / Anterior and anterolateral approach in the treatment of thoracic and lumbar vertebral metastasis causing spinal cord compression

Objetivos: Analizar los resultados de los pacientes con metástasis en columna torácica y lumbar intervenidos mediante abordaje anterior o anterolateral. Materiales y métodos: Se han analizado de forma retrospectiva los pacientes con lesiones vertebrales metastásicas a nivel dorsolumbar intervenidos por vía anterior o anterolateral en nuestra institución entre los años 2003 y 2012. Resultados: Se incluyeron un total de 22 pacientes, con una mediana de edad de 49,5 años (26-73 años) y una mediana de seguimiento de 9,5 meses (0-96 meses). Las neoplasias primarias más frecuentes fueron el adenocarcinoma renal y el adenocarcinoma de mama. Se realizó arteriografía prequirúrgica en 14 (63,6%) de los pacientes, llevándose a cabo la embolización de la lesión en 7 (31,8%) de ellos. Previo a la intervención, 12 (54,5%) de los pacientes eran capaces de deambular (Frankel D y E). En 5 (22,7%) de los pacientes aparecieron complicaciones médicas durante el postoperatorio inmediato, 2 (9,1%) de los cuales fallecieron. Entre los 20 restantes, el número de pacientes deambulantes (Frankel D y E) al final del seguimiento fue de 16 (72%). En el 90% se redujo la demanda de analgesia al menos un 50%. Durante el seguimiento, 16 (72,2%) de los pacientes fallecieron con una mediana de supervivencia de 10 meses (rango 0-48 meses). Conclusiones: La resección de las metástasis vertebrales dorsolumbares por vía anterior o anterolateral, pese a acompañarse de una morbimortalidad considerable, resulta efectiva de cara a preservar o recuperar la deambulación, así como para lograr el control del dolor. La arteriografía preoperatoria con la eventual embolización de la lesión constituye una herramienta importante

Objectives: To analyse the results of the anterior and anterolateral approaches in the treatment of thoracic and lumbar spine metastasis. Materials and methods: Patients who underwent surgery between 2003 and 2012 in our institution using an anterior or an anterolateral approach for the treatment of thoracic or lumbar spine metastasis were retrospectively reviewed. Results: Twenty-two patients with median age of 49.5 years (26-73 years) and median followup of 9.5 months (0-96 months) were analysed. The most common primary malignancies were renal cell carcinomas and breast adenocarcinomas. Before the intervention, 12 (54.5%) patients were able to walk (Frankel D and E). Preoperative arteriography was performed in 14 (63.6%) patients, and 7 (31.8%) of them underwent tumour embolisation. Medical complications occurred in 5 (22.7%) patients during the immediate postoperative period, 2 (9.1%) of whom died. At the end of follow-up, 16 (72%) of the remaining 20 patients were able to walk (Frankel D and E). Ninety percent of the patients could reduce at least 50% of their analgesic drug requirements. During follow-up 16 patients died, with a median survival of 10 months (range 0-48 months). Conclusions: Resection of thoracolumbar vertebral metastases by an anterior/anterolateral approach, despite its considerable risk of morbidity and mortality, offers the possibility of significant improvement in the quality of life of the patient; and it does so not only by preserving or restoring their ability to walk but also by ameliorating pain. Preoperative angiography, considering the embolisation of the lesion, is an important tool

[Anterior and anterolateral approach in the treatment of thoracic and lumbar vertebral metastasis causing spinal cord compression]. / Abordaje anterior y anterolateral en el tratamiento de la compresión medular metastásica a nivel torácico y lumbar.

OBJECTIVES: To analyse the results of the anterior and anterolateral approaches in the treatment of thoracic and lumbar spine metastasis. MATERIALS AND METHODS: Patients who underwent surgery between 2003 and 2012 in our institution using an anterior or an anterolateral approach for the treatment of thoracic or lumbar spine metastasis were retrospectively reviewed. RESULTS: Twenty-two patients with median age of 49.5 years (26-73 years) and median follow-up of 9.5 months (0-96 months) were analysed. The most common primary malignancies were renal cell carcinomas and breast adenocarcinomas. Before the intervention, 12 (54.5%) patients were able to walk (Frankel D and E). Preoperative arteriography was performed in 14 (63.6%) patients, and 7 (31.8%) of them underwent tumour embolisation. Medical complications occurred in 5 (22.7%) patients during the immediate postoperative period, 2 (9.1%) of whom died. At the end of follow-up, 16 (72%) of the remaining 20 patients were able to walk (Frankel D and E). Ninety percent of the patients could reduce at least 50% of their analgesic drug requirements. During follow-up 16 patients died, with a median survival of 10 months (range 0-48 months). CONCLUSIONS: Resection of thoracolumbar vertebral metastases by an anterior/anterolateral approach, despite its considerable risk of morbidity and mortality, offers the possibility of significant improvement in the quality of life of the patient; and it does so not only by preserving or restoring their ability to walk but also by ameliorating pain. Preoperative angiography, considering the embolisation of the lesion, is an important tool.