Opioid-free anesthesia for patients with joint hypermobility syndrome undergoing craneo-cervical fixation: a case-series study focused on anti-hyperalgesic approach.

BACKGROUND: Patients with Ehlers-Danlos Syndrome/Hypermobility Type (EDS-HT/JHS) and Craneo-Cervical Instability frequently suffer from severe widespread pain which is difficult to control. Chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization may explain this painful condition. The aim of this study was to determine if opioid-free anesthesia plus the postoperative administration of lidocaine, ketamine and dexmedetomidine can reduce postoperative pain and the need of methadone rescues in comparison with opioid-based management in these patients undergoing Craneo-Cervical Fixation (CCF). The secondary aim was to assess the needs of opioids at hospital-discharge, incidence of gastrointestinal complications and the requirement of anxiolytic. METHODS: A retrospective, consecutive case series study was designed. 42 patients with EDS-HT/JHS undergoing CCF were enrolled in two groups: an OFA-plus Group that received opioid-free anesthesia with propofol, lidocaine, ketamine and dexmedetomidine, and OP Group, opioid-based anesthesia-analgesia. The main variables: Preoperative Visual Analogue Score (VAS), postoperative VAS on the 1st, 2nd, 4th and 6th days, sufentanil or morphine requirements, need for methadone rescue, and VAS at hospital-discharge. Data was presented by mean ± SD, percentage, median or interquartile range. Chi-squared or Fisher's test. 95% C.I and P values < 0.05. RESULTS: Nineteen patients in OFA-plus, and 23 patients in OP group. VAS was lower in OFA-plus on the postoperative days evaluated (p < 0.001).VAS at hospital-discharge was lower in OFA-plus: 4.96 (4.54-5.37) vs. OP 6.39 (6.07-6.71) (p < 0.001). Methadone requirement was lower in the OFA-plus (p < 0.001). 78% of patients in OFA-plus didn't need methadone rescue. 95% in OP group needed methadone rescues at high doses(> 15 mg/day). No differences regarding equivalent doses of sufentanil or morphine consumption on the 2nd, 4th, and 6th postoperative days were found. OFA-plus decreased ileus, nausea and vomiting (p < 0.001). 60.9% in OFA-plus group decreased opioid requirements at hospital-discharge compared with preoperative values. A 77% reduction of anxiolytics requirements was shown. CONCLUSION: OFA-plus management for patients undergoing CCF with EDS-HT/JHS shows significant reduction in postoperative pain and at hospital-discharge compared with opioid-based anesthesia. OFA-plus management decreases the total doses of methadone rescues, reduces anxiolytic requirements and gastrointestinal side-effects, except for constipation. OFA-plus management is a feasible option to improve postoperative pain control, reducing the opioids' use and their postoperative side-effects in patients undergoing CCF with EDS-HT/JHS.

[Primary prophylaxis of early seizures after surgery of cerebral supratentorial tumors: Group for the Study of Functional-Sterotactic Neurosurgery of The Spain Society of Neurosurgery recommendations]. / Control de las crisis epilépticas durante el postoperatorio inmediato de los tumores cerebrales supratentoriales: recomendaciones del Grupo de Neurocirugía Funcional y Estereotáctica de la Sociedad Española de Neurocirugía.

Our review of the literature is basically focused on the primary prophylaxis of early seizures after surgery of cerebral supratentorial tumors, with the aim of suggesting several recommendations in medical antiepileptic treatment to avoid this kind of seizures which occur immediately after surgery. In conclusion, it is recommended to provide criteria for prophylaxis of early seizures after surgery of cerebral supratentorial tumors. It́s recommended a one week treatment with antiepileptic drugs in patients who didnt have seizures jet, starting immediately after the surgical treatment. If seizures appear during progress of the disease, a large period treatment will be needed. Preferred antiepileptic treatment is intravenous and with a low interactions profile. Levetiracetam, followed by valproic acid seem to be most appropriated drugs due to their properties and protective effects, particularly for our patients requirements. These recommendations are considered a general proposal to effective clinical management of early seizures after surgery, not taking into account the single circumstances of our patients. Always, clinical features of the patients could modify even significantly these guides in the benefit of each patient.

Control de las crisis epilépticas durante el postoperatorio inmediato de los tumores cerebrales supratentoriales: recomendaciones del Grupo de Neurocirugía Funcional y Estereotáctica de la Sociedad Española de Neurocirugía / Primary prophylaxis of early seizures after surgery of cerebral supratentorial tumors: Group for the Study of Functional-Sterotactic Neurosurgery of The Spain Society of Neurosurgery recommendations

Con la finalidad de proponer una serie de recomendaciones del tratamiento médico antiepiléptico, en el perioperatorio de los tumores cerebrales supratentoriales, se realiza una revisión de la literatura enfocada sobre todo a la profilaxis primaria de las crisis epilépticas precoces acaecidas en el postoperatorio inmediato. Se concluye que es recomendable pautar profilaxis primaria antiepiléptica poscirugía durante una semana en los pacientes con tumor cerebral supratentorial que no han presentado crisis epilépticas. Si las crisis aparecen durante la evolución de la enfermedad, es necesario pautar un tratamiento a largo plazo. Dadas las características de estos pacientes, se recomienda usar un fármaco antiepiléptico con presentación por vía intravenosa y un perfil bajo de interacciones. El levetiracetam, seguido del valproato, parecen ser los más adecuados. Dichas recomendaciones deben considerarse como una guía general de manejo, pudiendo ser modificadas, incluso de manera significativa, por las circunstancias propias de cada caso clínico (AU)

Our review of the literature is basically focused on the primary prophylaxis of early seizures after surgery of cerebral supratentorial tumors, with the aim of suggesting several recommendations in medical antiepileptic treatment to avoid this kind of seizures which occur immediately after surgery. In conclusion, it is recommended to provide criteria for prophylaxis of early seizures after surgery of cerebral supratentorial tumors. It's recommended a one week treatment with antiepileptic drugs in patients who didn't have seizures jet, starting immediately after the surgical treatment. If seizures appear during progress of the disease, a large period treatment will be needed. Preferred antiepileptic treatment is intravenous and with a low interactions profile. Levetiracetam, followed by valproic acid seem to be most appropriated drugs due to their properties and protective effects, particularly for our patients requirements. These recommendations are considered a general proposal to effective clinical management of early seizures after surgery, not taking into account the single circumstances of our patients. Always, clinical features of the patients could modify even significantly these guides in the benefit of each patient (AU)

Estimulación del nervio occipital para la cefalea en racimos refractaria al tratamiento farmacológico / Stimulation of the occipital nerve in the treatment of drug-resistant cluster headache

Objetivo. Evaluar la utilidad de la estimulación del nervio occipital en el tratamiento de la cefalea en racimos crónica refractaria al tratamiento farmacológico. Pacientes y métodos. Serie prospectiva de cuatro pacientes, tres varones y una mujer. La edad media es de 42 años. Hay historia de cefalea en racimos de entre 1 y 16 años, con mal control de las crisis mediante tratamiento farmacológico. En todos los casos se han colocado percutáneamente electrodos octopolares en ambas regiones occipitales. Se ha realizado un seguimiento de seis meses. Resultados. A los seis meses se obtuvo una reducción de la frecuencia de las crisis del 56% (rango: 25-95%), una disminución en la intensidad del 48,8% (rango: 20-60%) y una disminución de la duración de un 63,8% (rango: 0-88,8%), sin observarse empeoramiento ni progresión de la enfermedad en ningún caso. La mejoría en la calidad de vida respecto a la prequirúrgica fue de un 15,4% (rango: 6-31,5%) en el cuestionario de salud SF-36. Excepto en un caso, se objetivó una reducción significativa en la cantidad y la dosis de fármacos requeridos respecto al tratamiento prequirúrgico. No se han detectado complicaciones postoperatorias. Todos los pacientes aconsejarían el procedimiento como opción terapéutica. Conclusiones. La estimulación del nervio occipital puede ser una alternativa terapéutica segura y efectiva en el tratamiento de la cefalea en racimos crónica refractaria al tratamiento farmacológico. Sin embargo, son necesarios más estudios para valorar la efectividad de la técnica en un mayor número de pacientes y los resultados a largo plazo (AU)

Aim. To evaluate the occipital nerve stimulation therapy in as a treatment for drug-resistant cluster headache. Patients and methods. Prospective study of four patients, three males and one female. Mean age of 42 years. Patients complained of a cluster headache lasting between one and 16 years, with suboptimal control of the attacks with medication. In all cases octopolar electrodes were placed percutaneously in the occipital region bilaterally. Follow-up of 6 months. Results. At 6 months, there was a 56% (range: 25-95%) reduction in the frequency, a 48.8% (range: 20-60%) decrease in the intensity and a 63.8% (range: 0-88.8%) reduction in the duration of the attacks. Worsening or progression of the illness was not observed in any case. All patients referred a 15.4% (range: 6-31.5%) improvement in their quality of life compared to their previous basal situation in SF-36. In all cases but one there was a significant reduction in the amount and dosage of medication required. Postoperative complications were not observed. All patients would recommend the procedure. Conclusions. Occipital nerve stimulation may be considered a safe and effective therapeutic option in the drug-resistant cluster headache. However, studies with more patients and a longer follow-up are required to evaluate the efficacy of the technique (AU)

[Stimulation of the occipital nerve in the treatment of drug-resistant cluster headache]. / Estimulación del nervio occipital para la cefalea en racimos refractaria al tratamiento farmacológico.

AIM: To evaluate the occipital nerve stimulation therapy in as a treatment for drug-resistant cluster headache. PATIENTS AND METHODS: Prospective study of four patients, three males and one female. Mean age of 42 years. Patients complained of a cluster headache lasting between one and 16 years, with suboptimal control of the attacks with medication. In all cases octopolar electrodes were placed percutaneously in the occipital region bilaterally. Follow-up of 6 months. RESULTS: At 6 months, there was a 56% (range: 25-95%) reduction in the frequency, a 48.8% (range: 20-60%) decrease in the intensity and a 63.8% (range: 0-88.8%) reduction in the duration of the attacks. Worsening or progression of the illness was not observed in any case. All patients referred a 15.4% (range: 6-31.5%) improvement in their quality of life compared to their previous basal situation in SF-36. In all cases but one there was a significant reduction in the amount and dosage of medication required. Postoperative complications were not observed. All patients would recommend the procedure. CONCLUSIONS: Occipital nerve stimulation may be considered a safe and effective therapeutic option in the drug-resistant cluster headache. However, studies with more patients and a longer follow-up are required to evaluate the efficacy of the technique.

Cirugía endoscópica de los tumores hipofisarios / Endoscopic Surgery of Pituitary Tumors

Los abordajes transesfenoidales fueron propuestos, a principios del siglo XX, por Halstead, Cushing, Hirsch y otros autores. Aunque fueron abandonados y retomados en diversas ocasiones, la adaptación de los endoscopios a la cirugía endonasal supuso un avance en el acceso con la mínima agresión posible a la región sellar. En este artículo se describen las indicaciones para la cirugía funcional de la hipófisis, las vías de abordaje endoscópicas, la técnica quirúrgica y la reconstrucción del defecto sellar. Los resultados de la cirugía de los adenomas hipofisarios por técnica endoscópica son comparables a los de la técnica microquirúrgica, como lo demuestra la literatura revisada. Es de esperar que el incremento del número de casos en las series por publicar y la experiencia adquirida mejoren los resultados y puedan convertirla en la técnica de elección (AU)

Transsphenoidal approaches were proposed at the beginning of the XX century by Halstead, Cushing, Hirsch and other authors. Although these approaches were abandoned and readopted on several occasions, the adaptation of endoscopes to endonasal surgery represented a breakthrough in gaining minimally aggressive access to the sellar region. The present article describes the indications for functional pituitary surgery, endoscopic routes of access, the surgical technique, and reconstruction of the sellar defect. The results of endoscopic surgery of pituitary adenomas are comparable to those of microsurgery, as demonstrated by the literature reviewed. The increase in the number of cases in future published series and the greater experience acquired will likely improve the results of this approach, which could become the technique of choice (AU)