ABSTRACT
El objetivo principal del tratamiento en las metástasis espinales es el control local de la enfermedad, el alivio del dolor y el mantenimiento de la deambulación. Clásicamente, se ha recomendado una resección quirúrgica del tumor lo más amplia posible seguida de radioterapia o quimioterapia adyuvante. En la actualidad, la radioterapia estereotáxica corporal (SBRT) en dosis única o hipofraccionada proporciona tasas globales de control local al año superiores al 95% con mínima morbilidad, incluso en histologías que suelen considerarse radiorresistentes. Por otro lado, mediante cirugía de descompresión circunferencial posterolateral y estabilización de la columna es factible crear un espacio de 2-3 mm entre el borde tumoral y la duramadre (separation surgery) suficiente para permitir administrar de forma segura SBRT a dosis ablativas. Dado que con frecuencia se trata de pacientes frágiles, dicha cirugía puede realizarse mediante técnicas mínimamente invasivas, que reducen la agresividad quirúrgica y ayudan a minimizar el retraso de eventuales tratamientos sistémicos
The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2 to 3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies
Subject(s)
Humans , Female , Adult , Aged , Stereotaxic Techniques/instrumentation , Minimally Invasive Surgical Procedures/methods , Spinal Cord Neoplasms/surgery , Neoplasm Metastasis , Pain Management , Gait Disorders, Neurologic/therapy , Quality of Life , Algorithms , Radiosurgery/adverse effects , Spinal Cord Compression/diagnostic imaging , Spinal Cord Compression/surgery , Kyphosis/diagnostic imaging , ImmunotherapyABSTRACT
The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2 to 3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies.
Subject(s)
Radiosurgery , Spinal Neoplasms , Humans , Minimally Invasive Surgical Procedures/methods , Radiotherapy, Adjuvant/methods , Spinal Neoplasms/radiotherapy , Spinal Neoplasms/surgery , Treatment OutcomeABSTRACT
OBJECTIVE: To evaluate cylindrical depth electrodes in the interhemispheric fissure as an alternative to subdural strip electrodes for direct cortical stimulation (DCS) leg motor evoked potential (MEP) monitoring. METHODS: A cylindrical depth electrode was positioned in the interhemispheric fissure of 37 patients who underwent supratentorial brain surgery. Leg sensory and motor cortices were localized by highest tibial nerve somatosensory evoked potential amplitude and lowest DCS leg MEP threshold; the lowest-threshold electrode was then used for DCS leg MEP monitoring. RESULTS: Intraoperative leg MEPs were obtained from all the patients in the series. The mean intensity applied for leg MEP monitoring with the cylindrical depth electrode was 15.2 ± 4.0 mA. No complications secondary to neurophysiological monitoring were detected. CONCLUSIONS: Lower extremity MEPs were consistently recorded using a multi-contact cylindrical depth electrode in the interhemispheric fissure by DCS. SIGNIFICANCE: Cylindrical depth electrodes may be a safe and effective alternative for DCS in the interhemispheric fissure, where subdural strips are difficult to place.
Subject(s)
Electrodes, Implanted , Evoked Potentials, Motor/physiology , Evoked Potentials, Somatosensory/physiology , Intraoperative Neurophysiological Monitoring/instrumentation , Leg/physiology , Motor Cortex/physiology , Transcranial Direct Current Stimulation/instrumentation , Adolescent , Adult , Aged , Anesthesia, Intravenous , Brain/surgery , Brain Neoplasms/surgery , Equipment Design , Feasibility Studies , Female , Humans , Intracranial Arteriovenous Malformations/surgery , Intraoperative Neurophysiological Monitoring/methods , Male , Middle Aged , Sensory Thresholds/physiology , Subdural Space , Tibial Nerve/physiology , Transcranial Direct Current Stimulation/methodsABSTRACT
OBJECTIVES: Intraoperative neuromonitoring (IONM) is a common practice in spinal surgery, mostly during pedicle screw placement. However, there is not enough information about the factors that can interfere with IONM data. One of these factors may be existing damage of the nerve root whose function must be preserved. The main purpose of the present study is to evaluate the effect of chronic compression in lumbar nerve roots in terms of stimulation thresholds during direct nerve stimulation. PATIENTS AND METHODS: Direct electrical stimulation was performed in 201 lumbar nerve roots during lumbar spinal procedures under general anaesthesia in 80 patients with different lumbar spinal pathologies. Clinical and radiological data were reviewed in order to establish the presence of chronic compression. RESULTS: Chronically compressed nerve roots showed a higher stimulation threshold than non compressed nerve roots (11.93 mA vs. 4.33 mA). This difference was confirmed with intra-subject comparison (paired sample t test, p=0.012). No other clinical factors were associated with this higher stimulation threshold in lumbar nerve roots. CONCLUSION: A higher stimulation threshold is present in compressed lumbar nerve roots than non compressed roots. This needs to be taken into consideration during pedicle screw placement, where intraoperative neurophysiological monitoring is being used.
Subject(s)
Electric Stimulation , Intraoperative Neurophysiological Monitoring/methods , Lumbar Vertebrae/surgery , Radiculopathy/physiopathology , Spinal Diseases/surgery , Spinal Nerve Roots/physiopathology , Adult , Aged , Chronic Disease , Cohort Studies , False Negative Reactions , Female , Humans , Intervertebral Disc Displacement , Lumbar Vertebrae/injuries , Male , Middle Aged , Pedicle Screws , Prospective Studies , Scoliosis/surgery , Spinal Fractures/surgery , Spinal Neoplasms/surgery , Spinal Stenosis/surgery , Spondylolisthesis/surgeryABSTRACT
OBJECTIVE: To determine the use of multimodal intraoperative neurophysiological monitoring (IONM) during positioning procedures in cervical spine surgery. METHODS: IONM data was collected from 75 patients from the onset of positioning to the end of the surgical procedure. These included: transcranial motor evoked potentials (TcMEP), somatosensory evoked potentials (SEP) and free running electromyography (EMG) recordings. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (PNV) were calculated. RESULTS: IONM warnings were given in 5 cases during neck positioning. These consisted of the disappearance of TcMEP in all the cases, while two cases showed a loss of SEPs as well. Four of these patients presented a complete recovery of TcMEP and SEPs after neck repositioning. The patient in which this recovery was not present, woke up with new postoperative neurological deficits. Sensitivity, specificity, PPV and NPV of TcMEP during cervical positioning were all 100%. Sensitivity of SEPs was 40%; specificity and PPV were 100%; and the NPV of SEPs was 95.9%. CONCLUSION: Multimodal IONM is a useful method to prevent spinal cord injury during neck positioning in cervical spine surgical procedures. TcMEPs showed the highest sensitivity in detecting injuries to cervical spine related to neck positioning. SIGNIFICANCE: Multimodal IONM should not only be considered for detecting intra-operative warnings, but also during positioning.
Subject(s)
Cervical Vertebrae/surgery , Evoked Potentials, Motor/physiology , Evoked Potentials, Somatosensory/physiology , Intraoperative Neurophysiological Monitoring/methods , Neurosurgical Procedures/methods , Posture/physiology , Aged , Electromyography/methods , Female , Humans , Male , Middle Aged , Neurosurgical Procedures/adverse effects , Spinal Cord Injuries/etiology , Spinal Cord Injuries/prevention & control , Transcranial Magnetic Stimulation/methodsSubject(s)
Hematoma, Subdural, Chronic/complications , Oculomotor Nerve Diseases/etiology , Drainage , Hematoma, Subdural, Chronic/diagnostic imaging , Hematoma, Subdural, Chronic/surgery , Humans , Male , Middle Aged , Oculomotor Nerve Diseases/diagnosis , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
No disponible
Subject(s)
Male , Middle Aged , Humans , Oculomotor Nerve Diseases/diagnosis , Oculomotor Nerve Diseases/etiology , Hematoma, Subdural, Chronic/complications , Hematoma, Subdural, Chronic/diagnosis , Ophthalmoplegia/etiology , Tomography, X-Ray Computed , Hematoma, Subdural, Chronic/surgerySubject(s)
Discitis/microbiology , Endocarditis, Bacterial/microbiology , Food Contamination , Food Handling , Food Microbiology , Lumbar Vertebrae/microbiology , Meat/microbiology , Occupational Diseases/microbiology , Streptococcal Infections/microbiology , Streptococcus suis/isolation & purification , Sus scrofa/microbiology , Animals , Aortic Valve/microbiology , Atlantic Islands/epidemiology , Humans , Male , Middle Aged , Mitral Valve/microbiology , Restaurants , Spain/epidemiology , Streptococcal Infections/epidemiology , Streptococcal Infections/transmissionABSTRACT
No disponible