History and evolution of surgical treatment for spasticity: a journey from neurotomy to selective dorsal rhizotomy.

The evolution of neurosurgical approaches to spasticity spans centuries, marked by key milestones and innovative practitioners. Probable ancient descriptions of spasmodic conditions were first classified as spasticity in the 19th century through the interventions of Dr. William John Little on patients with cerebral palsy. The late 19th century witnessed pioneering efforts by surgeons such as Dr. Charles Loomis Dana, who explored neurotomies, and Dr. Charles Sherrington, who proposed dorsal rhizotomy to address spasticity. Dorsal rhizotomy rose to prominence under the expertise of Dr. Otfrid Foerster but saw a decline in the 1920s due to emerging alternative procedures and associated complications. The mid-20th century saw a shift toward myelotomy but the revival of dorsal rhizotomy under Dr. Claude Gros' selective approach and Dr. Marc Sindou's dorsal root entry zone (DREZ) lesioning. In the late 1970s, Dr. Victor Fasano introduced functional dorsal rhizotomy, incorporating electrophysiological evaluations. Dr. Warwick Peacock and Dr. Leila Arens further modified selective dorsal rhizotomy, focusing on approaches at the cauda equina level. Later, baclofen delivered intrathecally via an implanted programmable pump emerged as a promising alternative around the late 1980s, pioneered by Richard Penn and Jeffrey Kroin and then led by A. Leland Albright. Moreover, intraventricular baclofen has also been tried in this matter. The evolution of these neurosurgical interventions highlights the dynamic nature of medical progress, with each era building upon and refining the work of significant individuals, ultimately contributing to successful outcomes in the management of spasticity.

Signaling Pathways in the Relapse of Glioblastoma.

BACKGROUND: Glioblastoma is the most common primary neoplasm of the central nervous system. Standard treatment includes surgery with maximum safe resection and radiotherapy plus concomitant and adjuvant chemotherapy; however, almost invariably, tumor relapse occurs. We aimed to describe signaling pathways and molecular mechanisms present in tumor relapse of glioblastoma. METHODS: This systematic review followed the PRISMA guidelines. We searched the PubMed, EMBASE and Web of Science databases. We included studies that enrolled patients 15 years or older with a diagnosis of glioblastoma according to Louis criteria and focused on signaling pathways and molecular mechanisms present in tumor relapse of glioblastoma. The outcome of interest was progression-free survival. RESULTS: We identified 1470 articles; 31 met the inclusion criteria. From each publication, we obtained the associated markers O-6-methylguanine-DNA methyltransferase, isocitrate dehydrogenase, mRNA, epidermal growth factor receptor (EGFR), p53, and others. All publications were evaluated with the Q-Genie checklist tool for quality assessment. CONCLUSIONS: We identified a wide variety of signaling pathways and molecular processes that are involved in glioblastoma relapse. This diversity would explain intra- and intertumor heterogeneity, treatment evasion, and relapse. However, only a few molecular processes have robust evidence for clinical utility.

A Case Series of Stereotactic Biopsy of Brainstem Lesions through the Transfrontal Approach.

Background and Importance Brainstem lesions may be unresectable or unapproachable. Regardless, the histopathological diagnosis is fundamental to determine the most appropriate treatment. We present our experience with transfrontal stereotactic biopsy technique for brainstem lesions as a safe and effective surgical route even when contralateral transhemispheric approach is required for preservation of eloquent tissue. Clinical Presentation Twenty-five patients underwent surgery by transfrontal approach. Medical records were reviewed for establishing the number of patients who had postoperative histopathological diagnosis and postoperative complications. Twenty-four patients (18 adults and 7 children) had histopathological diagnosis. There were 18 astrocytomas documented, of which 12 were high grade and 6 low grade. The other diagnoses included viral encephalitis, post-renal transplant lymphoproliferative disorder, nonspecific chronic inflammation, Langerhans cell histiocytosis, and two metastases. No case was hindered by cerebrospinal fluid loss or ventricular entry. Complications included a case of mesencephalic hemorrhage with upper limb monoparesis and a case of a partially compromised third cranial nerve in another patient without associated bleeding. Conclusion Stereotactic biopsy of brainstem lesions by transfrontal ipsilateral or transfrontal transhemispheric contralateral approaches is a safe and effective surgical approach in achieving a histopathological diagnosis in both pediatric and adult populations.

Deep Brain Stimulation for Severe and Intractable Aggressive Behavior.

Aggressive behavior in patients with intellectual disability can be resistant to pharmacological treatment and have detrimental consequences to themselves, family members, and caregivers. Hypothalamic deep brain stimulation (DBS) has been used to improve this type of behavior in severe and refractory cases. Here, we present the description and analysis of DBS of the posteromedial hypothalamus (PMH) and its long-term impact as treatment to improve severe and refractory aggressive behaviors, even with previous bilateral hypothalamotomy without improvement in patients with intellectual disability. Eleven patients underwent bilateral DBS of the PMH. Their medical records were reviewed, and the impact on behavior was measured using preoperative and postoperative Modified Overt Aggression Scale (MOAS) during the last follow-up medical visit. Nine of 11 patients presented a significant decrease in the severity of aggressive behavior, with a preoperative and postoperative MOAS average value of 50.5 and 18.7, respectively. An overall improvement of 63% was seen with a mean follow-up time of 4 years. A patient who previously underwent a bilateral hypothalamotomy via radiofrequency was included in this group. During follow-up, 3 patients presented deterioration of symptoms subsequent to pulse generator depletion but made a full clinical recovery after battery replacement. We posit that DBS of the PMH may be a safe and effective in improving severe and refractory aggressive behavior in patients with long-term intellectual disability.

[Process of transformation toward integrated health networks in Peru]. / Proceso de transformación hacia las redes integradas de salud en el Perú.

Peru's Ministry of Health focuses on achieving the fourfold goal for its health system: seeking to improve the health of the population, a better user experience when using health services, better use of public resources being invested during the last decade, and better job satisfaction for healthcare workers. The enactment of Law 30885 on Integrated Health Networks marks a milestone in the country's effort to meet the care needs of citizens in a network and is the health sector´s proposal to improve the performance of the healthcare system. To this end, key elements for organization and functioning are proposed: identification of the population and families, assignment of liability for care, strengthening of the entry gates to the health system, stratification of individual and family risks, coordination to facilitate access to and use of health services, continuity and complementarity of care, and network governance. This new proposal involves adjustments to the health service network: 12- and 24-hour health facilities (family clinics) for individual care, family care, management of health determinants, and hospitals to supplement care. The model of care will be more complex and difficult to advance if it is not linked to adjustments in the financing, coverage, and management of the cultural change of workers and users of the system, and the health governance system.

El Ministerio de Salud del Perú se enfoca en el logro de la cuádruple meta para su sistema sanitario; buscando mejorar la salud de la población, una mejor experiencia del usuario cuando utiliza los servicios sanitarios, mejor uso de los recursos públicos que se vienen inyectando en la última década y una mejor satisfacción laboral de los trabajadores de salud. La promulgación de la Ley 30885 de Redes Integradas de Salud, marca un hito en el esfuerzo del país de lograr resolver las necesidades de atención de los ciudadanos en una red y es la apuesta del sector salud para mejorar el desempeño del sistema sanitario. Para ello se plantean elementos clave para la organización y funcionamiento: Identificación de población y familias, asignación de responsabilidad del cuidado, fortalecimiento de las puertas de entrada al sistema de salud, estratificación de riesgos individuales y familiares, coordinación para facilitar el acceso y utilización de servicios de salud, continuidad y complementariedad del cuidado, y gobernanza en la red. Esta nueva propuesta política implica ajustes en la red de servicios de salud: establecimientos de salud (clínicas de familia) de 12 y 24 horas para el cuidado individual, familiar, manejo de los determinantes de la salud y hospitales para complementar el cuidado. El modelo de cuidado será más complejo y de avance difícil si no está unido a ajustes en el financiamiento, aseguramiento y en la gestión del cambio cultural de los trabajadores, usuarios del sistema y del sistema de gobernanza en salud.

Proceso de transformación hacia las redes integradas de salud en el Perú / Process of transformation toward integrated health networks in Peru

RESUMEN El Ministerio de Salud del Perú se enfoca en el logro de la cuádruple meta para su sistema sanitario; buscando mejorar la salud de la población, una mejor experiencia del usuario cuando utiliza los servicios sanitarios, mejor uso de los recursos públicos que se vienen inyectando en la última década y una mejor satisfacción laboral de los trabajadores de salud. La promulgación de la Ley 30885 de Redes Integradas de Salud, marca un hito en el esfuerzo del país de lograr resolver las necesidades de atención de los ciudadanos en una red y es la apuesta del sector salud para mejorar el desempeño del sistema sanitario. Para ello se plantean elementos clave para la organización y funcionamiento: Identificación de población y familias, asignación de responsabilidad del cuidado, fortalecimiento de las puertas de entrada al sistema de salud, estratificación de riesgos individuales y familiares, coordinación para facilitar el acceso y utilización de servicios de salud, continuidad y complementariedad del cuidado, y gobernanza en la red. Esta nueva propuesta política implica ajustes en la red de servicios de salud: establecimientos de salud (clínicas de familia) de 12 y 24 horas para el cuidado individual, familiar, manejo de los determinantes de la salud y hospitales para complementar el cuidado. El modelo de cuidado será más complejo y de avance difícil si no está unido a ajustes en el financiamiento, aseguramiento y en la gestión del cambio cultural de los trabajadores, usuarios del sistema y del sistema de gobernanza en salud.

ABSTRACT Peru's Ministry of Health focuses on achieving the fourfold goal for its health system: seeking to improve the health of the population, a better user experience when using health services, better use of public resources being invested during the last decade, and better job satisfaction for healthcare workers. The enactment of Law 30885 on Integrated Health Networks marks a milestone in the country's effort to meet the care needs of citizens in a network and is the health sector´s proposal to improve the performance of the healthcare system. To this end, key elements for organization and functioning are proposed: identification of the population and families, assignment of liability for care, strengthening of the entry gates to the health system, stratification of individual and family risks, coordination to facilitate access to and use of health services, continuity and complementarity of care, and network governance. This new proposal involves adjustments to the health service network: 12- and 24-hour health facilities (family clinics) for individual care, family care, management of health determinants, and hospitals to supplement care. The model of care will be more complex and difficult to advance if it is not linked to adjustments in the financing, coverage, and management of the cultural change of workers and users of the system, and the health governance system.

Functional neurosurgery for secondary dystonia: indications and long-term results.

Dystonia is a movement disorder characterized by patterned, repetitive, phasic, or tonic sustained muscle contractions that produce abnormal, often twisting, postures or repetitive movements. When the disorder is genetic or the cause is unknown and dystonia is the sole feature, the disease is called primary or idiopathic, conversely secondary dystonia (SD) may be caused by various brain insults. Both primary dystonia and SD have been notorious for their poor response to medical treatment. Today, stereotactic neurosurgical procedures are offered to improve the disability and quality of life of patients who do not respond to medical therapy. However, SD shows less and more variable results than primary dystonia to neurosurgical procedures, the benefits of ablative or deep brain stimulation (DBS) procedures in basal structures being still subject to debate and much harder to fully appreciate. In this work, the authors show a 33-patient series with secondary dystonia, separating the statistic and clinical analysis into several etiology groups: perinatal insults, tardive syndromes, genetic syndromes, and posttraumatic. In these groups, we show the mean BFM score improvement in the different patient series, comparing our results with world literature, and finally propose a classification system for bettering the clinical approach in surgery decision when this is indicated.

Pseudoquiste pancreático complicado. reporte de un caso y revisión de la literatura / Complicated pancreatic pseudocyst: report of one case and literature review

Se presenta un caso de seudoquiste pancreático complicado (hemorragia intraquística), siete meses después de un episodio de pancreatitis aguda aparentemente resuelta, el cual fue drenado quirúrgicamente por medio de una cistogastrostomía interna con muy buenos resultados. Se hace una revisión de las características clínicas, radiológicas y modalidades terapéuticas de esta patología que ha cobrado mayor importancia debido al estudio radiológico cada vez utilizado en el diagnóstico de patología pancreática.

[COMPLICATED PANCREATIC PSEUDOCYST: REPORT OF ONE CASE AND LITERATURE REVIEW] / Pseudoquiste Pancreático Complicado. Reporte de un caso y revisión de la literatura.

We reported a complicated pancreatic pseudocyst (intracystic hemorrhage) seven months after an acute pancreatitis attack. A surgical drainage (internal cystogastrostomy) was carried out with excellent resolution. The clinical, radiological and therapeutic features of pancreatic pseudocysts are reviewed.

La cirugía temprana en colecistitis aguda: 1975-1984 / The early surgery in acute cholecystitis: 1975-1984

Se presenta 281 pacientes con diagnóstico de colecistitis aguda que fueron operados tempranamente en el curso de una hospitalización. El diagnóstico clínico fue confirmado por colangiografía médica en los primeros años y por ecosonografía en los últimos. Los pacientes fueron intervenidos entre las 24 y 72 horas y se practicó la colecistectomía en el 97.6% reservándose la colecistostomía (2.4) para los pacientes de muy alto riesgo. La mortalidad operatoria fue del 5% especialmente en los enfermos mayores de 60 años, siendo la causa mas frecuente la sepsis no controlada. En el 55% de los casos los hallazgos operatorios evidenciaron colecistitis complicada con empiema, gangrena y perforación libre o localizada. El tiempo de preparación y evolución pre-operatoria fue de 3 días y el post-operatorio de 13 días

Nueva alternativa quirúrgica para el manejo del traumatismo hepático no penetrante taponamiento hepático cerrado prolongado THCP / New alternative in the surgical management of hepatic trauma with prolonged closed gauze pack non-penetrating

La incidencia de las lesiones hepáticas por trumatismos cerrados en la vida civil, continúa incrementandose en los últimos años. En otras manos, resección masiva del hígado reportó una mortalidae de 10-20%. Diferentes técnicas quirúrgicas para resolver este problema han sido recomendadas para controlar la hemorragia, desde el tradicional desacreditado taponamiento de gasa exteriorizada (MIkulicz) hasta la resección hepática estandarizada, conc la mencionada mortalidad y elavada morbilidad. Desde 1975 al presente, en el Hospital Universitario Cayaetano Heredia nosostros hemos usado en 22 pacientes consecutivos con lesión masiva del hígado debido a traumatismo cerrado, la aplicación de lo que llamamos un "taponamaaiento con gasa cerrado prolongado" del hígado sin mortalidad. 9% de los pacientes tuvieron en el área perihepática, que fue drenado al tiempo de extraer las gasas a los 8-10 días. Considerando lo simple del procedimiento y los excelentes resultados, lo recomendamos como una buena alternativa en el manejo del tratamiento quirúrgico de lesiones hepáticas severas

Nueva alternativa quirúrgica para el manejo del traumatismo hepático no penetrante. Taponamiento hepático cerrado prolongado THCP. / Management of non penetrating hepatic trauma. A new surgical alternative using the prolonged close packing.

La incidencia de las lesiones hepáticas por traumatismos cerrados en la vida civil, continua incrementandose en los últimos años. En otra mano, resección masiva del hígado reportó una mortalidad de 10-20%. Diferentes técnicas quirúrgicas para resolver este problema han sido recomendadas para controlar la hemorragia, desde el tradicional desacreditado taponamiento de grasa exteriorizada (Mikulicz) hasta la resección hepática estandarizada, con la mencionada mortalidad y elevada morbilidad. Desde 1975 al presente, en el Hospital Cayetano Heredia nosotros hemos usado en 22 pacientes consecutivos con lesión masivadel hígado debido a traumatismo cerrado, la aplicación de lo que llamamos un "taponamiento con grasa cerrado prolongado" del hígado, sin mortalidad. 9% de los pacientes tuvieron colección con el área perihepática, que fue drenado al tiempo de extraer las grasas a los 8-10 días. Considerando lo simple del procedimiento y los excelentes resultados, lo recomendamos como una buena alternativa en el manejo del tratamiento quirúrgico de lesiones hepáticas severas.