Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery / Necesidad de recolocación de la cabeza y el cuello para revertir alteraciones neurofisiológicas intraoperatorias en el posicionamiento para cirugía de mielopatía cervical

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(AU)

Objetivo: Evaluar la incidencia de alteraciones neurofisiológicas intraoperatorias graves en el momento del posicionamiento del paciente, y la efectividad de la recolocación del cuello para revertir dichos cambios en los pacientes que se intervienen de mielopatía cervical.Material y métodos: Se empleó una monitorización intraoperatoria multimodal (potenciales evocados sensoriales [PES], motores [PEM] y electromiografía) antes y después de colocar al paciente en posición, en una cohorte de 103 pacientes consecutivos operados de mielopatía cervical. Se consideraron cambios significativos (de alarma): una disminución >50% de la amplitud o un aumento >10% de la latencia de los PES, o la abolición o disminución >50-80% en amplitud de los PEM.Resultados: De los 103 pacientes (el 34,9% mujeres, mediana de edad: 54,5 años), a 88 se les realizó laminectomía (85,4%) y a 15 (14,6%) un abordaje anterior. En el momento del posicionamiento, ocurrieron alteraciones de señal en 44 pacientes (42,7%), aunque solo en 11 (10,7%) estas fueron significativas. La recolocación inmediata del cuello consiguió revertir la alteración de señal completa (n=6) o parcialmente (n=4), sin producirse déficits postoperatorios. El paciente en el cual la recolocación no consiguió restaurar los potenciales despertó con déficit neurológico añadido. La precisión (verdaderos positivos+verdaderos negativos) de la monitorización intraoperatoria para detectar déficits postoperatorios fue del 99% (102/103) para la cohorte completa y del 100% (11/11) para el subgrupo con alteraciones significativas. Globalmente, solo un paciente, que mostró cambios no significativos, despertó con nuevo déficit neurológico (0,97% de falsos negativos).Conclusión: El 10,7% de los pacientes intervenidos de mielopatía cervical mostraron cambios neurofisiológicos de alarma en el momento del posicionamiento quirúrgico. La inmediata recolocación del cuello revirtió dichos cambios (completa o parcialmente)(AU)

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.

Angiographically occult and spontaneously thrombosed large brain arteriovenous malformation / Malformación arteriovenosa cerebral grande, angiográficamente oculta y espontáneamente trombosada

Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients (AU)

El tratamiento de las malformaciones arteriovenosas (MAV) cerebrales incluye combinaciones de cirugía, radiocirugía y embolización. Muy rara vez, ocurre una obliteración espontánea, fundamentalmente en MAV pequeñas, con drenaje venoso único superficial y antecedente de sangrado previo. Presentamos un caso de MAV sintomática grande, sin sangrado ni tratamientos previos, en la que se constató auto-trombosis espontánea. Aunque las imágenes de resonancia sugerían la presencia de una MAV, la arteriografía no mostró anomalía arterial compatible. En la cirugía se evidenció un nidus cortical con vasos tortuosos, idéntico a una MAV clásica, aunque sin flujo sanguíneo, por lo que pudo resecarse sin dificultad. La anatomía patológica confirmó la presencia de una MAV trombosada. A pesar del relativamente bajo riesgo de recanalización, la cirugía de una posible MAV trombosada puede ser una opción recomendable, con objeto de llegar al diagnóstico definitivo y evitar un eventual riesgo de sangrado, especialmente en personas jóvenes (AU)

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.

Importancia de la arteriografía cerebral y la monitorización neurofisiológica intraoperatoria en la endarterectomía carotídea / Importance of cerebral angiography and intraoperative neuromonitoring in carotid endarterectomy

Cada vez es más frecuente indicar una endarterectomía carotídea en función de la información proporcionada por pruebas no invasivas, como la eco-Doppler, la angio-RM o la angio-TAC, obviando la necesidad de la arteriografía. Presentamos un caso de estenosis carotídea sintomática izquierda del 80% en la que la arteriografía cerebral constató la ausencia del segmento A1 derecho y llenado del territorio cerebral anterior bilateral solo desde el lado izquierdo. A los 90 segundos del pinzamiento de las arterias en el cuello se produjo una disminución brusca de la oximetría cerebral y de la amplitud de los potenciales somatosensoriales, que cedieron tras el despinzamiento inmediato. Se desestimó realizar la endarterectomía y se colocó un stent carotídeo sin complicaciones. Este caso ejemplifica la importancia de conocer el estado de la circulación cerebral distalmente a la estenosis. De haberse intentado realizar la endarterectomía sin tener en cuenta la información proporcionada por la arteriografía, posiblemente habría ocurrido una isquemia bihemisférica grave (AU)

It is an increasingly common practice to indicate a carotid endarterectomy procedure based on the information provided by non-invasive tests like Duplex ultrasound, MR angiography or CT angiography, thereby obviating the performance of a conventional cerebral angiography. We present a case of symptomatic left carotid artery 80% stenosis in which cerebral angiography showed absence of the right A1 segment and bilateral anterior cerebral artery territories that filled only from a left injection. Just 90 seconds after carotid artery clamping at the neck, brain oximetry and somatosensory evoked potentials significantly dropped, that recovered after immediate clamp removal. Endarterectomy was dismissed and a carotid stent was successfully placed. This case highlights the importance of knowing the dynamics of cerebral blood circulation distal to the stenosis. If endarterectomy had been attempted, unawareness of the information provided by the cerebral angiography would have likely result in severe bi-hemispheric ischemia (AU)

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.

Importance of cerebral angiography and intraoperative neuromonitoring in carotid endarterectomy. / Importancia de la arteriografía cerebral y la monitorización neurofisiológica intraoperatoria en la endarterectomía carotídea.

It is an increasingly common practice to indicate a carotid endarterectomy procedure based on the information provided by non-invasive tests like Duplex ultrasound, MR angiography or CT angiography, thereby obviating the performance of a conventional cerebral angiography. We present a case of symptomatic left carotid artery 80% stenosis in which cerebral angiography showed absence of the right A1 segment and bilateral anterior cerebral artery territories that filled only from a left injection. Just 90seconds after carotid artery clamping at the neck, brain oximetry and somatosensory evoked potentials significantly dropped, that recovered after immediate clamp removal. Endarterectomy was dismissed and a carotid stent was successfully placed. This case highlights the importance of knowing the dynamics of cerebral blood circulation distal to the stenosis. If endarterectomy had been attempted, unawareness of the information provided by the cerebral angiography would have likely result in severe bi-hemispheric ischemia.

Angiographically occult and spontaneously thrombosed large brain arteriovenous malformation.

Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients.

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

Técnicas abandonadas en cirugía de columna / Abandoned techniques in spine surgery

En cirugía de columna, ciertos dispositivos y algunas técnicas quirúrgicas han sido abandonados por completo o se hallan en franco declive. Aunque empleados en miles de pacientes, dichos tratamientos no han demostrado una efectividad sólida y duradera y, ocasionalmente, asocian morbilidades inaceptables. Ejemplos de abandono son la quimionucleólisis, la discectomía percutánea, la discectomía por láser o los geles antifibrosis. Otras técnicas se encuentran en marcado retroceso como los dispositivos interespinosos o las prótesis discales lumbares. Generalmente una técnica se abandona por falta de efectividad, morbilidad excesiva, sustitución por otra técnica más eficaz y menos agresiva, por falta de comercialización o por prohibición de su uso. En las últimas décadas, la enorme presión comercial y una creciente demanda social han conseguido convencer a muchos cirujanos de columna para que empleen tratamientos no suficientemente sustentados por estudios sólidos ni avalados por el paso del tiempo, muchos de los cuales eventualmente se abandonan

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned

Abandoned techniques in spine surgery. / Técnicas abandonadas en cirugía de columna.

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned.

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

Adscripción de un médico internista al servicio de neurocirugía: ventajas e implicaciones clínicas y profesionales / The appointment of an internal medicine practitioner to a neurosurgical department: Advantages, and clinical and professional implications

La mayor edad y creciente complejidad de los pacientes neuroquirúrgicos ingresados ha supuesto un incremento en las interconsultas con Medicina Interna. Esta colaboración presenta inconvenientes debido a la falta de continuidad asistencial y a la discrecionalidad de su uso. La adscripción de un internista al servicio de Neurocirugía a tiempo completo y con atribuciones asistenciales completas, salvo las estrictamente quirúrgicas, es una opción organizativa factible. Este sistema minimiza la necesidad de interconsultas, mejora la calidad asistencial percibida, permite que el cirujano se centre en tareas puramente quirúrgicas, aporta una visión global del paciente y de su enfermedad, enriquece al grupo con conocimientos especializados no neuroquirúrgicos y eleva el nivel científico del equipo. En nuestro servicio se dispone de una internista en plantilla desde hace 14 años. Describimos sus atribuciones de trabajo diarias, las ventajas asistenciales que proporciona al servicio y las implicaciones profesionales y laborales derivadas

The increasing age and complexity of in-hospital neurosurgery patients have raised the number of consultations with Internal Medicine. This type of collaboration is discretional and lacks temporal continuity. The full-time appointment of an internal medicine practitioner to a Neurosurgery Department, with complete care attributions except for strict surgical work, is a feasible organizational option. This method minimizes the need for medical consultation, improves the perceived quality of care, allows neurosurgeons to focus on purely surgical tasks, provides an integral vision of the patient's condition, enriches the group with specialized non-neurosurgical knowledge, and raises the scientific level of the team. In our Neurosurgery Department, an internal medicine practitioner has been working as part of the staff for 14 years. We describe her medical activity duties, the advantages our department gains from her daily work, and the professional and working implications derived

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.

«Prehabilitación» en cirugía de columna degenerativa: revisión de la literatura / "Prehabilitation" in degenerative spine surgery: A literature review

La cirugía de columna lumbar degenerativa, aunque efectiva, produce resultados subóptimos y cierto grado de discapacidad en un porcentaje relevante de pacientes. El tratamiento rehabilitador postoperatorio no ha demostrado utilidad a medio y a largo plazo. La denominada «prehabilitación» (tratamientos físioterápicos y/o cognitivo-conductuales) busca aumentar las capacidades funcionales del paciente antes de la intervención mejorando el estado físico y la percepción del dolor, de la experiencia quirúrgica o de sus consecuencias. Diversos estudios sugieren que la prehabilitación mejora la funcionalidad postoperatoria, acorta la estancia hospitalaria y podría ahorrar costes frente a la rehabilitación postoperatoria clásica. Sin embargo, su efecto real parece influenciarse de variables como la obesidad, comorbilidades y, especialmente, una errónea percepción de la historia natural de estas enfermedades, en forma de catastrofismo y cinesifobia. En este trabajo se describe el concepto de prehabilitación, se revisa la literatura al respecto y se discute el papel de diversos condicionantes clínicos involucrados

Surgery for lumbar degenerative pathology, although effective, results in suboptimal outcome and degrees of disability in a relevant proportion of patients. Postoperative rehabilitation has failed to demonstrate efficacy in the mid and long term. So-called "prehabilitation" (physiotherapy and/or cognitive-behavioral therapy) focuses in augmenting patients' functional capacities before surgery by improving their physical condition and their perception of pain, surgical experience or its consequences. Several studies suggest that prehabilitation improves postoperative outcome, shortens hospital stay and may reduce costs compared to classic postoperative rehabilitation. However, its true effect seems to be influenced by factors like obesity, co-morbidity and, especially, by a wrong perception of the natural history of this pathology in terms of catastrophising and kinesiphobia. In this paper we describe the concept of prehabilitation, review the literature, and discuss the role of some clinical conditionings involved

The appointment of an internal medicine practitioner to a neurosurgical department: Advantages, and clinical and professional implications. / Adscripción de un médico internista al servicio de neurocirugía: ventajas e implicaciones clínicas y profesionales.

The increasing age and complexity of in-hospital neurosurgery patients have raised the number of consultations with Internal Medicine. This type of collaboration is discretional and lacks temporal continuity. The full-time appointment of an internal medicine practitioner to a Neurosurgery Department, with complete care attributions except for strict surgical work, is a feasible organizational option. This method minimizes the need for medical consultation, improves the perceived quality of care, allows neurosurgeons to focus on purely surgical tasks, provides an integral vision of the patient's condition, enriches the group with specialized non-neurosurgical knowledge, and raises the scientific level of the team. In our Neurosurgery Department, an internal medicine practitioner has been working as part of the staff for 14 years. We describe her medical activity duties, the advantages our department gains from her daily work, and the professional and working implications derived.

"Prehabilitation" in degenerative spine surgery: A literature review. / «Prehabilitación¼ en cirugía de columna degenerativa: revisión de la literatura.

Surgery for lumbar degenerative pathology, although effective, results in suboptimal outcome and degrees of disability in a relevant proportion of patients. Postoperative rehabilitation has failed to demonstrate efficacy in the mid and long term. So-called "prehabilitation" (physiotherapy and/or cognitive-behavioral therapy) focuses in augmenting patients' functional capacities before surgery by improving their physical condition and their perception of pain, surgical experience or its consequences. Several studies suggest that prehabilitation improves postoperative outcome, shortens hospital stay and may reduce costs compared to classic postoperative rehabilitation. However, its true effect seems to be influenced by factors like obesity, co-morbidity and, especially, by a wrong perception of the natural history of this pathology in terms of catastrophising and kinesiphobia. In this paper we describe the concept of prehabilitation, review the literature, and discuss the role of some clinical conditionings involved.

Medidas de protección radiológica: implicaciones en el diseño de quirófanos de neurocirugía / Radiation protection measures: Implications on the design of neurosurgery operating rooms

Objetivo: Describir pros y contras de diversas medidas de protección radiológica y sus implicaciones en el diseño de un quirófano de neurocirugía. Material y métodos: Se realizó una reforma estructural del quirófano de neurocirugía a propósito de la adquisición y uso de un O-arm. Se ampliaron las medidas y blindajes del quirófano, y se instaló una mampara blindada y abatible en su interior. Se midieron dosis de radiación delante y detrás de la mampara. Resultados: La mampara proporciona una radioprotección integral para todo el personal de quirófano (dosis < 5μSv a 2,5 m del gantry por cada exploración con O-arm; 0,0μSv tras la mampara por cada exploración de O-arm; dosis acumulada anual tras la mampara, indetectable), obvia la necesidad de delantales plomados y dosímetros personales y minimiza la circulación de personal. El aumento del tamaño del quirófano permite almacenar los equipos dentro y minimiza el riesgo de colisión o contaminación. Los quirófanos rectangulares permiten aumentar la distancia al foco emisor de radiación. Conclusiones: El blindaje de paredes, techos y suelos, la forma rectangular y la superficie lo más amplia posible, la presencia de una mampara plomada y abatible, y los sistemas de seguridad que impiden una irrupción inesperada en el quirófano mientras se está irradiando son cuestiones relevantes a tener en cuenta en el diseño del quirófano de neurocirugía

Objective: To describe pros and cons of some radiation protection measures and the implications on the design of a neurosurgery operating room. Material and methods: Concurring with the acquisition and use of an O-arm device, a structural remodeling of our neurosurgery operating room was carried out. The theater was enlarged, the shielding was reinforced and a foldable leaded screen was installed inside the operating room. Radiation doses were measured in front of and behind the screen. Results: The screen provides whole-body radiation protection for all the personnel inside the theater (effective dose <5μSv at 2,5 m from the gantry per O-arm exploration; 0,0μSv received behind the screen per O-arm exploration; and undetectable cumulative annual radiation dose behind the screen), obviates the need for leaded aprons and personal dosimeters, and minimizes the circulation of personnel. Enlarging the size of the operating room allows storing the equipment inside and minimizes the risk of collision and contamination. Rectangular rooms provide greater distance from the source of radiation. Conclusion: Floor, ceiling and walls shielding, a rectangular-shaped and large enough theater, the presence of a foldable leaded screen, and the security systems precluding an unexpected irruption into the operating room during irradiation are relevant issues to consider when designing a neurosurgery operating theater

[Radiation protection measures: Implications on the design of neurosurgery operating rooms]. / Medidas de protección radiológica: implicaciones en el diseño de quirófanos de neurocirugía.

OBJECTIVE: To describe pros and cons of some radiation protection measures and the implications on the design of a neurosurgery operating room. MATERIAL AND METHODS: Concurring with the acquisition and use of an O-arm device, a structural remodeling of our neurosurgery operating room was carried out. The theater was enlarged, the shielding was reinforced and a foldable leaded screen was installed inside the operating room. Radiation doses were measured in front of and behind the screen. RESULTS: The screen provides whole-body radiation protection for all the personnel inside the theater (effective dose <5µSv at 2,5 m from the gantry per O-arm exploration; 0,0µSv received behind the screen per O-arm exploration; and undetectable cumulative annual radiation dose behind the screen), obviates the need for leaded aprons and personal dosimeters, and minimizes the circulation of personnel. Enlarging the size of the operating room allows storing the equipment inside and minimizes the risk of collision and contamination. Rectangular rooms provide greater distance from the source of radiation. CONCLUSION: Floor, ceiling and walls shielding, a rectangular-shaped and large enough theater, the presence of a foldable leaded screen, and the security systems precluding an unexpected irruption into the operating room during irradiation are relevant issues to consider when designing a neurosurgery operating theater.