Biportal Endoscopic Spine Surgery: Clinical Results for 163 Patients.

BACKGROUND: Biportal endoscopy spine surgery is an endoscopic procedure that uses 2 portals, 1 for the endoscope and 1 for the instruments. It provides an excellent and very versatile field of view, with the advantage of another portal to approach the most common degenerative lumbar pathologies. METHODS: We evaluated a retrospective series of patients who underwent biportal endoscopy with ≥1 year of follow-up. Relevant epidemiological and clinical data, such as the Oswestry disability index and visual analog scale for pain, were also considered. Complications and the effects of the learning curve are also discussed. RESULTS: We included 163 patients treated within a 5-year period with ≥1 year of follow-up available. The main pathologies were disc herniation (53.4%), foraminal stenosis (19%), and central canal stenosis (16.6%). The outcomes regarding disability and pain scores after surgery were very good, with a redistribution of the patient sample to the mild categories of disability. Inferential analysis showed relative and absolute improvements for both disc herniation and canal stenosis in terms of the Oswestry disability index and visual analog scale for pain, especially for disc herniation. The incidence of complications was approximately 7%. The most common approach was interlaminar (89%), and the most common pathology was disc herniation (54.9%). The duration of surgery overall and for the different stages had improved at the end of the learning curve with a reduction of almost 58 minutes. CONCLUSIONS: Biportal endoscopy is a minimally invasive procedure that is safe and effective, with a low rate of complications. It has a reproducible learning curve and provides very good outcomes regarding functionality and pain scores.

Sinking skin syndrome in a decompressive craniectomy series: Clinical and radiological features.

Background: The sinking skin syndrome (SSS) is a particular complication after a decompressive craniectomy (DC). It still remains a poorly understood and underestimated entity. Methods: Retrospective case series of craniectomized patients with and without SSS. Clinical and radiological features (DC diameter, shape of craniectomy flap, and midline deviation) were described and relative volumes of intracranial loss were quantified. Results: Twenty-seven patients (63% with SSS). The most common indication for DC was traumatic brain injury: 48.15%. The p50 diameter of DC was 12.8 cm for patients with SSS and 11.1 cm for patients without (Z score = 0.32). DC area was 81.5 cm2 for patients with SSS and 71.43 cm2 for patients without the syndrome (Z score = 0.61). According to the shape of the craniectomy flap, we classified our patients as: «same level¼ (51.8%), «sunken¼ (25.9%), and «extracranial herniation¼ (14.8%). Two patients (7.4%) had paradoxical herniation. Midline deviation was present in 12 (70.6%) patients with SSS. The 3rd ventricle volume average was 1.2 cc for patients with SSS versus 2.35 cc for patients without (Z score = 0.04). About 94.11% of patients (16 out of 17) clearly improved after replacement of the cranial defect. Conclusion: In our series, low 3rd ventricle volumes had a good relation with SSS. The presence of a sunken flap does not guarantee SSS per se and we propose the following radiologic description: A = sunken, B = same level, C = extracranial herniation, and D = paradoxical. Replacement of the skull defect is the main treatment.

Retrospective Evaluation of Thoracolumbar Injury Classification System and Thoracolumbar AO Spine Injury Scores for the Decision Treatment of Thoracolumbar Traumatic Fractures in 458 Consecutive Patients.

BACKGROUND: Thoracolumbar Injury Classification System (TLICS) score and Thoracolumbar AO Spine Injury Score (TLAOSIS) are the scores preferred to classify and treat thoracolumbar fractures. Our study evaluates the reliability of both as guidelines for treatment. METHODS: Single-center and retrospective case series of 458 patients. Clinical variables, radiology, and treatment were analyzed. We classified fractures according to the AO Spine Thoracolumbar System and retrospectively applied both scales in 2 groups (surgical and conservative). A concordance analysis and statistical measures comparing both were performed. RESULTS: The patients were divided as follows: 257 patients (56.1%) in the conservative group and 201 patients (43.9%) in the surgical group. The concordance analysis between both scales was 89.7% (95% confidence interval, 86.5%-92.3%), and the Cohen kappa coefficient was 0.68 (95% confidence interval, 59%-76%). TLAOSIS had a higher tendency to classify patients in the gray zone (10.3% vs. 2.8%, P < 0.001), whereas TLICS had a more conservative nature (85.2% vs. 78.4%, P = 0.01). In the surgical group, the matching decision ratio was 29.9% for TLICS and 42.8% for TLAOSIS, but differences were found in TLICS being more conservative (70.1% vs. 57.2%, P = 0.01). In the conservative group, the matching decision ratio was 98.1% for both scales, being the main difference in the gray zone for TLAOSIS. CONCLUSIONS: Both scales have a good concordance in general, with TLICS being more conservative overall. They had rather low coincidence when predicting surgery. Because TLAOSIS placed more patients in the gray zone, we think it might be slightly better for giving surgeons more license to decide a surgical approach on certain controversial types of fractures.

Thalamic abscess in a patient with hereditary hemorrhagic telangiectasia successfully treated with an empiric antibiotic regime: case report and review of the literature.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease associated with neurological complications, including cerebral abscesses (CA). They tend to be unique, supratentorial and lobar. While the surgical intervention is a rule of thumb when treating and diagnosing the etiology of these lesions, this is not always possible due to dangerous or inaccessible locations. We report the case of a patient solely treated with empiric antibiotics without stereotaxic intervention and satisfactory results. CASE PRESENTATION: We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance. CONCLUSION: Carefully tailored antibiotic-only regime and vigilance of its adverse effects and close radiological following is a good treatment approach when surgery is not an option.

Intraventricular cryptococcoma mimicking a neoplastic lesion in an immunocompetent patient with hydrocephalus: A case report.

BACKGROUND: The aim of this study is to highlight the importance of cryptococcosis as one of the most common fungal infections of the central nervous system, stressing the consideration of a cryptococcoma within the list of differential diagnosis of intraventricular masses in immunocompetent hosts. CASE DESCRIPTION: We present the case of an immunocompetent 41-year-old female from Philippines with an intraventricular cryptococcoma due to Cryptococcus neoformans, mimicking an intraventricular primary brain tumor, who had hydrocephalus. She was approached as having a neoplastic lesion and underwent surgical resection plus third ventriculostomy through endoscopy. Later in her evolution, we realized the infectious nature of the lesion, and antifungal systemic therapy was initiated. In the end, she needed the placement of a ventriculoperitoneal shunt to maintain a good neurologic status. Despite all our efforts, she had a fatal outcome due to various complications. CONCLUSION: Our case is the first intraventricular cryptococcoma due to C. neoformans, as far as we know, to be reported in English, German, or Spanish literature. Our report stresses the importance to consider this kind of infection in immunocompetent patients, to raise the level of suspicion of this diagnosis, and to know the complications and management options.

Occult Transorbital Intracranial Injury by Windshield Wiper Handle: Case Report and Review of Literature.

BACKGROUND: We present the case of a 51-year-old male with an occult transorbital intracranial injury after a car accident. The identified foreign object was a windshield wiper handle. To our knowledge, this is the first case reported. CASE DESCRIPTION: Multidisciplinary treatment with maxillofacial and otorhinolaryngology departments was planned. A bifrontal craniotomy with removal of the foreign object and posterior orbital reconstruction were performed. A review of the literature was done, in order to highlight certain general principles in decision making despite the variability in case presentation. CONCLUSIONS: Occult TII is a rare subtype of penetrating brain injury. Diagnosis requires high suspicion as it can be missed during physical examination. Computed tomography (CT) scan, CT angiogram, and magnetic resonance imaging should be performed in order to design the optimal treatment for each patient. Magnetic resonance imaging should be avoided when metallic density on CT is observed. The use of a broad-spectrum antibiotic regimen is critical.

Giant Dumbbell-Shaped Thoracic Schwannoma in an Elderly Patient Resected Through a Single-Stage Combined Laminectomy and Video-Assisted Thoracoscopy: Surgical Strategy and Technical Nuances.

BACKGROUND: Dumbbell-shaped schwannomas involving the spinal canal, the intervertebral foramen, and the thoracic cavity are rare lesions. Surgical treatment represents a challenge, and there is no consensus regarding ideal management. Two major surgical routes have been used: combined laminectomy and open thoracotomy or posterolateral extrapleural approach with wide bone removal. This report describes a relatively easy surgical strategy, combined laminectomy and thoracoscopy, which allows safe resection under an adequate view with low risk of spinal instability, pain, or respiratory problems. CASE DESCRIPTION: A 74-year-old man presented with rapidly progressing motor impairment caused by a dumbbell-shaped, 65-mm, Eden type III lesion at the T5 level. Magnetic resonance imaging showed an intraspinal-extradural mass extending into the chest cavity and causing severe spinal cord compression. The patient underwent single-stage surgery performed by a neurosurgical and thoracic team. The extradural and foraminal tumor components were first removed through a 1-level laminectomy with foraminotomy and without facetectomy. Subsequently, video-assisted thoracic surgery was performed to approach the anterior paraspinal component. Total tumor removal, confirmed with postoperative magnetic resonance imaging, was achieved. Pathologic diagnosis was schwannoma. The postoperative course was uneventful. The patient's neurologic deficits resolved, and he experienced minimal pain after the operation. CONCLUSIONS: A single-stage operation using combined laminectomy and video-assisted thoracic surgery is a safe and efficacious strategy for achieving total removal of dumbbell-shaped thoracic schwannomas, even in cases involving giant lesions and elderly patients.

Thymoma dissemination through the thoracic intervertebral foramen: Pleural recurrence resulting in spinal cord compression.

BACKGROUND: Spinal dissemination of thymic tumors is rare but should be considered in the differential diagnosis of thoracic dumbbell-shaped lesions and/or vertebral tumors, irrespective of the time since the initial diagnosis. CASE DESCRIPTION: A 63-year-old man, with a history of invasive type AB thymoma treated 21 years ago, newly presented to the hospital with a dumbbell-shaped T8-T9 lesion compressing the spinal cord. A review of the literature showed only 16 previous cases of thymic tumors with thoracic spine involvement. Here, we report the lengthiest interval between the initial tumor diagnosis and the detection of spinal involvement, that was secondary to a pleural recurrence from his thymoma. The patient did well following successful excision of the intraspinal mass which had encased the T8 nerve root. CONCLUSION: Spinal dissemination of thymic tumors can occur due to vertebral metastasis or to extension of a pleural recurrence through the intervertebral foramen. Definitive treatment for spinal lesions should be considered to provide adequate cord decompression.

Spontaneous Regression of a Hypoglossal Neurinoma: Case Report and Review of the Literature.

BACKGROUND: Hypoglossal neurinomas are very rare intracranial tumors. The management choices include surgery, as the gold standard, and radiosurgery or a combination of both. Little is known about this condition and the behavior of this tumor. CASE DESCRIPTION: A 54-year-old woman presented with a right 12th nerve neurinoma with ipsilateral hemiatrophy of the tongue and spontaneous regression after 1 year of follow-up. CONCLUSIONS: Our case highlights the importance of considering careful observation and diligent follow-up as a treatment option, as these lesions can show spontaneous regression with no invasive approaches.

Frecuencia de las señales de alarma en pacientes con cefalea, atendidos en la emergencia de un hospital de Lima / Frequency of red flags in patients with headaches treated in an emergency unit in Lima

Las cefaleas en emergencia suelen ser un reto diagnóstico para el evaluador cuando se trata de diferenciarlas entreprimaria o secundaria a un trastorno neurológico subyacente.Objetivo: Describir la frecuencia de las señales de alarma en cefaleas secundarias y primarias en pacientes que acuden a emergencia.Materiales y Métodos: Estudio prospectivo de series de casos, que acuden a la Emergencia de Medicina de Adultos del Hospital Nacional CayetanoHeredia por cefalea, en un mes. Se excluyeron a los pacientes con cefalea traumática. Se usó un formato para laobtención de datos. Se clasificó a los pacientes en cefalea primaria o secundaria y se determinó la presencia de señales de alarma. Resultados:Se registraron 32 pacientes. Veintiséis (81%) tuvieron cefalea secundaria. De éstas, 9 se debieron a causas infecciosas y 9 a trastornos vasculares intracraneales. La cantidad de señales de alarma presentes en las cefaleas secundarias vario de 3 a 8, con una moda de 5; y en las primarias de 0 a 2, con una moda de 2. El empeoramiento progresivo y el examen neurológico anormal se presentaron en 96% de los casos de cefalea secundaria. Conclusiones: Las señales de alarma, empeoramiento progresivo y examen neurológico anormal fueronlos más frecuentes. Las cefaleas secundarias fueron más comunes que las cefaleas primarias. Se hace énfasis en la utilidad de usar esta metodología en emergencia

Headaches in the emergency room are usually a diagnostic challenge for the physician when they having to differentiate between a primary and secondary headaches and an underlying neurological disorder. Objectives: Describe the frequency of presentation of “red flags” in primary and secondary headaches, in patients presenting to an emergency department. Methods: A case-series prospective study was conducted in the Emergency room of Hospital Nacional Cayetano Heredia. All patients presenting with headaches within a month were evaluated. Trauma related headaches were excluded. A data collection form was used to determine the presence of red flags as well as other clinical data. The quantity of red flags was assessed in both types of headaches. Results: Thirty two patients were included for study. Twenty-six (81%) had secondary headaches. Nine of them were found to be secondary to infection and other 9 to intracranial vascular disorders. The quantity of red flags present on secondary headaches ranged from 3 to 8 with a mode of 5; on primary headaches they ranged from 0 to 2 with a mode of 2. Progressive worsening of headache and abnormal neurologic exam were present in 25 cases of secondary headache Conclusions: Red flags were progressive worsening of headache and abnormal neurologic exam. Thus the clinical assessment of red flags is useful in the evaluation of patients with secondary headache in the emergency room.