Does sagittal position of the CTDR-related centre of rotation influence functional outcome? Prospective 2-year follow-up analysis.

PURPOSE: Recent studies describe significant rates of heterotopic ossification (HO) after cervical total disc replacement (CTDR). Little is known about the reasons, and one aspect that requires further in vivo investigation is the biomechanical alteration after CTDR and the role of the implant-related centre of rotation (CORi) in particular. The role of the sagittal position of the CORi on functional outcome in two versions of a semi-constrained disc prosthesis with sagittally different CORi is the topic of this study. METHODS: Patients were candidates for single-level CTDR between C3 and C7 who suffered from CDDD and received a standard or flat version of activ C™ (Aesculap AG, Tuttlingen). Clinical and radiographic assessments were determined preoperatively, intraoperatively, at discharge and again at 6 weeks, 6 months, 1 and 2 years. Radiographic examinations were performed independently using specialized quantitative motion analysis software. RESULTS: Clinical outcome improved significantly regarding NDI as well as VAS on neck and arm pain with no differences in mean improvement by study group. Segmental angle measures show a significantly better lordotic alignment for both groups after surgery, but the degree of correction achieved is higher in the flat group. Correlation analysis proves that the more anterior the CORi is positioned, the higher the lordotic correction is achieved (Pearson rho -0.385). Segmental ROM decreased in the standard group but was maintained for flat implants. At present, our data do not demonstrate a correlation between CORi and ROM at 2 years. Two years after surgery, severe HO grade III-IV was present in 31.6 % standard and 13.1 % flat cases with significant differences. Grouping according to HO severity showed comparable sagittal positions of CORi for flat implants but a more posterior position in the severe HO group for standard implants. CONCLUSIONS: Our results confirm the influence of CORi location on segmental alignment, kinematics and HO for a semi-constrained CTDR, but it also indicates a multifactorial process.

[Cespace. Cervical interbody fusion system. Preliminary retrospective study in 104 cases (120 implants)]. / Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizado. Parte 2: Transferencias nerviosas intraplexuales.

Cespace is a cervical implant designed to obtain intervertebral fusion without bone grafting. The implant is built in titanium and coated with plasmapore (a sort of pure titanium powder). Bone growing through titanium microstructure is induced by the plasmapore, and fusion is progressively obtained once this boneinduction is completed. From January 2002 to December 2008 we operated upon 104 patients employing this implant at one or two cervical spine levels. The more frequent condition was radiculopathy caused by disc herniation or spondilosis (N= 85; 81.7%), followed by mielopathy (N=13; 12.5%). Six cases (5.7%) corresponded to cervical fractures or dislocations. In these latter ones Cespace was implanted as a method of spinal stabilization combined with Caspar plates, avoiding bone grafting. The total number of Cespace implants placed was 120. Clinical results were good in 85.5% of patients. Primary stability was obtained in all cases. Secondary stability (fusion) was evident after 1 to 2 years in all cases, confirming the bone-induction capability of plasmapore without bone grafting. No specific implant complications (pseudoartroses, settling, instability, etc) were registered. We conclude that radical microdiscectomy and Cespace box implant constitutes a good procedure for the treatment of cervical radiculopathy or mielopathy caused by disc herniation or spondylosis, avoiding bone grafting and providing high rates of vertebral fusion. In some cervical fractures associated to instability, Cespace can be used as a reliable substitute of intervertebral bone grafting in combination with anterior plate fixation.

Cespace: sistema de fusión intersomática cervical. Estudio preliminar en 104 casos (120 implantes) / Cespace. Cervical interbody fusion system. Preliminary retrospective study in 104 cases (120 implants)

Cespace es un implante diseñado para conseguir la fusión intervertebral cervical sin injerto óseo. El implante está hecho de titanio y recubierto con plasmapore (polvo de titanio puro). El crecimiento óseo a través de la microestructura de titanio es inducido por el plasmapore, y la fusión se consigue progresivamente una vez que la inducción ósea ha terminado. Desde Enero de 2002 a Diciembre de 2008 operamos a 104 pacientes empleando este implante en uno o dos niveles cervicales tras microdiscectomía radical. La patología más frecuente fue la radiculopatía causada por hernia discal o espondilosis (N= 85; 81.7%), seguida de mielopatía (N=13; 12,5%). Seis casos (5.7%) correspondían a fracturas cervicales o luxaciones. En estos últimos el sistema fue implantado como método de estabilización espinal combinado con placa de Caspar, evitando el injerto óseo. El número total de implantes Cespace fue de 120. Los resultados clínicos fueron buenos en el 85.5% de los pacientes (N=89). La estabilidad primaria se obtuvo en todos los casos. La estabilidad secundaria (fusión) fue evidente después de 1 o 2 años en todos los implantes, confirmando la capacidad del plasmapore para la inducción de hueso sin injerto óseo. No se registraron complicaciones específicas del implante (pseudoartrosis, hundimiento, inestabilidad, etc) en ningún caso. Concluimos que la microdiscectomía radical y el implante con caja Cespace constituye un buen procedimiento para el tratamiento de la radiculopatía o mielopatía causadas por una hernia discal o espondilosis, evitando el injerto óseo y consiguiendo altas tasas de fusión cervical. En algunas fracturas cervicales asociadas a inestabilidad, el sistema Cespace puede ser usado como un sustituto fiable del injerto óseo intervertebral en combinación con placa de fijación anterior (AU)

Cespace is a cervical implant designed to obtain intervertebral fusion without bone grafting. The implant is built in titanium and coated with plasmapore (a sort of pure titanium powder). Bone growing through titanium microstructure is induced by the plasmapore, and fusion is progressively obtained once this boneinduction is completed. From January 2002 to December 2008 we operated upon 104 patients employing this implant at one or two cervical spine levels. The more frequent condition was radiculopathy caused by disc herniation or spondilosis (N= 85; 81.7%), followed by mielopathy (N=13; 12,5%). Six cases (5.7%) corresponded to cervical fractures or dislocations. In these latter ones Cespace was implanted as a method of spinal stabilization combined with Caspar plates, avoiding bone grafting. The total number of Cespace implants placed was 120. Clinical results were good in 85,5% of patients. Primary stability was obtained in all cases. Secondary stability (fusion) was evident after 1 to 2 years in all cases, confirming the bone-induction capability of plasmapore without bone grafting. No specific implant complications (pseudoartroses, settling, instability, etc) were registered. We conclude that radical microdiscectomy and Cespace box implant constitutes a good procedure for the treatment of cervical radiculopathy or mielopathy caused by disc herniation or spondylosis, avoiding bone grafting and providing high rates of vertebral fusion. In some cervical fractures associated to instability, Cespace can be used as a reliable substitute of intervertebral bone grafting in combination with anterior plate fixation (AU)

[Ganglioneuroma coinciding with a lumbar disk herniation]. / Ganglioneuroma coincidente con una extrusión discal lumbar.

INTRODUCTION. Ganglioneuromas or gangliomas are tumours of the sympathetic ganglia that contain cells of the neural crest, so they can appear in all body localizations. They are generally benign, more frequent between 10 and 40 years, may secrete hormones and, sometimes, Neurofibromatosis type I and other genetic disorders can be associated. OBJECTIVE. To review the scientific literature related to the topic and to present a case treated in our service. DISCUSSION. The symptoms depend on location and vasoactive secreted hormones. In spite of that, they are generally benign tumours, although sometimes they can spread out. Since laboratory and image test are of limited usefulness, the conclusive diagnosis is anatomopathologic. In symptomatic patients the best procedure is surgical removing. CONCLUSION. Ganglioneuroma and disk herniation association constitute an exceptional disorder. Its treatment implies surgery resection.

Ganglioneuroma coincidente con una extrusión discal lumbar / Ganglioneuroma coinciding with a lumbar disk herniation

Introducción. Los ganglioneuromas o gangliomas son tumores de los ganglios simpáticos que contienen células de la cresta neural, pudiendo aparecer en cualquier parte del organismo. Son generalmente benignos, más frecuente entre los 10 y los 40 años, pueden secretar hormonas y, en ocasiones, asociarse a trastornos genéticos, como la neurofibromatosis tipo I.Objetivo. Revisar la literatura científica relacionada con el tema y presentar un caso tratado en nuestro servicio.Discusión. La sintomatología de estas lesiones depende de su ubicación y de las sustancias vasoactivas que puedan secretar. A pesar de que son tumores benignos en su mayoría, en ocasiones pueden metastatizar. Las pruebas de imagen y de laboratorio son inespecíficas, por lo que el diagnóstico definitivo es anatomopatológico. En los casos sintomáticos el tratamiento de elección es la resección quirúrgica.Conclusión. La asociación de un ganglioneuroma y de una hernia discal lumbar es algo excepcional. El tratamiento requiere su resección quirúrgica (AU)

Introduction. Ganglioneuromas or gangliomas are tumours of the sympathetic ganglia that contain cells of the neural crest, so they can appear in all body localizations. They are generally benign, more frequent between 10 and 40 years, may secrete hormones and, sometimes, Neurofibromatosis type I and other genetic disorders can be associated. Objective. To review the scientific literature related to the topic and to present a case treated in our service.Discussion. The symptoms depend on location and vasoactive secreted hormones. In spite of that, they are generally benign tumours, although sometimes they can spread out. Since laboratory and image test are of limited usefulness, the conclusive diagnosis is anatomopathologic. In symptomatic patients the best procedure is surgical revoming.Conclusión. Ganglioneuroma and disk herniation association constitute an excepcional disorder. Its treatment implies surgery resection (AU)

[Long-term outcomes of lumbar microdiscectomy in a working class sample]. / Resultados a largo plazo de la microdiscectomía lumbar en una población labo- ralmente activa.

INTRODUCTION: In the treatment of the lumbar disc herniaton (LDH) microdiscectomy constitutes one of the standard procedures. In the present study we have analyzed the clinical outcome of the lumbar microdis- cectomy in a series of worker patients who underwent surgery in our service. METHODS: Retrospective analysis and a 5-year follow up, of a series of 142 patients operated on by means of lumbar microdiscectomy in the 2004-2005 period. The clinical outcome was analyzed according to the "Herron and Turner" outline: pain reduction, use of medical treatment, restriction in the ability to perform physical activities, and return to work. RESULTS: 116 men and 26 women, with an average age of 37.9 and 45.4 years respectively, underwent surgery because of LDH. In the clinical aspect, sciatica was predominant over low back pain in a ratio of three to one. The L5-S1 discal level was operated on in 68.3% of the cases. It was considered that occupational activities gave rise to damage in 107 patients (75.3%). Besides a symptomatic disc, there was an additional injured disc in 44.3% of the cases. An initial unfavourable outcome was seen in 42 patients (33%), 15 of which recovered from in an interval of 3 months, and another fifteen within a one year period. A re-operation was necessa ry in 16 patients because of recurrent lumbar disc herniation (11%). Work reintegration was achieved in 83.3% (119/142) of the cases. After a 5-year follow up, we stated the consistency of the clinical result. DISCUSSION: We analyzed the intervertebral disc behaviour as regards sex, age, variety of discal herniation, additional disc, outcome and re-operation variables. After the analysis of the type of discal herniation and additional disc we defined three disc injury patterns. We consider microdiscectomy as the technique of choosing for the treatment of recurrence disc herniation. CONCLUSIONS: Between the working class, discal injury predominates in young men, as a consequence of the annulus breakage, or an annulus plus posterior longitudinal ligament breakage (traumatic herniae). Frequently it was observed that more than one disc was involved, and a left lateralization.

Resultados a largo plazo de la microdiscectomía lumbar en una población laboralmente activa / Long-term outcomes of lumbar microdiscectomy in a working class sample

Introducción. La microdiscectomía constituye un procedimiento estándar en el tratamiento de la hernia discal lumbar (HDL). En este estudio se ha analizado el resultado clínico de la microdiscectomía lumbar en una muestra de pacientes laboralmente activa, intervenidos en nuestro servicio. Material y métodos. Análisis retrospectivo y seguimiento durante 5 años, de una muestra de 142 pacien- tes intervenidos mediante microdiscectomía lumbar durante el bienio 2004-2005. El resultado clínico se evaluó en base al esquema propuesto por Herron y Turner, que evalúa la reducción del dolor, el uso de fármacos, la restricción de las actividades físicas y el regreso a la vida laboral. Resultados. 116 hombres y 26 mujeres, con edades medias de 37,9 y 45,4 años, respectivamente, fueron intervenidos por HDL. Clínicamente la ciatalgia pre- dominó sobre la lumbalgia en una proporción de 3 a 1. El nivel discal L5-S1 fue intervenido en el 68,3% de los casos. Se consideró el origen del padecimiento como accidente de trabajo en 107 pacientes (75,3%). En el 44,3% de la serie además del disco sintomático, existía un disco adicional afecto. Se apreció una evolu- ción postquirúrgica inicial desfavorable en 42 pacientes (33%), 15 de los cuales se recuperaron en el plazo de 3 meses, y otros quince a lo largo de un año. Fue preciso reintervenir a 16 pacientes por recidiva discal (11%). La reinserción laboral se consiguió en el 83,8% (119/ 142) de los pacientes (..) (AU)

Introduction. In the treatment of the lumbar discherniaton (LDH) microdiscectomy constitutes one ofthe standard procedures. In the present study we haveanalyzed the clinical outcome of the lumbar microdis-cectomy in a series of worker patients who underwentsurgery in our service.Methods. Retrospective analysis and a 5-year followup, of a series of 142 patients operated on by means oflumbar microdiscectomy in the 2004-2005 period. Theclinical outcome was analyzed according to the “Herronand Turner” outline: pain reduction, use of medicaltreatment, restriction in the ability to perform physicalactivities, and return to work.Results. 116 men and 26 women, with an average ageof 37.9 and 45.4 years respectively, underwent surgerybecause of LDH. In the clinical aspect, sciatica waspredominant over low back pain in a ratio of three toone. The L5-S1 discal level was operated on in 68.3% ofthe cases. It was considered that occupational activitiesgave rise to damage in 107 patients (75.3%). Besides asymptomatic disc, there was an additional injured discin 44.3% of the cases. An initial unfavourable outcomewas seen in 42 patients (33%), 15 of which recoveredfrom in an interval of 3 months, and another fifteenwithin a one year period. A re-operation was (..) (AU)

Hernia discal traumática: Implicaciones médico-legales / Traumatic disc herniation. Forensic implications

El origen traumático de la hernia discal es una cuestión relevante en Medicina Legal. El presente trabajo realiza una revisión de las causas de las hernias y protrusiones discales, en especial del papel de los factores mecánicos en su origen. Se concluye que el origen de la hernia discal es multifactorial (genético, bioantropométrico, metabólicos, de entorno), así como que las hernias traumáticas puras son excepcionales, ocurriendo corrientemente sobre discos ya degenerados. Se revisan los signos radiológicos y clínicos de degeneración espinal, así como aquellos que pueden denotar un origen traumático de la hernia. Ante una hernia discal después de un accidente, el perito deberá valorar siempre la posibilidad de un estado anterior, así como el papel del accidente en una eventual descompensación o agravamiento del mismo. Se propone una clasificación de la causalidad tanto para la valoración del grado de la misma como para la modalidad del papel del estado anterior (AU)

Traumatic origin of disc herniation, remains as a relevant Medico-Legal problem. The present paper makes a disc protrusion/herniation revision, mainly about mechanic and traumatic factors involved in their origin. A multifactorial (genetic, bio-antropometric, environnement, metabolic, etc.) causation is concluded to explain etiology of disc herniation. Pure disc herniation (occurring in a healthy non degenerated disc) is considered an exceptional phenomenon. Clinical and radiological spine degeneration sings are revised, along with others that can point to a traumatic origin. Dealing with a disc herniation after an accident, Medical Expert has always to consider the possibility of a precedent disc damage status, assessing the role of a worsening of such antecedent condition in each case. A classification of degree of causation accident-herniation, and antecedent disc damage decompensation are proposed (AU)

Ceguera tras cirugía discal lumbar. Aspectos asistenciales y médico-legales. Presentación de un caso y revisión de la Literatura / Blindness afer limbar diskectomy. Clinical and medico-legal aspects. Case report and literature review

Entre las complicaciones de la cirugía discal lumbar, una, poco frecuente pero especialmente incapacitante es la ceguera. Presentamos un caso de ceguera cortical transitoria tras una microcirugía discal convencional L5-S1 en una paciente sana. Se discuten las posibles causas propuestas por la literatura, y se propone el embolismo gaseoso como origen probable de la ceguera cortical experimentada por la paciente. Al tratarse de una complicación de diagnóstico difícil, pero con cierto grado de posibilidad de prevención, y de tratamiento eficaz, se analizan también los principales problemas médico-legales tanto relativos al análisis de mala praxis como a cuestiones relacionadas con el consentimiento informado (AU)

Between the complications of lumbar disc surgery, one with small frequency but very incapacitating consequences is blindness. We communicate a case of transitory cortical blindness after L5-S1 conventional microdiskectomy. Possible causes described by literature are discussed, proposing the air embolism as a probable origin of cortical blindness in this case. Considering that perioperative blindness it is a complication with difficult diagnosis, but potential preventive measures and treatment can be adopted, medico-legal problems are also analyzed, mainly in negligence expert assessment and informed consent (AU)

[Vertebral reinforcement by means of kyphoplasty in the treatment of non-osteoporotic thoraco-lumbar fractures. Study of 40 cases and review of the literature]. / Papel del refuerzo vertebral mediante cifoplastia en el tratamiento de las fracturas dorsolumbares de índole no osteoporótico. Revisión del tema y análisis de 40 casos.

OBJECT: We present a series of patients with acute thoraco-lumbar fractures in whom we performed balloon vertebroplasty (kyphoplasty), either alone (percutaneous) or combined to posterior transpedicular fusion (open kyphoplasty). We emphasize the possibility of extending the use of kyphoplasty to non-osteoporotic vertebral fractures, and combining this method with traditional posterior fusion procedures. METHODS: Between 2003 and 2005, 138 patients suffering from thoraco-lumbar acute fractures, were treated in our Department. 87 corresponded to one vertebral level fractures; 34 to two levels, and the remaining 17 patients had more than two vertebrae affected. 65 patients (47%) received conservative therapy (rest in bed, physiotherapy, and subsequent progressive mobilization with cast). The remaining ones (73 cases; 43%) were treated invasively, performing balloon vertebroplasty alone (n=25), or kyphoplasty associated to posterior fusion in 15 cases (11%). Different kinds of screw posterior fusions were performed in the remaining patients (n=33; 24%). The latter group was not included in the present study. In the conservatively treated group (CTG), seven patients (11%) had a bad outcome, showing a persistency of hyperintensity in MRI-T2 sequences of the vertebral body, suggesting local edema. Mean hospitalization rate was 29 days in CTG. None of the 40 patients treated with kyphoplasty alone or combined with fusion showed abnormalities in neurological examination. They were classified in two groups: "Group a": Kyphoplasty alone (n=25). Mean of sagittal index in this group was 11 degrees (range: 6 degrees -15 degrees). In 9 patients, vertebral body collapse exceeded 25%. Mean hospitalization rate was 14 days. "Group b": Kyphoplasty and posterior fusion techniques (n=15): Mean sagittal index was 23 degrees (range: 13 degrees - 40 degrees). All the patients presented with a vertebral body collapse superior to 25%. All of them had posterior body wall involvement. This group was treated by surgery (decompression and fusion) and open vertebral body kyphoplasty. Mean hospitalization rate was 35 days. Clinical results of these 40 patients were measured by means of work status, restriction of physical activities and analgesic drug intake. Except for four patients of "Group b", 36 returned to their work. In 11 cases a slight reduction of physical activity was registered. Average "Group a" follow-up was 47 months (range: 10-72 months). A mean kyphosis correction of 5,3 degrees (sagittal index) was reached in this group. Average "Group b" follow-up was 26 months (range: 9-54). Mean kyphosis correction was 10,3 degrees . As for complications, we registered three balloon disruptions and five leakages into the disc. CONCLUSIONS: Kyphoplasty could constitute an alternative and/or complementary treatment of traditional spinal stabilization-fusion procedures in non osteoporotic vertebral fractures. Therefore, it should be offered, when indicated, as a substantial possible part of the treatment, to the patients suffering from vertebral fractures. Additional advantages of combining kyphoplasty and posterior fusion are the possibility of reducing the number of fused levels (shorter instrumentations), and to perform a 360 degree stabilization-remodeling through a single posterior approach.

Papel del refuerzo vertebral mediante cifoplastia en el tratamiento de las fracturasdorsolumbares de índole no osteoporótico. Revisión del tema y análisis de 40 casos / Vertebral reinforcement by means of kyphoplasty in the treatment of non-osteoporotic thoraco-lumbar fractures. Study of 40 cases and review of the literature

Objetivo. Presentamos una serie de pacientes confracturas toraco-lumbares agudas en los que se hapracticado un refuerzo vertebral mediante cifoplastia,bien de forma aislada (cifoplastia percutánea) biencombinada con una fijación transpedicular posterior(cifoplastia abierta). Analizamos la posibilidad deampliar el uso de la cifoplastia a las fracturas vertebralesde causa no osteoporótica, así como combinarla a losmétodos tradicionales de fusión posterior.Método. En nuestro servicio, entre los años 2003 y2005, se trataron 138 pacientes afectos de una fracturaaguda toraco-lumbar. En 87 casos se apreció una fracturaa un nivel; en 34 a 2 niveles y, en los 17 restantesen más de dos. Un tratamiento conservador (reposo encama, fisioterapia y movilización progresiva con corsé),fue realizado en 65 pacientes (47%). Los 73 pacientesrestantes fueron tratados quirúrgicamente, realizándoseun refuerzo mediante cifoplastia percutánea en25 casos (18%), ó una cifoplastia asociada a fusiónvertebral posterior en otros 15 (11%). Diferentes modalidadesde fijaciones atornilladas se realizaron en los 33pacientes restantes (24%). Este último grupo no ha sidoobjeto del presente estudio.La estancia media hospitalaria de los pacientes tratadosconservadoramente fue de 29 días. Siete de ellos(11%) experimentaron una mala evolución, mostrandoen las secuencias T2 del control de resonancia magnéticauna persistencia de hiperintensidad en el somavertebral, sugerente de edema local.Todos los pacientes que fueron tratados mediantecifoplastia aislada (percutánea) o combinada (abierta)mantenían una integridad neurológica; fueron clasificadosen dos grupos:• "Grupo a": Tratados mediante cifoplastia percutánea(n=25). El índice medio sagital de este grupo fue de11° (6°-15°). En 9 pacientes, el acuñamiento vertebralsuperaba el 25%. La estancia media hospitalaria(..) (AU)

Object. We present a series of patients with acutethoraco-lumbar fractures in whom we performedballoon vertebroplasty (kyphoplasty), either alone(percutaneous) or combined to posterior transpedicularfusion (open kyphoplasty). We emphasize the possibilityof extending the use of kyphoplasty to non-osteoporoticvertebral fractures, and combining this method withtraditional posterior fusion procedures.Methods. Between 2003 and 2005, 138 patients sufferingfrom thoraco-lumbar acute fractures, were treatedin our Department. 87 corresponded to one vertebrallevel fractures; 34 to two levels, and the remaining17 patients had more than two vertebrae affected. 65patients (47%) received conservative therapy (restin bed, physiotherapy, and subsequent progressivemobilization with cast). The remaining ones (73 cases;43%) were treated invasively, performing balloon vertebroplastyalone (n=25), or kyphoplasty associated toposterior fusion in 15 cases (11%). Different kinds ofscrew posterior fusions were performed in the remaninigpacients (n=33; 24%). The latter group was notincluded in the present study.In the conservatively treated group (CTG), sevenpatients (11%) had a bad outcome, showing a persistencyof hyperintensity in MRI-T2 sequences of thevertebral body, suggesting local edema. Mean hospitalizationrate was 29 days in CTG.None of the 40 patients treated with kyphoplasty aloneor combined with fusion showed abnormalities inneurological examination. They were classified in twogroups:• "Group a": Kyphoplasty alone (n=25). Mean ofsagital index in this group was 11° (range: 6°-15°).In 9 patients, vertebral body collapse exceeded25%. Mean hospitalization rate was 14 days.• "Group b": Kyphoplasty and posterior fusiontechniques (n=15): Mean sagital index was 23°(range: 13°- 40° ). All the patients presented witha vertebral body collapse superior to 25%. (..) (AU)

Virtopsia. Aplicaciones de un nuevo método de inspección corporal no invasiva en ciencias forenses / Virtopsy. Applications of a new method of non-invasive body inspection in forensic sciences

Los modernos métodos de imagen, como la CT y la RNM proporcionan datos reales y tridimensionales de la superficie y las estructuras internas corporales. Esta información se almacena en ficheros DICOM (un protocolo estándar en adquisición de imagen radiológica). Sobre esos ficheros pueden realizarse muchos procedimientos de análisis de imagen, tales como visualización interactiva, morfometría, reconstrucciones tridimensionales, etc. Estas tareas son realizadas de una manera no invasiva y no destructiva, pudiéndose almacenar los resultados para documentación del caso. El presente trabajo describe las bases de los procedimientos de análisis de imagen sobre ficheros DICOM dirigidos a propósitos forenses (la llamada "virtopsia"), enfatizando la utilidad del método en Patología, Traumatología Forense y otros campos. La "virtopsia" debe ser considerada no sólo como un procedimientos post-mortem (complementando pero no sustituyendo a la autopsia tradicional), sino como un modo de examinar partes corporales de una manera interactiva, sea en el fallecido o en el sujeto vivo. Ello amplia su utilidad y hace apropiado el procedimiento siempre que se requiera un examen anatómico forense reproducible, preciso, interactivo y en tiempo real

Modern imaging methods, such as radiological CT/MRI scanning provides real, full 3D data of the body surface and internal structures. This information is stored in DICOM files (a standard protocol in radiology image acquisition). Many image-analysis procedures, such as interactive visualization, morphometry, densitometry, three dimensional reconstruction, etc., can be carried-out on these files. These tasks are performed in a non-invasive and non-destructive manner, and the results can be stored in order to document the case. The present paper describes the basis of imageanalysis procedures on DICOM files directed to forensic purposes (socalled "virtopsy"), emphasizing the utility of the method in Pathology, Forensic Traumatology and other fields. The virtopsy must be considered not only as a postmortem procedure (complementing but not substituting the traditional autopsy), but a way to examine body parts in an interactive manner, whatever the subject is dead or alive. That spreads its utility and makes the method appropriate whenever an accurate, real-time, interactive and reproducible forensic anatomic examination is required

Ferrum metabolism after permanence at extreme altitude on Mount Everest.

High altitude has always intrigued physiologists because of the remarkable ability of man to adapt to the hostile environment. Despite numerous studies examining the physiological alterations occurring during exercise after exposure to hypoxia and the adaptative effects of sustained residence at altitude, several issues remain unresolved. The aim of investigation of the Spanish Medical Research Expedition to Mount Everest in 1992 was an extensive study on the physiological adaptations to the hypobaric environment at extreme altitude. We are presenting advance results the gasometry, acid-base parameters and ferrum metabolism.

[Endovesical antireflux plastic surgery. Original technique]. / Plastie antireflux par voie endovésicale. Technique originale.

The authors present a technique of endovesical transposition of the urethra with orthotopic reimplantation of latter. This very effective technique is simple. In addition, it allows secondary catheterization and reduces post-operative complications.

Epidural neurostimulation in the treatment of frostbite.

Epidural spinal cord stimulation (SCS) and conventional treatment produced good therapeutic effects in four young patients with frostbite of the lower limbs. The mechanism of action is unknown but the treatment resulted in rapid recovery with reduced pain and a more peripheral level of amputation. These preliminary results warrant further studies of SCS in the treatment of frostbite.