Impact of surgery on pain, disability, and quality of life of patients with degenerative lumbar disease: Brazilian data.

OBJECTIVE: To study the impact of surgery on pain, disability, quality of life, and patient satisfaction in a sample of patients with Degenerative Lumbar Disease (DLD). METHODS: Retrospective analysis of prospectively collected data. Comparison between pre and postoperative (6 - 12 months) ODI and SF-36, plus postoperative Patient Satisfaction Index. RESULTS: From a total of 216 patients included, improvement was observed in average scores of pain (201.2%), disability (39.7%), physical quality of life (42%), and mental quality of life (37.8%). Among these patients, 57.7% reached or surpassed the minimal clinically important difference (MCID) for ODI, 57.7% for the SF-36 pain component, 59.7% for the SF-36 physical component summary, and 50.5% achieved or surpassed the MCID for the SF-36 mental component summary. CONCLUSIONS: Surgery produced a significantly positive impact on pain, disability, and quality of life of patients. Overall, 82.5% of the patients were satisfied.

Impact of surgery on pain, disability, and quality of life of patients with degenerative lumbar disease: Brazilian data / Impacto da cirurgia na dor, incapacidade e qualidade de vida de portadores de doença degenerativa lombar: dados brasileiros

ABSTRACT Objective: To study the impact of surgery on pain, disability, quality of life, and patient satisfaction in a sample of patients with Degenerative Lumbar Disease (DLD). Methods: Retrospective analysis of prospectively collected data. Comparison between pre and postoperative (6 - 12 months) ODI and SF-36, plus postoperative Patient Satisfaction Index. Results: From a total of 216 patients included, improvement was observed in average scores of pain (201.2%), disability (39.7%), physical quality of life (42%), and mental quality of life (37.8%). Among these patients, 57.7% reached or surpassed the minimal clinically important difference (MCID) for ODI, 57.7% for the SF-36 pain component, 59.7% for the SF-36 physical component summary, and 50.5% achieved or surpassed the MCID for the SF-36 mental component summary. Conclusions: Surgery produced a significantly positive impact on pain, disability, and quality of life of patients. Overall, 82.5% of the patients were satisfied.

RESUMO Objetivo: Descrever o impacto da cirurgia na dor, incapacidade, qualidade de vida e a satisfação global do paciente numa amostra unificada de pacientes portadores de DDL. Métodos: Análise retrospectiva de dados colhidos prospectivamente em pacientes operados no período de janeiro de 2014 a março de 2017, que tivessem avaliação pré-operatória e pelo menos uma avaliação pós-operatória entre 6 e 12 meses com os questionários de ODI, SF-36 e o ISP. Resultados: Um total 216 pacientes preenchia os critérios de inclusão. Houve melhora no escore médio de dor (201,2%), incapacidade (39,7%), qualidade de vida física (42%) e mental (37,8%). Da amostra, 57,7% alcançaram o MCID de dor, 59,7% de ODI, 59,7% 50,5% de PCS e 50,5% de MCS; 82,5% dos pacientes se consideraram "Satisfeitos". Conclusões: O efeito da cirurgia foi amplamente favorável na dor, incapacidade e qualidade de vida dos pacientes portadores de DDL. Estes dados podem servir de guia para aconselhamento pré-operatório quanto às perspectivas de sucesso.

A simple scoring system for predicting early major complications in spine surgery: the cumulative effect of age and size of surgery.

OBJECTIVE: To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery. METHODS: Retrospective analysis of 583 surgically-treated patients. Early "major" complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression. RESULTS: Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively. CONCLUSIONS: This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

A simple scoring system for predicting early major complications in spine surgery: the cumulative effect of age and size of surgery / Escore simples para predizer complicações precoces graves em cirurgia de coluna: o efeito cumulativo da idade e tamanho da cirurgia

ABSTRACT Objective To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery. Methods Retrospective analysis of 583 surgically-treated patients. Early “major” complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression. Results Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively. Conclusions This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

RESUMO Objetivo Analisar os efeitos cumulativos dos fatores de risco associados com complicações precoces graves relacionadas à cirurgia da coluna. Métodos Análise retrospectiva de 583 pacientes tratados cirurgicamente. Complicações graves foram definidas como as que pudessem levar a danos permanentes ou que necessitassem de reinterveção. Um escore foi construído usando modelo de regressão logística. Resultados Noventa e duas complicações precoces graves ocorreram em 76 pacientes (13%). Idade > 60 anos e cirurgia > 3 níveis foram identificadas como fatores de risco independentes na análise multivariada. O escore foi definido como: 0 pontos (nenhum fator de risco), 2 pontos (1 fator) ou 4 pontos (2 fatores). A incidência de complicação grave precoce em cada categoria foi 7% (0 pontos), 15% (2 pontos) e 29% (4 pontos). Conclusões Esse escore balanceado baseado em 2 fatores de risco representa uma ferramenta útil na indicação cirúrgica e para o aconselhamento dos pacientes antes da cirurgia.

Surgical Treatment of Chronic Subdural Hematoma: Systematic Review and Meta-Analysis of the Literature / Tratamento cirúrgico do hematoma subdural crônico: revisão sistemática e metanálise da literatura

Background There are many controversies in the literature on the treatment of chronic subdural hematoma (CSDH). Objective To assess the effects of different surgical techniques and postoperative care on recurrence of CSDH. Methods Systematic review through Medline search of articles published between January 1990 and July 2011. Controlled observational and randomized clinical trials (RCT) regarding surgical approach, irrigation, drainage, and postoperative patient position in patients with CSDH were included. The outcome was recurrence requiring reoperation. Independent extraction of articles was conducted by 2 authors using predefined data fields, including study risk of bias indicators. Results 35 publications met inclusion criteria. Pooled analyses did not demonstrate difference in recurrence rates when compared burr-hole craniostomy (BHC) x twist-drill craniostomy (TDC) (OR: 0.99; CI95%: 0.53­1.84; p » 0.97), BHC x craniotomy (OR: 1.23; CI95%: 0.78­1.95; p » 0.36), nor TDC x craniotomy (OR: 16.11; CI95%: 0.85­306.88; p » 0.06). In patients receiving BHC, pooled analysis showed a lower recurrence rate in patients receiving 2BHC compared with 1BHC (OR: 0.58; CI95%: 0.37­0.88; p » 0.01). The use of drainage system after evacuation of CSDH by BHC reduces the recurrence (OR: 0.41; CI95%: 0.23­0.74; p » 0.003).There is not enough evidence to support either a specific location of the tip of drain, nor the postoperative patient position as factors influencing on recurrence. Conclusion Well-designed studies are urgently needed to verify the effectiveness of most neurosurgical procedures routinely performed for CSDH.

Introdução Existem inúmeras controvérsias na literatura sobre o tratamento do hematoma subdural crônico (HSDC). Objetivo Avaliar os resultados das diferentes técnicas cirúrgicas e cuidados pós operatórios na recidiva do HSDC. Métodos Revisão sistemática de artigos publicados no Medline entre Janeiro de 1990 a Julho de 2011. Foram incluídos estudos observacionais controlados e ensaios clínicos randomizados (ECR) relacionados à abordagem cirúrgica, irrigação, uso de dreno e posicionamento no pós-operatório de pacientes com HSDC. O desfecho estudado foi recidivo necessitando reoperação. A extração dos dados foi conduzida de maneira independente por dois autores utilizando campos pré-definidos, incluindo indicadores de viés dos estudos. Resultados Trinta e cinco artigos foram incluídos na análise. A metanálise não demonstrou diferença nas taxas de recorrência quando comparadas às técnicas de trepanação burr-hole (BHC) X twist-drill (TDC) (OR: 0,99; IC95%: 0,53­1,84; p » 0,97), BHC X craniotomia (OR: 1,23; IC95%: 0,78­1,95; p » 0,36), nem TDC X craniotomia (OR: 16,11; IC95%: 0,85­306,88; p » 0.06). Em pacientes operados por BHC, a metanálise demonstrou menor taxa de recidiva em pacientes operados com 2BHC em comparação a 1BHC (OR: 0,58; IC95%: 0,37­0,88; p » 0,01). O uso de dreno no pós-operatório por BHC reduziu a recidiva (OR: 0,41; IC95%: 0,23­0,74; p » 0,003). Não há evidência suficiente que aponta do dreno ou a posição do paciente no pós operatório tenham influência na chance de recidiva. Conclusão Estudos bem delineados são necessários para comparar a efetividade da maioria dos procedimentos neurocirúrgicos realizados rotineiramente para HSDC.

Cerebellar Single Metastases from Bladder Transitional Cell Carcinoma: A Case Report / Metástase cerebelar única secundária a câncer de celulas transicionais de bexiga: relato de caso

Cerebral metastasis is the most common cancer in the Central Nervous System (CNS); however, the bladder is a rare primary origin. The incidence of bladder metastases to the brain tissue has slightly increased in the past decades, with a few case reports published inmedical literature, but not in Brazil. The authors describe a case of a female with prior diagnosis and treatment of transitional cellular cancer, without signs or symptoms of local or disseminated relapse, who suddenly developed clinical signs of cerebellum impairment. The patient was submitted to neurosurgical procedure with good outcome, followed by oncologic adjuvant treatment.

Asmetástases cerebrais são as patologias neoplásicasmais comuns no sistema nervoso central (SNC), contudo, o epitélio vesical é umsitio primário raro para os tumores que acometem o parênquima cerebral. A incidência do envolvimento cerebral em tumores de bexiga tem aumentado nos últimos anos, com alguns relatos de caso descritos na literatura médica, contudo nenhum caso foi descrito no Brasil. Os autores relatam o caso de uma paciente com diagnóstico de câncer de células transicionais cujo sítio primário já fora tratado previamente, sem sinais de recidiva local ou à distância, que subitamente iniciou com sinais clínicos de síndrome cerebelar. A paciente foi submetida a ressecção cirúrgica da lesão com boa evolução pós-operatória complementada com terapia oncológica adjuvante.

Long-term behavioral and cognitive outcomes following clipping for incidental unruptured intracranial aneurysms.

OBJECTIVE: Recent advances in neuroimaging techniques have resulted in more frequent detection of unruptured intracranial aneurysms. Regardless of the method employed, most interventions to treat lesions have low morbidity and mortality rates. Recently, some studies have suggested that changes in cognitive status are one complication of microsurgical treatments. However, no study to date has performed any behavioral analysis. Moreover, cognitive assessment beyond 12 months after surgical intervention is missing. The current study sought to evaluate the long-term impact of clipping on the behavioral and cognitive functions of patients with unruptured intracranial aneurysms. METHOD: A within-subjects prospective clinical trial was performed to evaluate 40 patients who underwent microsurgical clipping for incidental unruptured intracranial aneurysms. The participants underwent a full neuropsychological evaluation during the preoperative period, at 3 months after surgery and at 3 years after surgery. Paired Student's t tests and an ANOVA, followed by a Bonferroni post hoc test, were used to examine group differences. RESULTS: The cognitive and behavioral test performance of the patients did not deteriorate during either the short or the long term following intervention. Moreover, the patients' clinical and demographic characteristics did not predict behavioral or cognitive changes, and neither the surgical approach nor the topography, multiplicity, or size of the aneurysms affected the results. CONCLUSIONS: In either the short or the long term following clipping for patients with incidental unruptured intracranial aneurysms, behavioral and cognitive functions had no significant change from baseline. The intervention demonstrated high efficacy and was associated with a low morbidity rate.

Quantitative computed tomography and cranial burr holes: a model to evaluate the quality of cranial reconstruction in humans.

Current methods to evaluate the biologic development of bone grafts in human beings do not quantify results accurately. Cranial burr holes are standardized critical bone defects, and the differences between bone powder and bone grafts have been determined in numerous experimental studies. This study evaluated quantitative computed tomography (QCT) as a method to objectively measure cranial bone density after cranial reconstruction with autografts. In each of 8 patients, 2 of 4 surgical burr holes were reconstructed with autogenous wet bone powder collected during skull trephination, and the other 2 holes, with a circular cortical bone fragment removed from the inner table of the cranial bone flap. After 12 months, the reconstructed areas and a sample of normal bone were studied using three-dimensional QCT; bone density was measured in Hounsfield units (HU). Mean (SD) bone density was 1535.89 (141) HU for normal bone (P < 0.0001), 964 (176) HU for bone fragments, and 453 (241) HU for bone powder (P < 0.001). As expected, the density of the bone fragment graft was consistently greater than that of bone powder. Results confirm the accuracy and reproducibility of QCT, already demonstrated for bone in other locations, and suggest that it is an adequate tool to evaluate cranial reconstructions. The combination of QCT and cranial burr holes is an excellent model to accurately measure the quality of new bone in cranial reconstructions and also seems to be an appropriate choice of experimental model to clinically test any cranial bone or bone substitute reconstruction.

Microsurgical clipping in forty patients with unruptured anterior cerebral circulation aneurysms: an investigation into cognitive outcome.

OBJECTIVE: It is a consensus that most unruptured intracranial aneurysms (UIA) can be treated with acceptably low morbidity. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributable to surgical damage. Our goal is to evaluate cognitive function before and after microsurgical clipping in patients with UIA. METHOD: A consecutive series of 40 patients who underwent microsurgical clipping for UIA were studied. The cognitive assessment (Mini Mental State Examination, MMSE) was performed immediately before and at least one month after surgery. Paired Student's "t" test and analysis of variance (ANOVA) were used for statistical purposes. RESULTS: The mean MMSE score in the preoperative analysis was 28.12 (SD, 1.34). In the postoperative period the mean MMSE score was 28.40 (SD, 1.46). Paired Student's "t" test was applied to the scores and no significant difference was found (p = 0.315). ANOVA did not find independent associations between MMSE scores and age, hypertension, smoking, dyslipidemia, education, aneurysm location, number, laterality or size. CONCLUSION: The present study suggests that microsurgical clipping for UIA does not result in major cognitive dysfunction as determined by the MMSE.

Microsurgical clipping in forty patients with unruptured anterior cerebral circulation aneurysms: an investigation into cognitive outcome / Clipagem microcirúrgica em 40 pacientes com aneurisma de circulação cerebral anterior não-roto: uma investigação cognitiva

OBJECTIVE: It is a consensus that most unruptured intracranial aneurysms (UIA) can be treated with acceptably low morbidity. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributable to surgical damage. Our goal is to evaluate cognitive function before and after microsurgical clipping in patients with UIA. METHOD: A consecutive series of 40 patients who underwent microsurgical clipping for UIA were studied. The cognitive assessment (Mini Mental State Examination, MMSE) was performed immediately before and at least one month after surgery. Paired Student's "t" test and analysis of variance (ANOVA) were used for statistical purposes. RESULTS: The mean MMSE score in the preoperative analysis was 28.12 (SD, 1.34). In the postoperative period the mean MMSE score was 28.40 (SD, 1.46). Paired Student's "t" test was applied to the scores and no significant difference was found (p=0.315). ANOVA did not find independent associations between MMSE scores and age, hypertension, smoking, dyslipidemia, education, aneurysm location, number, laterality or size. CONCLUSION: The present study suggests that microsurgical clipping for UIA does not result in major cognitive dysfunction as determined by the MMSE.

OBJETIVO: É consenso que a maioria dos aneurismas intracranianos não-rotos (AINR) podem ser tratados com aceitável taxa de morbidade. Entretanto, alguns estudos reportaram déficits cognitivos no pós-operatório, sugerindo que poderiam ser atribuídos ao dano cirúrgico. O objetivo desse estudo é avaliar a função cognitiva antes e após clipagem microcirúrgica em pacientes com AINR. MÉTODO: Uma série de 40 pacientes com AINR submetidos à clipagem microcirúrgica foi estudada. A avaliação cognitiva (Mini Exame do Estado Mental, MEEM) foi realizada antes e após a intervenção cirúrgica. A análise estatística foi realizada com teste "t" de Student e análise de variância (ANOVA). RESULTADOS: A média dos escores do MEEM na análise pré-operatória foi 28,12 (DP, 1,34). No período pós-operatório, a média dos escores foi 28,40 (DP, 1,46). Não houve diferença estatística (teste "t" de Student; p=0,315). A ANOVA não encontrou associações independentes entre os escores de MEEM e idade, hipertensão, tabagismo, dislipidemia, educação e características dos aneurismas (topografia, número, lado e tamanho). CONCLUSÃO: O presente estudo sugere que a clipagem microcirúrgica não está associada a danos cognitivos maiores em pacientes com AINR.

Comparative study between cortical bone graft versus bone dust for reconstruction of cranial burr holes.

BACKGROUND: As a consequence of the progressive evolution of neurosurgical techniques, there has been increasing concern with the esthetic aspects of burr holes. Therefore, the objective of this study was to compare the use of cortical bone graft and bone dust for correcting cranial deformities caused by neurosurgical trephines. METHODS: Twenty-three patients were enrolled for cranial burr hole reconstruction with a 1-year follow-up. A total of 108 burr holes were treated; 36 burr holes were reconstructed with autogenous cortical bone discs (33.3%), and the remaining 72 with autogenous wet bone powder (66.6%). A trephine was specifically designed to produce this coin-shaped bone plug of 14 mm in diameter, which fit perfectly over the burr holes. The reconstructions were studied 12 months after the surgical procedure, using three-dimensional quantitative computed tomography. Additionally, general and plastic surgeons blinded for the study evaluated the cosmetic results of those areas, attributing scores from 0 to 10. RESULTS: The mean bone densities were 987.95 ± 186.83 Hounsfield units (HU) for bone fragment and 473.55 ± 220.34 HU for bone dust (P < 0.001); the mean cosmetic scores were 9.5 for bone fragment and 5.7 for bone dust (P < 0.001). CONCLUSIONS: The use of autologous bone discs showed better results than bone dust for the reconstruction of cranial burr holes because of their lower degree of bone resorption and, consequently, better cosmetic results. The lack of donor site morbidity associated with procedural low cost qualifies the cortical autograft as the first choice for correcting cranial defects created by neurosurgical trephines.

Intracranial intrasellar kissing carotid arteries: case report.

Intracranial "kissing" carotid arteries are a rare variant of the carotid arteries, where both internal carotid arteries deviate medially and touch each other near the midline within the sphenoid sinus or the sphenoid bone, including the sella. This anomaly is particularly important since it may cause or mimic pituitary disease and also may complicate transsphenoidal surgery. We report a rare case of intracranial intrasellar kissing carotid arteries in a 57-years-old woman that was submitted to a computed tomography angiography during investigation of a sudden headache, and to discuss the clinical relevance of this radiological finding.

Intracranial intrasellar kissing carotid arteries: case report

Intracranial "kissing" carotid arteries are a rare variant of the carotid arteries, where both internal carotid arteries deviate medially and touch each other near the midline within the sphenoid sinus or the sphenoid bone, including the sella. This anomaly is particularly important since it may cause or mimic pituitary disease and also may complicate transsphenoidal surgery. We report a rare case of intracranial intrasellar kissing carotid arteries in a 57-years-old woman that was submitted to a computed tomography angiography during investigation of a sudden headache, and to discuss the clinical relevance of this radiological finding.

Artérias carótidas intracranianas "que se beijam" representam rara variação da anatomia arterial, onde ambas as artérias carótidas internas desviam-se medialmente e tocam-se próximo à linha media dentro do seio esfenoidal ou do osso esfenóide, incluindo a sela túrcica. Essa anomalia é particularmente importante, pois pode causar ou simular doença pituitária e ainda pode complicar uma cirurgia transesfenoidal. Relatamos um raro caso de artérias carótidas intracranianas "que se beijam" em mulher de 57 anos, a qual foi investigada por angiotomografia por quadro de cefaléia súbita. Discutimos a relevância clínica desse achado radiológico.