Barbed versus conventional suture in elective posterior spine surgery.

PURPOSE: Barbed sutures are tissue control devices that can reduce operating room time and costs. We analyzed the utility of barbed sutures in posterior spinal surgery in order to prove non-inferiority to conventional methods for wound closure. METHODS: A cohort of patients undergoing elective posterior spinal surgery in which barbed (prospective) versus conventional sutures (retrospective) were used was analyzed. The primary endpoint was the occurrence of wound healing complications or the need for surgical revision. Secondary endpoints included postoperative stay, readmission rate, and duration and cost of wound closure. RESULT: A total of 483 patients participated in the study, 183 in the Barbed group and 300 in the Conventional group. Wound dehiscence or seroma occurred in 3.8% and 2.7% of the Barbed and Conventional groups, respectively (p = 0.6588). Both superficial (1.6% versus 4.0%, P = 0.2378) and deep infections (2.7% versus 4.7%, p = 0.4124) occurred similarly in both groups. Overall, the rate of re-intervention due to wound healing problems was also similar (4.9% versus 5.3%, p = 0.9906), as well as, total median hospital stay, postoperative stay and 30-day re-admission rates. The average duration of wound closure (1.66 versus 4.16 min per level operated, p < 0.0001) strongly favored the Barbed group. The mean cost of wound closure per patient was higher in the Barbed group (43.23 € versus 22.67 €, p < 0.0001). CONCLUSIONS: In elective posterior spinal procedures, the use of barbed sutures significantly reduced the duration of wound closure. The wound healing process was not hindered and the added cost related to the suture material was small.

Perioperative risk factors for major complications after bone replacement in decompressive craniectomy.

INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Predicting histological grade in symptomatic meningioma by an objective estimation of the tumoral surface irregularity.

INTRODUCTION: Predicting the histopathologic grade of meningioma is relevant because local recurrence is significantly greater in WHO grade II-III compared to WHO grade I tumours, which would ideally benefit from a more aggressive surgical strategy. It has been suggested that higher WHO grade tumours are more irregularly-shaped. However, irregularity is a subjective and observer-dependent feature. In this study, the tumour surface irregularity of a large series of meningiomas, measured upon preoperative MRI, is quantified and correlated with the WHO grade. METHODS: Unicentric retrospective observational study of a cohort of symptomatic meningiomas surgically removed in the time period between January 2015 and December 2022. Using specific segmentation software, the Surface Factor (SF) was calculated for each meningioma. SF is an objective parameter that compares the surface of a sphere (minimum surface area for a given volume) with the same volume of the tumour against the actual surface of the tumour. This ratio varies from 0 to 1, being 1 the maximum sphericity. Since irregularly-shaped meningiomas present proportionally greater surface area, the SF tends to decrease as irregularity increases. SF was correlated with WHO grade and its predictive power was estimated with ROC curve analysis. RESULTS: A total of 176 patients (64.7% females) were included in the study; 120 WHO grade I (71.9%), 43 WHO grade II (25.7%) and 4 WHO grade III (2.4%). A statistically significant difference was found between the mean SF of WHO grade I and WHO grade II-III tumours (0.8651 ±â€¯0.049 versus 0.7081 ±â€¯0.105, p < 0.0001). Globally, the SF correctly classified more than 90% of cases (area under ROC curve 0.940) with 93.3% sensibility and 80.9% specificity. A cutoff value of 0.79 yielded the maximum precision, with positive and negative predictive powers of 82.6% and 92.6%, respectively. Multivariate analysis yielded SF as an independent prognostic factor of WHO grade. CONCLUSION: The Surface Factor is an objective and quantitative parameter that helps to identify aggressive meningiomas preoperatively. A cutoff value of 0.79 allowed differentiation between WHO grade I and WHO grade II-III with high precision.

Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery.

OBJECTIVE: To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS: We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS: Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION: Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery.

OBJECTIVE: To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS: We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS: Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION: Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

Volumetric growth rate of incidental asymptomatic meningiomas: a single-center prospective cohort study.

BACKGROUND: Decision about treatment of incidentally found intracranial meningiomas is controversial and conditioned by the growth potential of these tumors. We aimed to evaluate the growth rate of a cohort of incidentally found asymptomatic meningiomas and to analyze their natural course and the need for eventual treatment. METHODS: A total of 193 patients harboring intracranial meningiomas (85 with 109 incidental and 108 with 112 symptomatic) were included between 2015 and 2019. In the prospective cohort of incidental meningiomas, we measured size at diagnosis, volumetric growth rate (by segmentation software), appearance of symptoms, and need for surgery or radiotherapy. Progression-free survival and risk factors for growth were assessed with Kaplan-Meier survival and Cox regression analyses. RESULTS: Among incidental meningiomas, 94/109 (86.2%) remained untreated during a median follow-up of 49.3 months. Tumor growth was observed in 91 (83.5%) and > 15% growth in 40 (36.7%). Neurological symptoms developed in 1 patient (1.2%). Volume increased an average of 0.51 cm3/year (95% CI, 0.20-0.82). Nine patients were operated (9.2%) and 4 underwent radiotherapy (4.7%). Treatment-related complication rates of incidental and symptomatic meningiomas were 0% and 35.4%, respectively. Persistent neurological defects occurred in 46 (40.7%) of symptomatic versus 2 (2.3%) of incidental meningiomas. Among covariates, only brain edema resulted in an increased risk of significant tumor growth in the female subgroup (Cox regression HR 2.96, 95% CI 1.02-8.61, p = 0.046). Size at diagnosis was significantly greater in the symptomatic meningioma group (37.33 cm3 versus 4.74 cm3, p < 0.001). CONCLUSIONS: Overall, 86% of incidentally found meningiomas remained untreated over the first 4 years of follow-up. The majority grew within the 20% range, yet very few developed symptoms. Treatment-related morbidity was absent in the incidental meningioma group.

Polvo de vancomicina tópico para la prevención de infección de herida quirúrgica en cirugía electiva de columna por vía posterior / Vancomycin powder for the prevention of surgical site infection in posterior elective spinal surgery

OBJETIVO: Evaluar la efectividad y seguridad del polvo de vancomicina tópico como profilaxis de infección de herida quirúrgica (IHQ) en cirugía de columna electiva por abordaje posterior. MATERIAL Y MÉTODOS: Estudio unicéntrico cuasiexperimental de comparación pre- y postintervención. El grupo postintervención recibió profilaxis antibiótica estándar preoperatoria junto a 1g de polvo de vancomicina en el lecho quirúrgico antes del cierre de la herida. El grupo preintervención solo recibió la profilaxis intravenosa. RESULTADOS: Participaron 150 pacientes en cada grupo. Ocurrieron 12 infecciones (7 superficiales, 5 profundas) en el grupo postintervención y 16 infecciones (7 superficiales, 9 profundas) en el grupo preintervención. El riesgo de IHQ profunda se redujo del 6% al 3,3% (OR 0,54; IC 95% 0,17-1,65; p = 0,411) con el tratamiento. El porcentaje de IHQ profunda por gramnegativos-positivos fue del 80-20% en el grupo tratado con vancomicina y del 33-67% en los no tratados (p = 0,265). No se produjeron efectos adversos locales ni sistémicos por el tratamiento. CONCLUSIÓN: La profilaxis con polvo de vancomicina en cirugía electiva de columna por abordaje posterior no redujo de forma significativa la incidencia de IHQ superficial o profunda. Se constató una tendencia al aumento de IHQ profunda por microorganismos gramnegativos en los tratados con vancomicina

OBJECTIVE: To assess the effectiveness and safety of vancomycin powder as surgical site infection (SSI) prophylaxis in posterior bilateral elective spinal surgery. MATERIALS AND METHODS: Single-center quasi-experimental pre and postintervention comparative cohort study. The post-intervention group received standard intravenous antibiotic prophylaxis plus 1g of vancomycin powder into the surgical field before wound closure, and the pre-intervention group only the intravenous prophylaxis. RESULTS: 150 patients were included in each group. Twelve SSI (7 superficial and 5 deep) occurred in the post-intervention group and 16 SSI (7 superficial and 9 deep) in the pre-intervention group. The risk of deep SSI decreased from 6.0% to 3.3% (OR 0,54, 95%CI 0.17-1.65, p = 0.411) with vancomycin powder. The percentage of deep SSI due to gram negative-positive germs were 80%-20% and 33%-67% for the post- and pre-intervention groups, respectively (p = 0.265). No local or systemic adverse effects occurred attributable to vancomycin powder. CONCLUSIÓN: In posterior elective spinal surgery, prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI. There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin

Vancomycin powder for the prevention of surgical site infection in posterior elective spinal surgery. / Polvo de vancomicina tópico para la prevención de infección de herida quirúrgica en cirugía electiva de columna por vía posterior.

OBJECTIVE: To assess the effectiveness and safety of vancomycin powder as surgical site infection (SSI) prophylaxis in posterior bilateral elective spinal surgery. MATERIALS AND METHODS: Single-center quasi-experimental pre and postintervention comparative cohort study. The post-intervention group received standard intravenous antibiotic prophylaxis plus 1g of vancomycin powder into the surgical field before wound closure, and the pre-intervention group only the intravenous prophylaxis. RESULTS: 150 patients were included in each group. Twelve SSI (7 superficial and 5 deep) occurred in the post-intervention group and 16 SSI (7 superficial and 9 deep) in the pre-intervention group. The risk of deep SSI decreased from 6.0% to 3.3% (OR 0,54, 95%CI 0.17-1.65, p=0.411) with vancomycin powder. The percentage of deep SSI due to gram negative-positive germs were 80%-20% and 33%-67% for the post- and pre-intervention groups, respectively (p=0.265). No local or systemic adverse effects occurred attributable to vancomycin powder. CONCLUSION: In posterior elective spinal surgery, prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI. There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin.

Cauda equina syndrome due to disk herniation: Long-term functional prognosis / Síndrome de cola de caballo por hernia discal: pronóstico funcional a largo plazo

Objective: Cauda equina syndrome (CES) caused by lumbar disk extrusion is classically considered an indication of urgent surgery. CES can be subdivided into CESI (incomplete CES) and CESR (complete CES with urinary retention and incontinence). This paper evaluates the long-term functional outcome of a CES cohort operated on due to disk herniation. Methods: Single-center retrospective observational study. CES patients due to disk herniation that underwent surgery between 2000 and 2016 were included in the study. Demographic data, time intervals to diagnosis and surgery, preoperative neurologic status and outcome at the end of follow up were recorded. Results: Twenty-two patients were included (median age 44 years). Eight patients were CESR and 14 CESI. Median time from symptom onset to diagnosis was 78h (range, 12-720h), and from diagnosis to surgery 24h (range, 5-120h). Median follow up was 75 months (range, 20-195 months). At the end of follow up, in the CESR group (median time from diagnosis to surgery, 23h) only pain significantly improved after surgery (p=0.007). In the CESI group (median time from diagnosis to surgery 23h) low back pain, sciatica and urinary sphincter function significantly improved (p<0.001). There were no significant differences between early (<48h) operation (n=4) and late (n=18) in terms of sphincter recovery (Fisher's Exact Test, p=0.076). Conclusion: Pain associated to CES improved both in the CESI and CESR groups. However, urinary sphincter impairment significantly improved only in the CESI group. No significant differences were found regarding long-term functional outcome between early and late surgery

Objetivo: El síndrome de cola de caballo (SCC) producido por extrusión discal se ha considerado clásicamente una urgencia neuroquirúrgica. El SCC puede dividirse en SCC-I (incompleto) y en SCC-C (completo, con retención urinaria e incontinencia). Este trabajo evalúa el pronóstico funcional a largo plazo de una cohorte de pacientes con SCC por hernia discal intervenidos. Material y métodos: Estudio observacional retrospectivo unicéntrico. Se incluyeron todos los pacientes diagnosticados de SCC por hernia discal e intervenidos en el período 2000-2016. Se recogieron datos demográficos, intervalos de tiempo entre el inicio de síntomas, el diagnóstico y la cirugía, y estado neurológico preoperatorio y al final del seguimiento. Resultados: Se incluyeron un total de 22 pacientes (edad mediana de 44 años). Ocho casos fueron SCC-C y 14 SCC-I. El tiempo medio desde el inicio de los síntomas hasta el diagnóstico fue de 78h (rango, 12-720h), y desde el diagnóstico hasta la cirugía de 24h (rango, 5-120h). El seguimiento mediano fue de 75 meses (rango, 20-195). Al final del seguimiento, en el grupo SCC-C (tiempo medio desde diagnóstico hasta la cirugía, 23h) sólo el dolor mejoró de forma significativa tras la cirugía (p = 0,007). En el grupo SCC-I (tiempo medio desde diagnóstico hasta la cirugía, 23h) mejoraron significativamente el dolor lumbar, la ciática y el control del esfínter urinario (p < 0.01). No se constataron diferencias significativas entre los operados precozmente (antes de 48h, n = 4) y tardíamente (n = 18) en relación a la recuperación esfinteriana (Test exacto de Fisher, p = 0,076). Conclusión: El dolor asociado al SCC mejoró tanto en los casos completos como incompletos. Sin embargo, el control del esfínter urinario sólo mejoró significativamente en los pacientes con síndromes incompletos. No se encontraron diferencias significativas en cuanto al resultado funcional a largo plazo entre intervenidos precoz y tardíamente

Cauda equina syndrome due to disk herniation: Long-term functional prognosis.

OBJECTIVE: Cauda equina syndrome (CES) caused by lumbar disk extrusion is classically considered an indication of urgent surgery. CES can be subdivided into CESI (incomplete CES) and CESR (complete CES with urinary retention and incontinence). This paper evaluates the long-term functional outcome of a CES cohort operated on due to disk herniation. METHODS: Single-center retrospective observational study. CES patients due to disk herniation that underwent surgery between 2000 and 2016 were included in the study. Demographic data, time intervals to diagnosis and surgery, preoperative neurologic status and outcome at the end of follow up were recorded. RESULTS: Twenty-two patients were included (median age 44 years). Eight patients were CESR and 14 CESI. Median time from symptom onset to diagnosis was 78h (range, 12-720h), and from diagnosis to surgery 24h (range, 5-120h). Median follow up was 75 months (range, 20-195 months). At the end of follow up, in the CESR group (median time from diagnosis to surgery, 23h) only pain significantly improved after surgery (p=0.007). In the CESI group (median time from diagnosis to surgery 23h) low back pain, sciatica and urinary sphincter function significantly improved (p<0.001). There were no significant differences between early (<48h) operation (n=4) and late (n=18) in terms of sphincter recovery (Fisher's Exact Test, p=0.076). CONCLUSION: Pain associated to CES improved both in the CESI and CESR groups. However, urinary sphincter impairment significantly improved only in the CESI group. No significant differences were found regarding long-term functional outcome between early and late surgery.

Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos / Role of surgery in spontaneous spondylodiscitis: Experience in 83 consecutive patients

Objetivo: Describir y discutir el papel del tratamiento quirúrgico en la espondilodiscitis espontánea. Pacientes y métodos: Análisis retrospectivo de resultados y complicaciones de una cohorte de pacientes intervenidos por espondilodiscitis espontánea (no posquirúrgica) de cualquier nivel espinal y etiología. Resultados: En el período 1995-2014 se trataron 83 pacientes (45% mujeres, edad mediana 66 años) con diagnóstico de espondilodiscitis (confirmación microbiológica en el 67,4%). Existió déficit neurológico preoperatorio en el 44,5%. El nivel más frecuentemente afectado fue el dorsal (54,2%). Los principales gérmenes aislados fueron Mycobacterium tuberculosis (22,9%), Staphylococcus aureus (20,5%) y SARM (7,2%). Se intervinieron 81 pacientes mediante: laminectomía simple y/o biopsia (22,2%), laminectomía, desbridamiento y artrodesis posterior (43,2%), y desbridamiento y fijación anterior (34,5%). El 86,7% de los pacientes intervenidos obtuvieron buena evolución postoperatoria (mejoría sintomática o del déficit). Se estabilizaron 7 pacientes y empeoraron 2. Aparecieron complicaciones en 35 pacientes, fundamentalmente derrame pleural (9), anemia (7) y necesidad de reintervención y desbridamiento (7). La mediana de estancia postoperatoria fue de 14 días. Tras un seguimiento medio de 8,5 meses se consideraron curados 46 pacientes, 10 presentaron secuelas, se perdieron 22 pacientes y 5 fallecieron. La cirugía no motivó reingresos. Conclusiones: Aunque la antibioterapia específica y prolongada es el tratamiento estándar, la cirugía permite obtener muestra para estudio microbiológico e histopatológico, desbridar el foco infeccioso y estabilizar la columna. En nuestra experiencia la utilización de material metálico de fijación acelera la recuperación y no predispone a ulteriores infecciones o a cronificación de las mismas

Objective: To describe and discuss the role of surgery in the management of spontaneous spondylodiscitis. Patients and methods: Retrospective review on the outcome and complications of a cohort of patients undergoing surgery for spontaneous (non-postoperative) spondylodiscitis of any spinal level or aetiology. Results: From 1995 to 2014, 83 patients (45% females, median age 66) with spondylodiscitis were treated. Microbiological confirmation was obtained in 67.4%. Forty-four percent of patients presented with neurological defect. The most common affected level was thoracic (54.2%). The most frequent isolations were Mycobacterium tuberculosis (229%), Staphylococcus aureus (20.5%) and MRSA (7.2%). Eighty-one patients underwent surgery: simple laminectomy and/or biopsy (22.2%), debridement and posterior fixation (43.2%) and debridement and anterior fixation (34.5%). Improvement of pain or neurological defect was achieved in 86.7% of the patients; 7 patients stabilized and 2 worsened. Complications occurred in 35 patients, mainly pleural effusion (9), anaemia (7) and need for re-debridement (7). Median postoperative stay was 14 days. After a median follow up of 8.5 months, 46 patients were considered completely cured, 10 presented sequelae, 22 patients were lost and 5 patients died. No readmissions occurred because of the infectious episode. Conclusions: Although prolonged and specific antibiotic therapy remains the mainstay of treatment in spontaneous spondylodiscitis, surgery provides samples for microbiological confirmation and histopathologic study, allows debridement of the infectious foci and stabilizes the spine. In our experience, the use of internal metallic fixation material accelerates recovery and does not predispose to chronic infection

[Role of surgery in spontaneous spondylodiscitis: Experience in 83 consecutive patients]. / Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos.

OBJECTIVE: To describe and discuss the role of surgery in the management of spontaneous spondylodiscitis. PATIENTS AND METHODS: Retrospective review on the outcome and complications of a cohort of patients undergoing surgery for spontaneous (non-postoperative) spondylodiscitis of any spinal level or aetiology. RESULTS: From 1995 to 2014, 83 patients (45% females, median age 66) with spondylodiscitis were treated. Microbiological confirmation was obtained in 67.4%. Forty-four percent of patients presented with neurological defect. The most common affected level was thoracic (54.2%). The most frequent isolations were Mycobacterium tuberculosis (229%), Staphylococcus aureus (20.5%) and MRSA (7.2%). Eighty-one patients underwent surgery: simple laminectomy and/or biopsy (22.2%), debridement and posterior fixation (43.2%) and debridement and anterior fixation (34.5%). Improvement of pain or neurological defect was achieved in 86.7% of the patients; 7 patients stabilized and 2 worsened. Complications occurred in 35 patients, mainly pleural effusion (9), anaemia (7) and need for re-debridement (7). Median postoperative stay was 14days. After a median follow up of 8.5 months, 46 patients were considered completely cured, 10 presented sequelae, 22 patients were lost and 5 patients died. No readmissions occurred because of the infectious episode. CONCLUSIONS: Although prolonged and specific antibiotic therapy remains the mainstay of treatment in spontaneous spondylodiscitis, surgery provides samples for microbiological confirmation and histopathologic study, allows debridement of the infectious foci and stabilizes the spine. In our experience, the use of internal metallic fixation material accelerates recovery and does not predispose to chronic infection.

Fundamentos y complicaciones del abordaje anterolateral extrapleural-retroperitoneal en fracturas inestables toracolumbares: experiencia en 86 pacientes consecutivos / Rationale and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable thoracolumbar fractures: Experience in 86 consecutive patients

Objetivos: Describir los fundamentos, las ventajas, los inconvenientes y las complicaciones del abordaje anterolateral extrapleural-extraperitoneal en fracturas toracolumbares inestables (TLICSS>4). Pacientes y métodos: Se evalúan retrospectivamente datos clínicos y radiológicos, resultados y complicaciones de una cohorte intervenida mediante dicho abordaje. Todos los pacientes fueron intervenidos exclusivamente por 5 neurocirujanos entrenados en cirugía de columna. Resultados: Un total de 86 pacientes fueron intervenidos entre junio de 1999 y diciembre de 2015 (mediana de edad 42años y nivel más frecuente L1). El 32,5% presentaban defecto neurológico preoperatorio. Tras la intervención (duración media: 275min), el 75,6% quedaron sin secuelas neurológicas y solo un tercio de pacientes precisó transfusión. La estancia media postoperatoria fue de 7días. La corrección de la cifosis se consideró correcta y subóptima pero aceptable en el 91 y el 9% de los casos, respectivamente. Ocurrieron complicaciones en 36 pacientes, la gran mayoría transitorias. Se constataron 2 fallos de material (colapso de caja expansible y extrusión de tornillo de bloqueo). No ocurrieron infecciones, lesiones vasculares, lesiones viscerales, empeoramiento neurológico permanente ni mortalidad durante el ingreso. Un paciente precisó estabilización posterior tardía por persistencia del dolor. El seguimiento mediano fue de 252días (27,9% pérdidas). Conclusiones: El abordaje extrapleural-extraperitoneal proporciona una estabilización anterior sólida, permite una amplia descompresión del canal y una corrección adecuada y duradera de la cifosis. Las tasas de infección, fallo del material, necesidad de reoperación y lesiones vasculares o viscerales son mínimas

Objectives: To describe the rationale, pros and cons, and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable (TLICS>4) thoracolumbar fractures. Patients and methods: Clinical and radiological data and outcomes from a cohort treated surgically via said approach were retrospectively reviewed. All patients were operated on exclusively by 5 neurosurgeons trained in spine surgery. Results: Between June 1999 and December 2015, 86 patients underwent surgery (median age 42years, most common level: L1). Approximately 32.5% presented with a preoperative neurological defect. After surgery (mean duration: 275minutes), 75.6% presented with no neurological sequelae and only one-third required blood transfusion. Median postoperative stay was 7days. Correction of kyphosis was considered adequate and suboptimal but acceptable in 91% and 9% of the patients, respectively. Complications occurred in 36 patients, the majority being transient. We observed failure of the construct in 2 cases (collapse of an expandable cage and extrusion of a locking screw). No infections, vascular or visceral lesions, permanent neurological worsening or mortality occurred during hospitalisation. One patient ultimately needed additional posterior fixation due to persistence of pain. Median follow-up was 252days (27.9% was lost to follow-up). Conclusions: The extrapleural extraperitoneal approach provides solid anterior reconstruction, allows wide decompression of the spinal canal, and permits adequate and long-lasting correction of kyphosis. The rates of infection, construct failure, need for reoperation and vascular or visceral lesions are minimal

Hernia discal lumbar: historia natural, papel de la exploración, timing de la cirugía, opciones de tratamiento y conflicto de intereses / Lumbar disc herniation: Natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests

Introducción: La cirugía de la hernia discal lumbar (HDL) es una de las intervenciones con mayor variabilidad geográfica en su indicación. Desarrollo: Se realiza una revisión bibliográfica sobre la historia natural, el papel de la exploración neurológica, el timing de la cirugía, el tratamiento basado en la evidencia y el conflicto de intereses relativos a la HDL. La cirugía acorta significativamente el tiempo de dolor respecto al tratamiento conservador, aunque este efecto se diluye a partir del año. No parece existir una modalidad terapéutica superior al resto respecto del control del dolor o de la recuperación neurológica, ni una técnica quirúrgica claramente superior a la discectomía simple. La gran variabilidad geográfica puede deberse a una ausencia de criterios científicos sólidos en la indicación. Conclusiones: La historia natural de la HDL es favorable y debe respetarse un mínimo de 6semanas antes de indicar pruebas de imagen o considerar la cirugía. Es preciso concretar y respetar la indicación quirúrgica, evitando los conflictos de intereses

Introduction: Indication for surgery in lumbar disc herniation (LDH) varies widely depending on the geographical area. Development: A literature review is presented on the natural history, role of physical examination, timing of surgery, evidence-based treatment, and conflicts of interests in LDH. Surgery is shown to provide significant faster relief of pain compared to conservative therapy, although the effect fades after a year. There is no treatment modality better than the rest in terms of pain control and neurological recovery, nor is there a surgical technique clearly superior to simple discectomy. The lack of sound scientific evidence on the surgical indication may contribute to its great geographical variability. Conclusions: Since LDH has a favourable natural history, neuroimaging and surgery should not be considered until after a 6-week period. It is necessary to specify and respect the surgical indications for LDH, avoiding conflicts of interests

Vertebrectomía total en bloque en tumores vertebrales: consideraciones técnicas y detalles quirúrgicos / Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details

Objetivo: Describir detalles quirúrgicos específicos y comentar algunas lecciones aprendidas, a partir de una serie de pacientes con tumores vertebrales a los que se les practicó una vertebrectomía total en bloque (VTB). Métodos: Presentamos una serie retrospectiva de casos. Se analizan variables clínicas, técnicas y de resultado. Resultados: Se intervinieron 10 pacientes (2000-2016) mediante VTB por tumor primario vertebral (osteosarcoma, condrosarcoma, fibrosarcoma y cordoma) o secundario (pulmón, mama, tiroides, esófago y meningioma). Según la clasificación de Tomita, 2 pacientes presentaban lesiones intracompartimentales y el resto extracompartimentales. Todos los pacientes mejoraron del dolor tras la cirugía. Nueve pacientes conservaron la capacidad de caminar en el postoperatorio y uno desarrolló paraplejía. Seis pacientes precisaron reoperaciones por desbridamiento de la herida quirúrgica, recidiva o revisión de la fijación. Otras complicaciones fueron neumotórax, derrame pleural y trombosis venosa. Cuatro pacientes sobreviven (tras 4 meses y hasta 15 años). El resto fallecieron por progresión del tumor primario (de 6,5 meses a 12 años). Se realiza una descripción detallada de los pasos quirúrgicos, consejos y dificultades de la técnica. Se comentan ciertas modificaciones de la técnica y otras cuestiones relativas a la resección. El respeto a ciertas consideraciones (selección de los candidatos, disección vertebral cuidadosa, control estricto del sangrado, manejo cuidadoso de la médula y mantenimiento del concepto de resección radical en todo momento) es clave para realizar con éxito esta intervención. Conclusión: La VTB es una intervención paradigmática en la que el concepto de resección radical implica efectividad funcional y mejora la supervivencia en pacientes seleccionados portadores de tumores vertebrales. Esta experiencia preliminar nos permite destacar algunas de sus características relevantes, especialmente aquellas dirigidas a simplificar la técnica y hacerla más segura

Objective: To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES). Methods: A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes. Results: A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance. Conclusion: TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation

[Rationale and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable thoracolumbar fractures: Experience in 86 consecutive patients]. / Fundamentos y complicaciones del abordaje anterolateral extrapleural-retroperitoneal en fracturas inestables toracolumbares: experiencia en 86 pacientes consecutivos.

OBJECTIVES: To describe the rationale, pros and cons, and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable (TLICS>4) thoracolumbar fractures. PATIENTS AND METHODS: Clinical and radiological data and outcomes from a cohort treated surgically via said approach were retrospectively reviewed. All patients were operated on exclusively by 5 neurosurgeons trained in spine surgery. RESULTS: Between June 1999 and December 2015, 86 patients underwent surgery (median age 42years, most common level: L1). Approximately 32.5% presented with a preoperative neurological defect. After surgery (mean duration: 275minutes), 75.6% presented with no neurological sequelae and only one-third required blood transfusion. Median postoperative stay was 7days. Correction of kyphosis was considered adequate and suboptimal but acceptable in 91% and 9% of the patients, respectively. Complications occurred in 36 patients, the majority being transient. We observed failure of the construct in 2 cases (collapse of an expandable cage and extrusion of a locking screw). No infections, vascular or visceral lesions, permanent neurological worsening or mortality occurred during hospitalisation. One patient ultimately needed additional posterior fixation due to persistence of pain. Median follow-up was 252days (27.9% was lost to follow-up). CONCLUSIONS: The extrapleural extraperitoneal approach provides solid anterior reconstruction, allows wide decompression of the spinal canal, and permits adequate and long-lasting correction of kyphosis. The rates of infection, construct failure, need for reoperation and vascular or visceral lesions are minimal.

[Lumbar disc herniation: Natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests]. / Hernia discal lumbar: historia natural, papel de la exploración, timing de la cirugía, opciones de tratamiento y conflicto de intereses.

INTRODUCTION: Indication for surgery in lumbar disc herniation (LDH) varies widely depending on the geographical area. DEVELOPMENT: A literature review is presented on the natural history, role of physical examination, timing of surgery, evidence-based treatment, and conflicts of interests in LDH. Surgery is shown to provide significant faster relief of pain compared to conservative therapy, although the effect fades after a year. There is no treatment modality better than the rest in terms of pain control and neurological recovery, nor is there a surgical technique clearly superior to simple discectomy. The lack of sound scientific evidence on the surgical indication may contribute to its great geographical variability. CONCLUSIONS: Since LDH has a favourable natural history, neuroimaging and surgery should not be considered until after a 6-week period. It is necessary to specify and respect the surgical indications for LDH, avoiding conflicts of interests.

Spinal cord herniation repair with microstaples: case report.

Idiopathic spinal cord herniation (ISCH) is a relatively rare and frequently misdiagnosed condition. It preferentially affects women and causes progressive thoracic myelopathy that presents as a Brown-Séquard syndrome or as spastic paraparesis. Although its etiology and pathogenesis are controversial, ISCH is characterized by the presence of an anterior dural defect that allows the incarceration of a segment of the cord. Typically, a C-shaped ventral displacement and kinking of the cord are visible on sagittal MRI. Surgery aimed at stopping or reversing myelopathic symptoms is usually recommended for symptomatic patients. Surgical options include reduction of the hernia and direct suturing, or enlargement of the dural defect, with or without patching. Suturing under the cord in a very tight space can be troublesome and may lead to neurological deterioration. The authors present the case of a symptomatic ISCH in which nonpenetrating titanium microstaples were used to close the dural defect after cord reduction. The patient experienced a good outcome, and the follow-up MRI study showed adequate cord repositioning and stability of the suture. The use of microstaples, which allows for an easier and faster dural closure than conventional suturing, is a novel technical adjunct that has not been previously reported for this condition. In addition, microstaples produce minimal metallic artifact that does not hinder the quality of follow-up MR images.

[Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details]. / Vertebrectomía total en bloque en tumores vertebrales: consideraciones técnicas y detalles quirúrgicos.

OBJECTIVE: To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES). METHODS: A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes. RESULTS: A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance. CONCLUSION: TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation.

Hemorragia subaracnoidea aneurismática: resultados tras la introducción de la terapia endovascular en un centro de medio-bajo volumen / Aneurysmal subarachnoid haemorrhage: Results after introducing endovascular therapy in a medium-low volume centre

Objetivos: Valorar el impacto de la introducción del tratamiento endovascular en pacientes con hemorragia subaracnoidea espontánea aneurismática (HSAa) en un centro de medio-bajo volumen. Material y métodos: Estudio observacional retrospectivo donde se comparan los resultados clínicos de pacientes con HSAa en 2 períodos, antes y después de disponer de tratamiento embolizador. Las variables estudiadas más relevantes fueron: modalidad de tratamiento, mortalidad intrahospitalaria y diferida, complicaciones intraprocedimiento, tasas de resangrado y vasoespasmo, y resultados al final del seguimiento medidos mediante la escala de resultado de Glasgow (GOS). Resultados: Se trató en total a 71 pacientes en 2 períodos: 2010-2011 (32 pacientes; 19 clipajes, 6 embolizaciones,7 no tratados) y 2012-2013 (39 pacientes; 3 clipajes, 34 embolizaciones, 2 no tratados). Ambas cohortes no presentaron diferencias significativas en cuanto a edad, sexo, grado clínico al ingreso, tipo y localización de los aneurismas y puntuación de Fisher, así como en mortalidad intrahospitalaria (28,1% vs. 25,6%, p = 0,35), resultado clínico valorado según la puntuación de GOS (salvo en GOS 5: 43,37% vs. 53,8%, p = 0,045), tasa de hidrocefalia e incidencia de vasoespasmo sintomático. La segunda cohorte obtuvo mejores resultados agregados respecto a la primera para GOS 1+2+3 (36,3% vs. 43,75%, p = 0,034) y para GOS 4+5 (61,5% vs. 56,25%, p = 0,078). El porcentaje de pacientes que no fueron tratados fue significativamente inferior en el segundo período (5,1% vs. 21,8%, p < 0,01), así como la tasa de resangrados (0% vs. 9,4%, p < 0,01). En el segundo período se trataron los pacientes de forma más precoz (2,51 vs. 3,95 días) y la estancia en Unidad de Cuidados Intensivos y total fueron menores (15,2 y 24,6 vs. 10,3 y 18 días), diferencias en el límite de la significación estadística. Conclusiones: El tratamiento endovascular permitió tratar un porcentaje mayor de pacientes con HSAa con una disminución en la tasa de resangrados. Este hecho se tradujo en una modesta reducción en la morbimortalidad

Objective: To evaluate the impact of introducing endovascular therapy for patients with aneurysmal subarachnoid haemorrhage (aSAH) in a medium-low volume centre. Material and methods: A retrospective observational study was conducted by comparing the clinical outcome of patients with aSAH before and after introducing endovascular therapy in our centre. The main variables analysed were: type of treatment, hospital and late mortality, intra-procedural morbidity, rate of re-bleeding and vasospasm, and clinical outcome according to the Glasgow Outcome Score (GOS). Results: Seventy-one patients were treated in two periods: 2010-2011 (32 patients; 19 clipped, 6 coiled, 7 untreated), and 2012-2013 (39 patients, 3 clipped, 34 coiled, 2 untreated). No significant differences were found in age, sex, clinical grade at admission, type and location of aneurysm, Fisher score, or in hospital mortality (28.1% vs 25.6%, P = .35), GOS (except for GOS 5: 43.37% vs 53.8%, P = .045), rate of hydrocephalus and rate of vasospasm. The second cohort obtained better results for aggregated GOS 1+2+3 (36.3% vs 43.75%, P = .034) and for GOS 4 + 5 (61.5% vs 56.25%, P=.078). The percentage of patients left untreated was significantly lower in the second period (5.1% vs 21.8%, P < .01), as well as the rate of re-bleeding (0% vs 9.4%, P < .01). Patients were treated earlier (2.51 vs 3.95 days), and hospital and total stay were lower (15.2 and 24.6 vs 10.3 and 18 days) in the second period, these differences not reaching statistical significance. Conclusions: Endovascular therapy allowed treating more patients with aSAH, and with a lower re-bleeding rate. This led to a modest reduction in morbidity and mortality