Actualización en la fisiopatología de la hidrocefalia crónica del adulto idiopática: ¿nos enfrentamos a otra enfermedad neurodegenerativa? / Current concepts on the pathophysiology of idiopathic chronic adult hydrocephalus: Are we facing another neurodegenerative disease?

INTRODUCCIÓN: Desde la descripción hace 5 décadas de la hidrocefalia crónica del adulto idiopática (HCAi), su fisiopatología ha sido considerada básicamente relacionada con el efecto que la dilatación ventricular ejerce sobre las estructuras adyacentes al sistema ventricular. Sin embargo, las alteraciones en el flujo sanguíneo cerebral (FSC) y, sobre todo, la reducción en el recambio licuoral parecen emerger como componentes fisiopatológicos principales de esta enfermedad. DESARROLLO: En la HCAi se observa una compresión del tracto piramidal, de los circuitos cortico-subcorticales fronto-estriatales y fronto-reticulares, y de las fibras profundas del fascículo longitudinal superior. En el cuerpo calloso se objetiva un descenso en el número de fibras comisurales, que son reemplazadas por gliosis. El FSC se encuentra alterado, con un patrón de última pradera en la región subcortical adyacente a los ventrículos, correspondiente a la intersección entre las arterias subependimarias y las arterias perforantes dependientes de los grandes troncos arteriales de la circulación anterior. El recambio diario del LCR se ve disminuido en un 75%, lo que conlleva una reducción del aclaramiento de neurotóxicos y la interrupción de las señalizaciones neuroendocrinas y paracrinas que ocurren a través del LCR. CONCLUSIONES: La HCAi emerge como una entidad nosológica compleja, en la que los efectos de la microangiopatía subcortical y la disminución del recambio de LCR desempeñan un papel fundamental. Esta base fisiopatológica aleja la HCAi del concepto clásico de hidrocefalia y la acerca al perfil de otras enfermedades neurodegenerativas, como la enfermedad de Alzheimer o la enfermedad de Binswanger

INTRODUCTION: Since its description five decades ago, the pathophysiology of idiopathic chronic adult hydrocephalus (iCAH) has been traditionally related to the effect that ventricular dilatation exerts on the structures surrounding the ventricular system. However, altered cerebral blood flow, especially a reduction in the CSF turnover rate, are starting to be considered the main pathophysiological elements of this disease. DEVELOPMENT: Compression of the pyramidal tract, the frontostriatal and frontoreticular circuits, and the paraventricular fibres of the superior longitudinal fasciculus have all been reported in iCAH. At the level of the corpus callosum, gliosis replaces a number of commissural tracts. Cerebral blood flow is also altered, showing a periventricular watershed region limited by the subependymal arteries and the perforating branches of the major arteries of the anterior cerebral circulation. The CSF turnover rate is decreased by 75%, leading to the reduced clearance of neurotoxins and the interruption of neuroendocrine and paracrine signalling in the CSF. CONCLUSIONS: iCAH presents as a complex nosological entity, in which the effects of subcortical microangiopathy and reduced CSF turnover play a key role. According to its pathophysiology, it is simpler to think of iCAH more as a neurodegenerative disease, such as Alzheimer disease or Binswanger disease than as the classical concept of hydrocephalus

Current concepts on the pathophysiology of idiopathic chronic adult hydrocephalus: Are we facing another neurodegenerative disease? / Actualización en la fisiopatología de la hidrocefalia crónica del adulto idiopática: ¿nos enfrentamos a otra enfermedad neurodegenerativa?

INTRODUCTION: Since its description five decades ago, the pathophysiology of idiopathic chronic adult hydrocephalus (iCAH) has been traditionally related to the effect that ventricular dilatation exerts on the structures surrounding the ventricular system. However, altered cerebral blood flow, especially a reduction in the CSF turnover rate, are starting to be considered the main pathophysiological elements of this disease. DEVELOPMENT: Compression of the pyramidal tract, the frontostriatal and frontoreticular circuits, and the paraventricular fibres of the superior longitudinal fasciculus have all been reported in iCAH. At the level of the corpus callosum, gliosis replaces a number of commissural tracts. Cerebral blood flow is also altered, showing a periventricular watershed region limited by the subependymal arteries and the perforating branches of the major arteries of the anterior cerebral circulation. The CSF turnover rate is decreased by 75%, leading to the reduced clearance of neurotoxins and the interruption of neuroendocrine and paracrine signalling in the CSF. CONCLUSIONS: iCAH presents as a complex nosological entity, in which the effects of subcortical microangiopathy and reduced CSF turnover play a key role. According to its pathophysiology, it is simpler to think of iCAH more as a neurodegenerative disease, such as Alzheimer disease or Binswanger disease than as the classical concept of hydrocephalus.

ODZ1 allows glioblastoma to sustain invasiveness through a Myc-dependent transcriptional upregulation of RhoA.

Long-term survival remains low for most patients with glioblastoma (GBM), which reveals the need for markers of disease outcome and novel therapeutic targets. We describe that ODZ1 (also known as TENM1), a type II transmembrane protein involved in fetal brain development, plays a crucial role in the invasion of GBM cells. Differentiation of glioblastoma stem-like cells drives the nuclear translocation of an intracellular fragment of ODZ1 through proteolytic cleavage by signal peptide peptidase-like 2a. The intracellular fragment of ODZ1 promotes cytoskeletal remodelling of GBM cells and invasion of the surrounding environment both in vitro and in vivo. Absence of ODZ1 by gene deletion or downregulation of ODZ1 by small interfering RNAs drastically reduces the invasive capacity of GBM cells. This activity is mediated by an ODZ1-triggered transcriptional pathway, through the E-box binding Myc protein, that promotes the expression and activation of Ras homolog family member A (RhoA) and subsequent activation of Rho-associated, coiled-coil containing protein kinase (ROCK). Overexpression of ODZ1 in GBM cells reduced survival of xenografted mice. Consistently, analysis of 122 GBM tumour samples revealed that the number of ODZ1-positive cells inversely correlated with overall and progression-free survival. Our findings establish a novel marker of invading GBM cells and consequently a potential marker of disease progression and a therapeutic target in GBM.

Sacral nerve stimulation lead implantation in partial sacral agenesis using intra-operative computerized tomography.

AIM: Sacral nerve stimulation (SNS) lead implantation is a straightforward procedure for individuals with intact spinal vertebrae. When sacral anomalies are present, however, the anatomical and radiological reference points used for the accurate placement of the electrode may be absent or difficult to identify. METHOD: We describe an innovative surgical procedure of percutaneous nerve evaluation for SNS in a patient with faecal incontinence secondary to a congenital imperforate anus and partial sacral agenesis using a surgical imaging platform (O-arm system) under neurophysiological control. RESULTS: Using intra-operative CT and neuronavigation, the insertion point at the skin was identified. The lead was introduced into the right-sided S3 foramen and placed at the correct depth. An appropriate motor response was obtained after stimulation and neurophysiological control confirmed that the right S3 root was being stimulated. CONCLUSION: Our experience showed that O-arm guided navigation can be used to overcome the difficulty of SNS lead placement in patients with partial sacral agenesis who have faecal incontinence.

Blockade of the NFκB pathway drives differentiating glioblastoma-initiating cells into senescence both in vitro and in vivo.

Glioblastoma multiforme is one of the most devastating cancers and presents unique challenges to therapy because of its aggressive behavior. Cancer-initiating or progenitor cells have been described to be the only cell population with tumorigenic capacity in glioblastoma. Therefore, effective therapeutic strategies targeting these cells or the early precursors may be beneficial. We have established different cultures of glioblastoma-initiating cells (GICs) derived from surgical specimens and found that, after induction of differentiation, the NFκB transcriptional pathway was activated, as determined by analyzing key proteins such as p65 and IκB and the upregulation of a number of target genes. We also showed that blockade of nuclear factor (NF)κB signaling in differentiating GICs by different genetic strategies or treatment with small-molecule inhibitors, promoted replication arrest and senescence. This effect was partly mediated by reduced levels of the NFκB target gene cyclin D1, because its downregulation by RNA interference reproduced a similar phenotype. Furthermore, these results were confirmed in a xenograft model. Intravenous treatment of immunodeficient mice bearing human GIC-derived tumors with a novel small-molecule inhibitor of the NFκB pathway induced senescence of tumor cells but no ultrastructural alterations of the brain parenchyma were detected. These findings reveal that activation of NFκB may keep differentiating GICs from acquiring a mature postmitotic phenotype, thus allowing cell proliferation, and support the rationale for therapeutic strategies aimed to promote premature senescence of differentiating GICs by blocking key factors within the NFκB pathway.

Abscesos cerebrales en un hospital de tercer nivel: epidemiología y factores que influyen en la mortalidad / Brain abscess in a tertiary medical center: epidemiology and prognostic factors related to mortality

Objetivos: Analizar la epidemiología, la evolución clínica,el tratamiento y los factores pronósticos de mortalidad de pacientescon absceso cerebral ingresados en un hospital de tercernivel.Métodos: Estudio observacional de cohortes retrospectivode pacientes diagnosticados de absceso cerebral en un hospitalde tercer nivel durante un periodo de 13 años.Resultados: Desde Enero de 1992 a Diciembre de 2005 sediagnosticaron 71 pacientes con absceso cerebral. Hubo unpredominio masculino (73%), con una edad media de 45 años.Fiebre, cefalea y alteración del estado mental fueron las manifestacionesclínicas más frecuentes. La localización más frecuentefue el lóbulo frontal (28 pacientes). Cincuenta y cuatro(76,1%) pacientes tenían abscesos uniloculados y 17 (23,9%)abscesos múltiples. Los estafilococos fueron los microorganismosmás frecuentemente aislados. La tomografía computarizadafue suficiente para realizar el diagnóstico en todos los casos.Se practicó drenaje quirúrgico a 26 pacientes con untiempo medio diagnóstico-intervención de 15,4 días. Precisaroningreso en la Unidad de Cuidados Intensivos (UCI) 34 pacientes.La mortalidad fue de un 21,4% (15 pacientes), siendoen todos los casos atribuible a la infección. Seis pacientes fallecieronen la UCI. En el análisis multivariante el ser mayor de 65años (OR, 1,0; CI 95%, 1,0-1,1) el tratamiento médico aislado(OR, 8,9; CI 95%, 1,1-73,8), la presencia de abscesos múltiples(OR, 6,0; CI 95%, 1,0-34,9), la inmunosupresión (OR, 21,5; CI95%, 2,9-157,2) y el tiempo desde el diagnóstico hasta la instauraciónde la antibioterapia (OR, 1,5 por día de retraso; CI95%, 1,0-2,1) fueron factores independientes de mortalidad...(AU)

Objective. To document the epidemiology, causes,treatment and prognostic factors associated with mortalityof patients with brain abscess in a tertiary medicalcenter.Methods. Observational retrospective cohort study ofpatients with cerebral abscess admitted at a tertiary hospitalduring 13 years.Results. The case records of 71 patients admitted to atertiary hospital between January 1992 and December2005 and diagnosed of brain abscess were review. Brainabscess occurred at all ages, more frequently in menthan in women. Fever, headache and altered mental statuswere common presenting symptoms. The most commonsite of infection was the frontal lobe (28 patients).Seventeen patients had multiple abscesses. Staphylococcalinfection was seen most commonly. Computed tomographyprovided sufficient diagnostic information in allcases. Twenty six patients had early surgical drainage.Thirty four patients were admitted to the intensive careUnit (ICU). The overall mortality was 21% (15 patients),all of that related to the infection. Six patients died inICU. More than 65 years of age (OR, 1,0; CI 95%, 1,0-1,1), medical treatment without surgery (OR, 8,9; CI 95%,1,1-73,8), presence of multiple abscesses, (OR, 6,0; CI95%, 1,0-34,9), immunosuppression (OR, 21,5; CI 95%, 2,9-157,2) and delay in starting antibiotherapy (OR, 1,5per day of delay; CI 95%, 1,0-2,1) were independent predictorsof in-hospital death.Conclusions: In spite of improvement in diagnosisand treatment of patients with cerebral abscess, mortalityis still high. Factors related to patient underlying diseasesand the delay in the start an antibiotic treatmentwere associated with increased mortality (50% increaseof mortality risk per day in the delay of starting antibiotherapy)(AU)

Multidrug-resistant Acinetobacter baumannii ventriculitis: successful treatment with intraventricular colistin.

Acinetobacter baumannii has emerged as an important nosocomial pathogen that can cause a multitude of severe infections. In neurosurgical patients the usual presentation is ventriculitis associated with external ventricular drainage. Carbapenems have been considered the gold standard for the treatment of Acinetobacter baumannii ventriculitis, but resistant isolates are increasing worldwide, reducing the therapeutic options. In many cases polymyxins are the only possible alternative, but their poor blood-brain barrier penetration could require them to be directly administered intraventricularly and clinical experience with this route is limited. We review the literature concerning intraventricular use of colistin (polymyxin E) for A. baumannii ventriculitis and add three cases successfully treated with this method. Our experience suggests that intraventricular colistin is a potentially effective and safe therapy for the treatment of multidrug-resistant A. baumannii central nervous system infections.

[Brain abscess in a third-level hospital: epidemiology and prognostic factors related to mortality]. / Abscesos cerebrales en un hospital de tercer nivel: epidemiología y factores que influyen en la mortalidad.

OBJECTIVE: To document the epidemiology, causes, treatment and prognostic factors associated with mortality of patients with brain abscess in a tertiary medical center. METHODS: Observational retrospective cohort study of patients with cerebral abscess admitted at a tertiary hospital during 13 years. RESULTS: The case records of 71 patients admitted to a tertiary hospital between January 1992 and December 2005 and diagnosed of brain abscess were review. Brain abscess occurred at all ages, more frequently in men than in women. Fever, headache and altered mental status were common presenting symptoms. The most common site of infection was the frontal lobe (28 patients). Seventeen patients had multiple abscesses. Staphylococcal infection was seen most commonly. Computed tomography provided sufficient diagnostic information in all cases. Twenty six patients had early surgical drainage. Thirty four patients were admitted to the intensive care Unit (ICU). The overall mortality was 21% (15 patients), all of that related to the infection. Six patients died in ICU. More than 65 years of age (OR, 1.0; CI 95%, 1.0-1.1), medical treatment without surgery (OR, 8.9; CI 95%, 1.1-73.8), presence of multiple abscesses, (OR, 6.0; CI 95%, 1.0-34.9), immunosuppression (OR, 21.5; CI 95%, 2.9-157.2) and delay in starting antibiotherapy (OR, 1.5 per day of delay; CI 95%, 1.0-2.1) were independent predictors of in-hospital death. CONCLUSIONS: In spite of improvement in diagnosis and treatment of patients with cerebral abscess, mortality is still high. Factors related to patient underlying diseases and the delay in the start an antibiotic treatment were associated with increased mortality (50% increase of mortality risk per day in the delay of starting antibiotherapy).

[Cervical myelopathy: retrospective analysis of surgical results in 53 cases treated by anterior cervical discectomy and interbody fusion]. / Mielopatía cervical: análisis retrospectivo de los resultados quirúrgicos de 54 pacientes tratados mediante descectomía y fusión intersomática por vía anterior.

PATIENTS AND METHODS: We perform a retrospective analysis of clinical results in 53 consecutive patients surgically treated for cervical myelopathy or myelo-radiculopathy with anterior cervical discectomy and interbody fusion by means of the Cloward procedure. RESULTS: 64.2% of the patients had good outcome as measured by the improvement in one or more grades in the Nurick's scale. No mortality related to the surgical procedure was noted, although 9.4% of the cases suffered neurological deterioration. Correct fusion was achieved in 92.5% of the patients, with a rate of post-surgical kyphosis of 9.4%. Multivariate analysis identified as factors related to the clinical outcome: age (p = 0.008), vascular risk factors (p = 0.031), duration of symptoms (p = 0.002), pre-surgical neurological status (p < 0.001), neuroradiological diagnosis (p = 0.014), intra-medullary high signal intensity changes in T2-weighted images (p = 0.008), prolongation of the central somato-sensory or motor conduction times (p = 0.004) and neurologic complications (p = 0.012) CONCLUSIONS: Treatment optimisation of the patient suffering cervical spondylotic myelopathy requires individualised evaluation. Prospective randomised studies are needed to answer the questions when and how to operate.

Mielopatía cervical: análisis retrospectivo de los resultados quirúrgicos de 54 pacientes tratados mediante discectomía y fusión intersomática por vía anterior / Cervical myelopathy: Retrospective analysis of surgical results in 53 cases treated by anterior cervical discectomy and interbody fusion

Pacientes y métodos. Se analiza de forma retrospectiva el resultado clínico de una serie consecutiva de 53 pacientes afectos de mielopatía o mielorradiculopatía cervical que fueron intervenidos mediante discectomía cervical y artrodesis por vía anterior utilizando la técnica de Cloward, con un seguimiento medio de 3 años. Resultados. El 64.2% de los pacientes se benefició del tratamiento quirúrgico, mejorando en uno o más grados en la escala de Nurick. No se produjo mortalidad, aunque apareció deterioro neurológico en el 9.4% de los casos. Se objetivó una correcta fusión de los segmentos intervenidos en el 92.5% de las cirugías, desarrollando un 9.4% de los enfermos cifosis postquirúrgica. En el análisis multivariante se identificaron como factores relacionados con el resultado clínico: edad (p=0.008), presencia de factores de riesgo vascular (p=0.031), duración de la clínica (p=0.002), estado neurológico prequirúrgico (p<0.001), diagnóstico neurorradiológico (p=0.014), presencia de hiperseñal intramedular en las secuencias de resonancia magnética potenciadas en T2 (p=0.008), alteración de la conducción medular en el estudio neurofisiológico (p=0.004) y desarrollo de complicaciones quirúrgicas (p=0.012). Conclusiones. Dadas las discrepancias existentes en la actualidad, la optimización del tratamiento de estos pacientes pasa por una valoración individualizada, y por la realización de estudios prospectivos y randomizados que respondan a las preguntas cuándo y cómo operar

Patients and methods. We perform a retrospective analysis of clinical results in 53 consecutive patients surgically treated for cervical myelopathy or myelo-radiculopathy with anterior cervical discectomy and interbody fusion by means of the Cloward procedure. Results. 64.2% of the patients had good outcome as measured by the improvement in one or more grades in the Nurick´s scale. No mortality related to the surgical procedure was noted, although 9.4% of the cases suffered neurological deterioration. Correct fusion was achieved in 92.5% of the patients, with a rate of post-surgical kyphosis of 9.4%. Multivariate analysis identified as factors related to the clinical outcome: age (p=0.008), vascular risk factors (p=0.031), duration of symptoms (p=0.002), pre-surgical neurological status (p<0.001), neuroradiological diagnosis (p=0.014), intra-medullary high signal intensity changes in T2-weighted images (p=0.008), prolongation of the central somato-sensory or motor conduction times (p=0.004) and neurologic complications (p=0.012) Conclusions. Treatment optimisation of the patient suffering cervical spondylotic myelopathy requires individualised evaluation. Prospective randomised studies are needed to answer the questions when and how to operate

Controversias en la fisiopatología de la mielopatía cervical espondilótica / Current controversies in pathophysiology of cervical spondylotic myelopathy

La mielopatía cervical espondilótica es la consecuencia más grave de los cambios degenerativos que acontecen en el raquis cervical. En este artículo se realiza una revisión bibliográfica de la situación actual de esta enfermedad. Las líneas actuales de trabajo de la mayor parte de los grupos dedicados al estudio de esta patología se centran en perfeccionar las técnicas quirúrgicas diseñadas para su tratamiento, siendo realmente escasos los estudios que enfocan el problema fisiopatológico. De hecho, la mayor parte de lo que conocemos en torno a la mielopatía espondilótica se basa en trabajos realizados en las décadas de 1960 y 1970, careciendo prácticamente la literatura de estudios a nivel neuroquímico paralelos a los existentes en el traumatismo raquimedular en la última década. De igual forma, únicamente se han llevado a cabo tres ensayos clínicos prospectivos comparando el tratamiento conservador con el tratamiento quirúrgico, y ninguno de ellos ha demostrado una clara ventaja de la cirugía. La alta prevalencia de esta enfermedad justifica la necesidad, por una parte, de un profundo conocimiento de sus bases fisiopatológicas, neuroquímicas y moleculares y, por otra parte, de la optimización del tratamiento quirúrgico, hecho que probablemente implica la realización de estudios prospectivos controlados para determinar las características de los pacientes que van a beneficiarse de la cirugía (AU)

[Current controversies in pathophysiology of cervical spondylotic myelopathy]. / Controversias en la fisiopatología de la mielopatía cervical espondilótica.

Cervical spondylotic myelopathy is the most severe consequence of degenerative disease of cervical spine. In this article we perform a bibliographic review, addressing current controversies in its pathophysiology. Present work lines of most groups dedicated to the study of this condition are focused on improving surgical techniques designed for the treatment of this disease. Pathophysiological studies are scarce, and most of our pathophysiological knowledge of cervical spondylotic myelopathy is based in works done in 60s and 70s. Literature of the last decade lacks neurochemichal studies parallel to those existing for acute spinal injury. In the same way, only three prospective clinical trials comparing conservative and surgical treatment have been done, and none of them has demonstrated clear superiority of surgery. Given the high prevalence of this disease, the need for deep knowledge of its pathophysiologic, neurochemichal and molecular basis, and the optimization of surgical treatment is justified. This probably implies the need for prospective randomized trials to determine which patients are going to benefit from surgery.

[Anterior cervical diskectomy and interbody arthrodesis using Cloward technique: retrospective study of complications and radiological results of 167 cases]. / Discectomía cervical y artrodesis intersomática mediante técnica de Cloward: análisis retrospectivo de las complicaciones y los resultados radiológicos en 167 casos.

PATIENTS AND METHODS: We performed a retrospective analysis of complications and radiological results in 167 patients surgically treated, for discal or spondylotic disease of the cervical spine, with Cloward procedure. Using uni and multivariate analysis, we tried to identify risk factors that might be correlated with surgical complications or radiological results. RESULTS: Surgical treatment was indicated for cervical radiculopathy in 68% of the patients and for myelopathy or radiculomyelopathy in the remaining 32%. The pathologic disease responsible of the symptomatology was soft disk herniation in 59% of the cases and spondylotic changes in 41%. The patients that underwent surgery because of myelopathy were one decade older, had a longer symptomatic period and presented multi-segmentary spondylotic disease with higher frequency than patients affected of radiculopathy. The most common segments operated were CS-C6 (44.3%) and C6-C7 (30.5%). Surgical mortality was 0.6% and morbidity 29.3%. Most of the complications were transient, although 4.8% of the patients developed permanent neurological deterioration. CONCLUSIONS: Complications were most commonly seen in the group of the patients undergoing surgery because of long-lasting myelopathy with multi-segmentary spondylotic disease, in those with vascular risk factors and in those operated of more than one segment. Surgeon anatomic knowledge and experience are critical for diminishing such complications. Non-union rate was 9.6%, and another 9.6% of the patients developed post-surgical kyphosis. Both factors correlated with the need of re-operation.

[Spinal angiolipoma: case report]. / Angiolipoma espinal: presentación de un caso.

Spinal extradural angiolipomas are rare benign tumours, accounting for only 0.14-1.2% of all spinal neoplasms. They are usually localized within the thoracic extradural space of the spinal canal and their common clinical presentation is myelopathy, mainly in the way of a slowly progressive paraparesis and sometimes in an acute form. We report the case of a 85 year old man who complained of bilateral lower limb weakness with sphincter disturbance of acute instauration. The MRI showed a posterior extradural lesion at L1-L2 level that compressed conus medularis and cauda equina. He underwent urgent surgical treatment and we achieved total resection of the lesion via a L1-L2 laminectomy. The pathological examination confirmed the tumour as an angiolipoma.

[Cauda equina meningioma in a girl: presentation of a case and review of the literature]. / Meningioma de la cauda equina en una niña: presentación de un caso y revisión de la literatura.

Meningiomas are unusual in childhood, and the intraspinal location is very uncommon. Those arising from lumbar dura matter are the most rare among spinal neoplasms of meningeal origin. We present the case of a 12-years-old girl with a cauda equina meningioma. As in previously reported cases, the initial complain was back pain with radicular irradiation. The girl had few neurological findings, with pyramidal signs of both lower limbs as single neurological impairment. She underwent surgical treatment through an open door laminoplasty and the tumour was completely removed without neurological deficit. After 2-year of follow-up she remains asymptomatic.

Meningioma de la cauda equina en una niña: presentación de un caso y revisión de la literatura / Meningioma of the caudal equina in a child: case report and review of the literature

Los meningiomas son tumores raros en los niños, siendo especialmente inusual su localización raquídea y excepcional su origen en la duramadre de la teca lumbar. Presentamos el caso de una niña de 12 años con un meningioma de cauda equina. En concordancia con la literatura el síntoma inicial fue lumbalgia con irradiación radicular, siendo escasos los hallazgos de la exploración neurológica, que se limitaban a la presencia de signos piramidales en ambas extremidades inferiores. Fue intervenida mediante una laminoplastia en puerta abierta, consiguiéndose la resección completa de la tumoración sin déficit neurológico postoperatorio. La niña permanece asintomática dos años después de la cirugía (AU)

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Angiolipoma espinal: presentación de un caso / Spinal angiolipoma: Case report

Los angiolipomas espinales extradurales son tumores de carácter benigno poco frecuentes, que representan el 0,14-1,2 por ciento de todas las neoplasias raquídeas y se localizan preferentemente a nivel torácico. Clínicamente suelen presentarse como mielopatía, que puede debutar de forma aguda o instaurarse crónicamente. Presentamos el caso de un varón de 85 años con clínica de inicio agudo consistente en paraparesia espástica, acompañada de alteración de esfínteres. En la RM dorso-lumbar se objetivó una neoformación intrarraquídea a nivel L1-L2, que ocupaba el espacio epidural posterior, comprimiendo el cono medular y la cauda equina. El paciente fue intervenido con carácter urgente, realizándose una laminectomía L1-L2 y consiguiéndose la exéresis total de la neoformación. El estudio anatomopatológico fue informado como angiolipoma (AU)

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Discectomía cervical y artrodesis intersomática mediante técnica de Cloward: Análisis retrospectivo de las complicaciones y los resultados radiológicos en 167 casos / Anterior cervical discectomy and interbody fusion using Cloward procedure: Retrospective analysis of complications and radiologic results in 167 cases

Pacientes y métodos: Se analizan de forma retrospectiva las complicaciones y resultados radiológicos de 167 pacientes intervenidos de forma consecutiva por patología discal o espondilótica del raquis cervical utilizando la técnica de Cloward. Mediante análisis estadístico uni y multivariante se intentan identificar factores de riesgo ligados al desarrollo de complicaciones quirúrgicas o que pudiesen influenciar el resultado radiológico. Resultados: La cirugía se indicó en el 68 por ciento de los pacientes por un cuadro de radiculopatía resistente al tratamiento conservador, y en el 32 por ciento restante por mielopatía o mielorradiculopatía. El proceso patológico causante de la clínica fue una hernia discal en el 59 por ciento de los pacientes y cambios espondilóticos en el 41 por ciento. Los pacientes intervenidos por mielopatía eran una década mayores, presentaban una evolución sintomática más larga y cambios espondilóticos multisegmentarios con mayor frecuencia. Los espacios intervenidos más frecuentemente fueron el C5-C6 (44.3 por ciento) y el C6-C7 (30.5 por ciento). La mortalidad de la técnica quirúrgica fue del 0.6 por ciento, y la morbilidad del 29.3 por ciento. La mayor parte de las complicaciones fueron transitorias, aunque en el 4.8 por ciento de los pacientes el deterioro neurológico fue definitivo. Conclusiones: Las complicaciones fueron más frecuentes en aquellos pacientes afectos de mielopatía de larga evolución, sobre todo si ésta se debía a cambios espondilóticos multisegmentarios, y el paciente presentaba factores de riesgo vascular y era intervenido de más de un espacio. La experiencia y el conocimiento anatómico del cirujano resultan fundamentales a la hora de disminuir las complicaciones quirúrgicas de esta técnica. En el 9.6 por ciento de los pacientes se objetivó pseudoartrosis y otro 9.6 por ciento desarrolló cifosis postquirúrgica, correlacionándose ambos factores con la necesidad de una segunda cirugía (AU)

[Intradural lumbar disk hernia]. / Hernia discal lumbar intradural.

Intradural disc herniation is a rare complication of degenerative disc disease. A correct diagnosis of this process is frequently difficult. If this entity is not preoperatively diagnosed and is omitted at surgery, severe neurologic sequels may be provoked. We report a case of a pathologically proven intradural disc herniation preoperatively diagnosed by MR imaging. Clinically, it was manifested by sudden onset of right leg ciatalgia and progressive right lower extremity weakness. The patient also referred a one-month history of sexual dysfunction. MR imaging revealed interruption of the low signal of the anulus fibrosus and of the posterior longitudinal ligament at L2-L3 level and a voluminous disc fragment migrated in the dural sac that showed rim enhancement with gadolinium.The clinical, neuroradiological, and surgical management of lumbar intradural disc herniation are reviewed.

Hernia discal lumbar intradural / Intradural lumbar disk hernia

La hernia intradural es una complicación infrecuente de la enfermedad degenerativa discal, de difícil diagnóstico. Si este proceso no se diagnostica preoperatoriamente y se pasa por alto en el acto quirúrgico, puede condicionar importantes secuelas neurológicas. Presentamos un caso de hernia discal intradural diagnosticado preoperatoriamente con resonancia magnética (RM). Clínicamente, se manifestaba por un cuadro de lumbociatalgia derecha de instauración súbita, disminución progresiva de la fuerza en la extremidad inferior derecha y disfunción sexual de un mes de evolución. La RM demostró interrupción de la hiposeñal normal del anillo fibroso discal y del ligamento longitudinal común posterior en L2-L3, así como un voluminoso fragmento discal migrado en el saco tecal, con realce anular tras la administración de contraste. Se revisa la nosología de la hernia discal intradural lumbar, con especial atención a los hallazgos neurorradiológicos y a su abordaje quirúrgico (AU)