Abordaje mínimamente invasivo para el tratamiento de tumores espinales intradurales extramedulares / Minimally invasive approach for the treatment of extramedullary intradural spinal tumors

Introducción: Describir la técnica de abordaje mínimamente invasiva para el tratamiento de tumores intradurales extramedulares en los diferentes segmentos espinales. Material y Métodos: Se detallan la planificación, posicionamiento, marcación, pasos técnicos del abordaje mínimamente invasivo, exéresis lesional y cierre de lesiones ID-EM a nivel cervical, dorsal, lumbar y sacro. Se proporcionan recomendaciones para descomplejizar maniobras quirúrgicas, acortar el tiempo operativo y evitar potenciales complicaciones. Conclusiones: El abordaje MISS es una opción segura y eficaz para el tratamiento quirúrgico de determinados tumores ID-EM.

Objective: To describe the technique of minimally invasive approach for the treatment of intradural extramedullary tumors in the different spinal segments. Material and Methods: The planning, positioning, skin marking, technical steps of the minimally invasive approach, lesion resection, and closure of ID-EM lesions at the cervical, dorsal, lumbar and sacral levels are detailed. Recommendations are provided to simplify surgical maneuvers, shorten operative time and avoid potential complications. Conclusions: The MIS approach is a safe and effective option for the surgical treatment of certain ID-EM tumors.

[Usefulness of minimally invasive spine surgery for the management of thoracolumbar spinal metastases]. / Utilidad de la cirugía espinal mínimamente invasiva en el manejo de las metástasis espinales toraco-lumbares.

OBJECTIVE: To describe the surgical results and evolution of patients who underwent minimally invasive spine surgery (MISS) for the treatment of thoracolumbar spinal metastases, using the NOMS (Neurological, Oncological, Mechanical, Systemic) assessment for the therapeutic decision. METHODS: Patients who underwent MISS technique for the treatment of thoracolumbar spinal metastases were prospectively enrolled at the Hospital Italiano de Buenos Aires, from June 2014 to June 2017. In all cases, the NOMS assessments were performed for therapeutic decision making. Surgical results were analyzed in terms of improvements in Karnofsky performance status, pain relief (VAS - visual analog scale), Frankel, blood loss, need for transfusions, complications, use of opioids and hospitalization length. A P < 0.05 value was considered statistically significant. RESULTS: During the study period 26 patients were included, 13 of them were women. The average age was 57-year-old (27-83 years). Breast cancer was the most frequent primary tumor (27%). The main symptom was pain (96%), although 12 patients presented with myelopathy (46%). High-grade epidural spinal cord compression requiring decompression was observed in 17 cases (65%). According to the SINS (spinal instability neoplastic score), most lesions were potentially unstable or unstable (89%) requiring MISS stabilization. After surgery, pain relief (VAS) and neurological recovery (Frankel) improved significantly in the 77% and 67% of the cases, respectively, with low intraoperative blood loss and without any transfusions. Only one minor surgical complication was presented (4%). The average of hospital stay was 5.5 days. CONCLUSION: In our series and using the NOMS as a therapeutic algorithm, MISS was effective for decompression and spinal stabilization, with a low rate of complications and rapid postoperative recovery.

[Minimally invasive resection of spinal synovial cysts: Technical note]. / Resección mínimamente invasiva de quistes sinoviales espinales. Nota técnica.

OBJECTIVE: To present the treatment algorithm, surgical technique, and results of a series of patients with spinal synovial cysts operated with minimally invasive techniques (MIS). INTRODUCTION: Spinal synovial cysts originate from the dilation and potential rupture of the synovial sheath of a facet joint. Surgical resection is considered the treatment of choice in symptomatic patients. The use of MIS techniques could reduce the disruption of the facet joint involved, reducing the risk of postoperative instability. MATERIALS AND METHODS: We retrospectively evaluated 21 patients with spinal synovial cysts operated by MIS approach and decompression. We analyzed the signs, symptoms, surgical time, hospital stay, evolution, and complications. The visual analog scale (VAS) was used to evaluate pain and the Weiner scale and the modified Macnab criteria to measure the patient's postoperative satisfaction. RESULTS: A total of 21 patients were surgically treated with MIS technique; 76.2% (n = 16) did not require arthrodesis, the remaining 23.8% (n = 5) were fused. We performed 13 (61.9%) contralateral hemilaminectomies, 7 ipsilateral hemilaminectomies (33.3%), and 1 laminectomy in S1-S2. The average follow-up was 26 months; surgical time was 150.33 ± 63.31 min, with a hospital stay of 2.5 ± 1.78 days. The VAS decreased from 8.3 preoperatively to 2.3 postoperatively. Sixteen patients reported excellent results, four good and one regular in the scale of Macnab. 95.2% of patients perceived that the procedure was very/quite successful according to the Weiner scale. CONCLUSION: The minimally invasive approach is a safe and effective procedure for the complete resection of spinal synovial cysts. It provides excellent clinical-functional results by preserving muscles, ligaments, and joint facets.

Minimally Invasive Resection of a Cervical Anterolateral Meningioma: 2-Dimensional Operative Video.

Intradural extramedullary spinal tumors were historically managed through traditional midline approaches. Although conventional laminectomy or laminoplasty provides a wide tumor and spinal cord exposure, they may cause prolonged postoperative neck pain and late kyphosis deformity. Minimally invasive ipsilateral hemilaminectomy preserves midline structures, reduces the paraspinal muscle disruption, and could avoid postoperative kyphosis deformity. A safe tumor resection through this approach could be complicated in large sized or anteromedullary located lesions. We present a surgical video of C3 antero located meningioma removed en bloc through a minimally invasive approach. The patient signed a written consent to publish video, recording, photograph, image, illustration, and/or information about him.

Resección Mínimamente Invasiva de Quistes Sinoviales Espinales. Nota Técnica / Minimally Invasive Resection of Spinal Synovial Cysts. Technical note

Objetivo: Presentar el algoritmo de tratamiento, técnica quirúrgica y resultados de una serie de pacientes con quistes sinoviales espinales resecados con técnica mínimamente invasiva (MIS). Introducción: Los quistes sinoviales espinales se originan a partir de la dilatación y potencial ruptura de la vaina sinovial de una articulación facetaria. La resección quirúrgica es considerada el tratamiento de elección en pacientes sintomáticos. La utilización de técnicas MIS podrían disminuir la disrupción de la faceta articular comprometida reduciendo el riesgo de inestabilidad postoperatoria. Material y métodos: Se evaluaron retrospectivamente 21 pacientes con quistes sinoviales espinales operados mediante abordaje y descompresión MIS, se analizaron los signos, síntomas, tiempo quirúrgico, estadía hospitalaria, evolución y complicaciones. Se utilizó la escala visual analógica (EVA), para evaluar el dolor y la escala de Weiner y los criterios de Macnab modificados para medir la satisfacción posoperatoria del paciente. Resultados: Se trataron quirúrgicamente 21 pacientes (13 mujeres, 8 hombres), el 76,2% (n=16) de los pacientes de la serie no requirió artrodesis, el 23,8% (n=5) restante fue fusionado. Realizamos 13 (61,9%) hemilaminectomías contralaterales, 7 hemilaminectomías ipsilaterales (33,3%) y una laminectomía en el QS S1-S2 con técnica MIS. El seguimiento promedio fue de 26 meses, el tiempo de cirugía fue de 150,33 ± 63,31 min., con una estadía hospitalaria de 2,5 ± 1,78 días. La EVA disminuyó de 8,3 preoperatoria a 2,3 postoperatoria. Siguiendo la escala de Macnab; 16 pacientes refirieron resultados excelentes, 4 buenos y 1 regular, el 95,2% de los pacientes percibió que el procedimiento tuvo mucho/bastante éxito según la escala de Weiner. Conclusión: El abordaje mínimamente invasivo es un procedimiento seguro y eficaz para la resección completa de quistes sinoviales espinales. Proporciona resultados clínico-funcionales excelentes preservando músculos, ligamentos y facetas articulares.

Introduction: Spinal synovial cysts originate from the dilation and potential rupture of a facet joint's synovial sheath. Surgical resection is considered the treatment of choice in symptomatic patients; however, the use of minimally-invasive surgery (MIS) techniques could reduce any disruption of the facet joint involved, reducing the risk of postoperative instability. Objective: To present the treatment algorithm, surgical technique and results in a series of patients with spinal synovial cysts treated by MIS. Methods and Materials: We retrospectively evaluated 21 patients with spinal synovial cysts who underwent therapeutic MIS with decompression. Signs, symptoms, surgical time, hospital stay, course and complications were evaluated. A visual analog scale (VAS) was used to rate pain, while the Weiner scale and modified Macnab criteria were employed to measure patients' postoperative satisfaction. Results: Twenty-one patients were surgically treated with MIS, among whom 76.2% (n = 16) required no arthrodesis; the remaining 23.8% (n = 5) were fused. We performed 13 (61.9%) contralateral hemilaminectomies, seven ipsilateral hemilaminectomies (33.3%), and one laminectomy at S1-S2. The average follow-up was 26 months, surgical time 150.33 ± 63.31 minutes, and mean hospital stay 2.5 ± 1.8 days. The VAS pain rating decreased from 8.3 preoperatively to 2.3 postoperatively. Sixteen patients reported excellent results, four good and one fair. On the Macnab scale, all but one patient (1/21, 4.8%) perceived that the procedure had been very/quite successful. Conclusions: Minimally-invasive surgery is a safe and effective approach for the complete resection of spinal synovial cysts. It provides excellent clinical and functional results, by preserving muscles, ligaments and facet joints.

Utilidad de la cirugía espinal mínimamente invasiva (MISS) en el manejo de las metástasis espinales toraco-lumbares / Utility of minimally invasive spinal surgery (MISS) in the management of thoraco-lumbar spinal metastases

Objetivo: Describir los resultados quirúrgicos y evolución de pacientes con metástasis espinales toraco-lumbares operadas con técnica mínimamente invasiva (MISS) utilizando para la decisión terapéutica la evaluación: Neurológica, Oncológica, Mecánica y Sistémica (NOMS). Material y Métodos: Se incluyeron en forma prospectiva pacientes con metástasis espinales toraco-lumbares operados con técnica MISS por el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, entre junio de 2014 y junio de 2017. Se utilizó en todos los casos el algoritmo de evaluación NOMS para la decisión terapéutica. Se analizaron los resultados quirúrgicos postoperatorios como el Karnofsky Performance Status (KPS), dolor (VAS: Visual Analogue Scale), Frankel, pérdida sanguínea, necesidad de transfusiones, complicaciones, uso de opioides y días de internación. Se consideró como estadísticamente significativo una p<0,05. Resultados: Durante el período de estudio 26 pacientes cumplieron los criterios de inclusión, de los cuales 13 fueron mujeres. La edad promedio fue 57 (27-83) años. El origen más frecuente de las lesiones fue cáncer de mama (27%). El síntoma más constante fue el dolor (96%), aunque 12 pacientes manifestaron inicialmente mielopatía (46%). Se observaron grados avanzados de invasión del canal con requerimiento de descompresión en el 65% de los casos. Acorde al Spinal Instability Neoplastic Score (SINS), 23 pacientes (89%) presentaron lesiones potencialmente inestables o inestables, requiriendo estabilización. Se evidenció una mejoría estadísticamente significativa del VAS en el 77% y del Frankel en el 67% de los casos tras la cirugía. No hubo necesidad de transfusiones. Se registró sólo una complicación quirúrgica leve (4%). La media de internación fue de 5,5 días. Conclusión: En nuestra serie y utilizando como algoritmo terapéutico el NOMS, la cirugía MISS resultó efectiva tanto para la descompresión para la estabilización espinal, con baja tasa de complicaciones y rápida recuperación postoperatoria.

Objective: To describe the surgical results and evolution of patients who undergo minimally-invasive spinal surgery (MISS) to treat thoracolumbar metastases, using the NOMS (Neurological, Oncological, Mechanical, Systemic) assessment tool to aid therapeutic decisions. Methods: Patients who underwent MISS to treat thoracolumbar metastases were prospectively enrolled at the Hospital Italiano de Buenos Aires, from June 2014 to June 2017. In all cases, the NOMS assessment tool was employed for therapeutic decision-making. Surgical results were analyzed, in terms of improvements in Karnofsky Performance Status (KPS), pain severity (VAS), and the Frankel neurological scale; also measured were blood loss and the need for transfusions, complications, use of opioids, and the length of hospitalization. P values <0.05 were considered statistically significant. Results: Twenty-six patients were enrolled (13 women) of mean age 57 years old (27-83). Breast cancer was the most frequent primary tumor (27%). The main presenting symptom was pain (96%), although 12 patients presented with myelopathy (46%). High-grade epidural spinal cord compression requiring decompression was observed in 17 patients (65%). According to the SINS (Spinal Instability Neoplastic Score), most lesions were either potentially unstable or unstable (89%), requiring stabilization. After surgery, pain severity and neurological status improved significantly in 77% and 67% of patients, respectively, with low intraoperative blood loss and no need for transfusions. Only one minor surgical complication occurred (4%). The average hospital stay was 5.5 days. Conclusion: In our series, using the NOMS instrument as the therapeutic algorithm, MISS was effective for spinal decompression and stabilization, with a low rate of complications and rapid postoperative recovery.

[Learning curve of minimally invasive pedicle screw placement]. / Curva de aprendizaje en la colocación de tornillos pediculares percutáneos mínimamente invasivos.

OBJECTIVE: The aim of this study was to estimate the learning curve needed for correct placement of minimally invasive percutaneous pedicle screws (PPS). INTRODUCTION: PPS are the most common system used for instrumentation of spinal lesions that require stabilization. METHODS: We retrospectively assessed the insertion of 422 PPS (T5 to S1) in 75 patients operated between 2013-2016 under two-dimensional fluoroscopic guidance. The surgeon 1 always placed the PPS on the right side and the surgeon 2 on the left side. Screw positioning and pedicle rupture was determined with the Gertzbein tomographic classification. We compared the accuracy of PPS placement in our series with a reference rupture rate of 8.08%, value obtained from a meta-analysis. RESULTS: Of the 422 TTP, 395 were inserted into the pedicle without violation of its cortical wall (Grade 1 = 93.6%), 27 (6.4%) disrupted the pedicle, of which 3.8% were Grade 2, 1.65% Grade 3 and only 0.9% Grade 4. The Surgeon 1, presented an overall break rate of 6.6% reaching standard values of accuracy by placing 74 PPS, Surgeon 2 showed a disruption rate of 6.1%, reaching baseline values at 64 PPS; the difference between them was not statistically significant (P = 0.9009). CONCLUSION: In our series, it was necessary to place approximately 70 PPS to achieve intrapedicular accuracy comparable to results reported by experienced surgeons in this minimally invasive technique.

[Minimally invasive extraforaminal lumbar interbody fusion]. / Fusión intersomática lumbar extraforaminal mínimamente invasiva.

OBJECTIVES: The objective of the present study was to determine the indications, surgical technique, results, and complications of minimally invasive extraforaminal lumbar interbody fusion (ELIF). INTRODUCTION: ELIF is characterized as removal of the superior articular process (SAP) to access the intra-canalicular root and disc through Kambin's triangle. METHODS: A retrospective study was conducted of 40 patients operated upon between 2013 and 2015. Patients with low back pain or root pain due to degenerative disc disease, spondylolisthesis grade 1 and 2, recurrent disc herniation, and recess-foraminal stenosis were included. A visual analogue scale (VAS), the Oswestry index, the Weiner scale and the modified MacNab criteria were used to assess pain, clinical and functional results and patient satisfaction one year after surgery. Complications were documented and rated according to their severity, in four degrees. RESULTS: We operated on 25 women and 15 men of average age 57 years. Of the forty, 47.5% were treated for spondylolisthesis, 25% by recess foraminal stenosis. In total, 54 interbody cages and 188 percutaneous pedicle screws were placed; and the mean duration of surgery was 245 (±25.4) minutes. The mean hospitalization time was 3.5 (±0.49) days. We observed nine Grade 1 and one Grade 2 complication. The mean preoperative ODI score was 51.9 ± 4.96, which improved to 12.2 ± 3.19 at one year (P < 0.0001). The mean VAS low back pain rating improved from 8.81 ± 0.62 to 2.12 ± 0.89 (P < 0.0001). By one year post-operatively, 77.5% of the patients had fusion (Bridwell grade 1 or 2). CONCLUSIONS: ELIF is a safe and effective surgical approach. Satisfactory clinical outcomes, comparable to traditional techniques, can be achieved with facet resection limited to the superior articular process.

Intraoperative monitoring for spinal radiculomedullary artery aneurysm occlusion treatment: What, when, and how long?

BACKGROUND: Spinal radiculomedullary artery aneurysms are extremely rare. Treatment should be tailored to clinical presentation, distal aneurysm flow, and lesion anatomical features. When a surgical occlusion is planned, it is necessary to evaluate whether intraoperative monitoring (IOM) should be considered as an indispensable tool to prevent potential spinal cord ischemia. METHODS: We present a patient with symptoms and signs of spinal subarachnoid hemorrhage resulting from the rupture of a T4 anterior radiculomedullary aneurysm who underwent open surgical treatment under motor evoked potential (MEP) monitoring. RESULTS: Due to the aneurysmal fusiform shape and preserved distal flow, the afferent left anterior radiculomedullary artery was temporarily clipped; 2 minutes after the clamping, the threshold stimulation level rose higher than 100 V, and at minute 3, MEPs amplitude became attenuated over 50%. This was considered as a warning criteria to leave the vessel occlusion. The radiculomedullary aneurysm walls were reinforced and wrapped with muscle and fibrin glue to prevent re-bleeding. The patient awoke from general anesthesia without focal neurologic deficit and made an uneventful recovery with complete resolution of her symptoms and signs. CONCLUSION: This paper attempts to build awareness of the possibility to cause or worsen a neurological deficit if a radiculomedullary aneurysm with preserved distal flow is clipped or embolized without an optimal IOM control. We report in detail MEP monitoring during the occlusion of a unilateral T4 segmental artery that supplies an anterior radiculomedullary artery aneurysm.

Polyetheretherketone interbody cages versus autogenous iliac crest bone grafts with anterior fixation for cervical disc disease.

OBJECTIVE: The aim of this study was to compare the fusion rate, operation time, recovery of disc space height, clinical duration and improvement, return to activities of daily living, and complication rate associated with anterior cervical discectomy with interbody fusion by using polyetheretherketone cages or autogenous iliac crest bone grafts as disc replacement in a series of 60 patients. MATERIALS AND METHODS: Between November 2006 and February 2010 a retrospective analytical observational cohort study was carried out in 60 consecutive patients surgically treated with anterior cervical discectomy with interbody fusion for degenerative disc desease at the Neurosurgical Department of the Hospital Italiano de Buenos Aires. The patients were divided into 2 groups for the assessment of clinical characteristics, demographics, fusion rates, duration of surgical procedure, neurological and functional outcomes, imaging results, and complications. Group A included patients treated with autogenous iliac crest bone grafts, and group B included patients treated with polyetheretherketone cages. RESULTS: The mean age of the patients was 50.8 years. Female patients comprised the majority in both groups (63.3%). Cervicobrachialgia was the most common presentation. Clinical improvement, fusion rates, and recovery of disc space height were similar in both groups. The operation time was significantly shorter in the polyetheretherketone group (P<0.001). Twenty percent (n=6) of the patients in group A suffered complications, >80% of which were associated with iliac crest bone graft harvesting. Patients in group B had no complications (P<0.05). CONCLUSIONS: Although outcomes were very successful in both groups in terms of fixation stability, recovery of disc space, return to activities of daily living and work, and remission of symptoms, operation time was considerably shorter for patients in the polyetheretherketone group, who had none of the complications associated with iliac crest bone graft harvesting, both differences being statistically significant.

Multicentric extramedullary myxopapillary ependymomas: Two case reports and literature review.

BACKGROUND: Ependymoma has been described typically as an intramedullary tumor derived from ependymal cells. Intradural extramedullary presentation is rarely described and almost always as a unique lesion. Myxopapillary ependymoma is a histological variant that distinguishes from the ordinary type of ependymoma because of its generally better prognosis. We present two cases of multicentric extramedullary myxopapillary ependymomas. CASE DESCRIPTION: Case 1 was a 30-year-old man with progressive paresthesia and paresis in the lower limbs, urinary sphincter disturbances, gait instability, ataxia, and chronic low back pain with multiple intradural extramedullary lesions at C2-C3, D2-D4-D5, and D12-L1. Case 2 was a 32-year-old man, presented with low back pain and mild paresthesia in the right lower limb. Magnetic resonance imaging (MRI) showed multiple intradural extramedullary lesions with homogeneous enhancement after gadolinium injection at C7, D2, D4, D5, D8, D10, D11, L1, L3, L5, S1, and S2. Complete tumor resection of the approached tumors was archived in both cases. Histological studies confirm myxopapillary ependymomas. Patient's neurologic outcome was good and no residual tumor was present at MRI control at 10 years in case 1 and 12 months in case 2. CONCLUSIONS: We report the first two cases of multicentric extramedullary myxopapillary ependymomas, this etiology must be taken into account in the differential diagnosis of intradural extramedullary tumors.

Supratentorial and infratentorial brain abscesses: surgical treatment, complications and outcomes--a 10-year single-center study.

OBJECTIVE: To analyze the variables determining morbidity, mortality and outcome in subjects with brain abscesses treated at a single center over a 10-year period. METHODS: A retrospective study was conducted on a series of 59 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision. Such variables as age, gender, clinical presentation, number of days to diagnosis, location, number of lesions, predisposing factors, mechanism of infection, etiological agent, and therapy were analyzed independently. Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery, and classified according to a four-point gradual severity scale. Postoperative outcome was appraised through the Glasgow Outcome Scale (GOS) 6 months after surgery, 0-4 points were considered poor outcome and 5 points good outcome. RESULTS: Eighty abscesses were diagnosed and surgically managed in 59 patients. The mean age was 44.69 years (range: 0.16-77); 59.3% were female. The median number of days to diagnosis was 7. Most frequent clinical presentations included fever (52.5%), headache (42.4%), and focal neurologic deficits (39%). Mechanism of infection was mainly hematogenous spread (32.2%). Stereotactically guided aspiration was the treatment of choice for 74.6% of the patients, whereas 25.4% of the cases were managed through open craniotomy excision. Outcome was favorable in 81.35% (n = 48) of the subjects. General morbidity was 27.1%, and mortality stood at 10.16%. Out of a total 38.98% (n = 23) of complications, two-thirds were due to medical causes. The analysis of variables revealed that only age (p = 0.02), immunosuppression (OR 5.83; p = 0.012) and hematogenous spread (p < 0.01) were associated with poor outcomes. CONCLUSIONS: Immunosuppression, hematogenous spread and advanced age were predictors of poor prognosis. Most of the complications following brain abscess management were not directly related to surgery or surgical technique.

A new classification of complications in neurosurgery.

OBJECTIVE: To define and grade neurosurgical and spinal postoperative complications based on their need for treatment. METHODS: Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery. A four-grade scale was proposed based on the therapy used to treat the complications: grade I, any non-life-threatening complications treated without invasive procedures; grade II, complications requiring invasive management such as surgical, endoscopic, and endovascular procedures; grade III, life-threatening adverse events requiring treatment in an intensive care unit (ICU); and grade IV, deaths as a result of complications. Each grade was classified as a surgical or medical complication. An observational test of this system was conducted between January 2008 and December 2009 in a cohort of 1190 patients at the Hospital Italiano de Buenos Aires. RESULTS: Of 167 complications, 129 (10.84%) were classified as surgical, and 38 (3.19%) were classified as medical complications. Grade I (mild) complications accounted for 31.73%, grade II (moderate) complications accounted for 25.74%, and grade III (severe) complications accounted for 34.13%. The overall mortality rate was 1.17%; 0.84% of deaths were directly related to surgical procedures. CONCLUSIONS: The authors present a simple, practical, and easy to reproduce way to report negative outcomes based on the therapy administered to treat a complication. The main advantages of this classification are the ability to compare surgical results among different centers and times, the ability to compare medical and surgical complications, and the ability to perform future meta-analyses.

Hemangioma capilar medular: Reporte de un caso y revisión de la literatura / Spinal cord capillary hemangioma: Report of a case and bibliographical review

Objective. To describe a rare case of intramedullary capillary haemangioma of the thoracic spinal cord asociated with extensive cord edema and review of the literature. Description. A 65-yeard-old male pacient presented a 4-months history of dorsal back pain, progressive 4/5 paraparesis and sensory abnormality of the lower extremities. MR studies of the thoracic spine show a well-defined intramedullary mass at the D6 level, isointense on T1, hiperintense on T2 and homogeneous, strong enhancement with gadolinium, compatible with vascular lesion, asociated with extensive cord edema from D8-C2. Intervention. A D6-D7 laminectomy was performed and the tumor was completly removed en bloc by using standard microneurosurgical technique. Conclusion. It is very important to know about the existence of intramedullary capillary haemangiomas. Despite of being extremely rare, they are benign vascular neoplasms with a good outcome after their complete resection. Therefore, it´s necessary to distinguish them of other malignant tumors, to avoid overtreatment of these benign lesions.

Subluxación atlanto-axial anterior secundaria a osteoartritis: reporte de un caso / Anterior atlanto-axial subluxation secondary to osteoarthritis: a case report

Objetivo. Describir un caso de subluxación atlantoaxial anterior secundaria a una osteoartritis. Descripción. Un paciente masculino de 60 años de edad con una tetraparesia moderada, rápidamente progresiva, piramidalismo y trastornos sensitivos superficiales y profundos, de cuatro meses de evolución. Las radiografías de columna cervical frente y perfil muestraron una subluxación atlanto-axial anterior. La resonancia magnética mostró un tejido patológico periodontoideo con extensión a articulares y mielomalacia compresiva a nivel C1-C2 a expensas de elementos posteriores por la subluxación. Las radiografías del resto de la columna, manos, rodillas y hombros mostraron cambios degenerativos artrósicos. Se realiza una interconsulta con el servicio de reumatología que, luego del analizar los resultados serológicos, clínicos y radiológicos, arribó al diagnóstico de osteoartritis. Intervención. Consistió en un abordaje posterior, con apertura del foramen magno, laminectomía de C1 y osteosíntesis occipitocervical con la colocación de injertos óseos autólogos. Conclusión. La osteoartritis es una causa infrecuente de subluxación atlantoaxial anterior. Más allá de la patología causal, sabemos que el tratamiento quirúrgico es fundamental en los pacientes sintomáticos.

Objetive. To describe a new case of an anterior atlanto-axial suluxation caused by osteoarthritis. Dewscription. A 60-year-old male patient presented a 4 month history of progressive cuadriparesis, bipyramidalism and deep and superficial hipoestesia. The anterior and lateral radiographs showed an anterior C1-C2 subluxation and the magnetic resonance periodontoidal tissue mass that caused a compressive myelopathy. Intervention. Through a posterior approach, we openned theforamen magnum and performed a C1 laminectomy. After the decompression we performed an occipitocervical arthrodesis with an "Y" plate implant and autologous bone grafts. Conclusion. Osteoarthritis is an unusual cause of anterior atlantoaxial subluxation, that must be treated surgically in symptomatic patients.

Quiste aracnoide espinal: presentacion de un caso / Spinal arachnoidal cyst: case presentation

Objective: to present a case of an extradural arachnoid dorsal cyst in a 30 year-old woman. Description: a patient (30 years, female) who refers eight-months history of radicular pain and progressive right leg weakness, with exacerbations and remissions. On examination the patient had righ hemihypesthesia with T-10 sensitive level and right leg 4/5 palsy. Magnetic resonance imaging showed an extradural cystic lesion in T11-T12 hypointense in T1 and hyperintense en T2, without contrast enhancement. The cyst contained fluid tha demonstrated the same signal as cerebrospinal fluid. Intervention: After laminectomy of T-10 and T-11 the cystic lesion was exposed. The cyst was filled with CSF-fluid like. A surgical resection of the cyst wall was made. A small dural defect that allowed communication between the cyst and the subarachnoid space was revealed during the surgery, and a closure was made with a suture. Histopathological examination confirmed a cystic lesion with a single-cell lining of meningothelial cells, that contained no neural tissue neither ganglion cells. Conclusion: extradural arachnoid cysts showed characteristic images in the MRI in the preoperative stage. There was no need to use other invasive methods such as myelography or mielotomography to decide the indication for surgery or the surgical technique. Definitive diagnosis is based on the free comunication with the subarachnoidal space and the lack of neural tissue in the histopatological examination, which allowed us to distinguish between extradural arachnoid cysts and Tarlov cysts (AU)

Quiste aracnoide espinal: presentacion de un caso / Spinal arachnoidal cyst: case presentation

Objective: to present a case of an extradural arachnoid dorsal cyst in a 30 year-old woman. Description: a patient (30 years, female) who refers eight-months history of radicular pain and progressive right leg weakness, with exacerbations and remissions. On examination the patient had righ hemihypesthesia with T-10 sensitive level and right leg 4/5 palsy. Magnetic resonance imaging showed an extradural cystic lesion in T11-T12 hypointense in T1 and hyperintense en T2, without contrast enhancement. The cyst contained fluid tha demonstrated the same signal as cerebrospinal fluid. Intervention: After laminectomy of T-10 and T-11 the cystic lesion was exposed. The cyst was filled with CSF-fluid like. A surgical resection of the cyst wall was made. A small dural defect that allowed communication between the cyst and the subarachnoid space was revealed during the surgery, and a closure was made with a suture. Histopathological examination confirmed a cystic lesion with a single-cell lining of meningothelial cells, that contained no neural tissue neither ganglion cells. Conclusion: extradural arachnoid cysts showed characteristic images in the MRI in the preoperative stage. There was no need to use other invasive methods such as myelography or mielotomography to decide the indication for surgery or the surgical technique. Definitive diagnosis is based on the free comunication with the subarachnoidal space and the lack of neural tissue in the histopatological examination, which allowed us to distinguish between extradural arachnoid cysts and Tarlov cysts