Cervical dorsal rhizotomy for upper limbs spasticity. Case report.

Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.

Aggressive vertebral hemangiomas in asymptomatic patients: A review.

BACKGROUND: Hemangioma is the most common benign tumor of the spine. Most patients are asymptomatic, but some lesions can become aggressive, leading to spinal compression. Here, we reviewed the natural history and treatment of aggressive hemangiomas in asymptomatic patients. METHODS: An electronic review of the literature was performed regarding the diagnosis/treatment modalities for asymptomatic aggressive hemangiomas of the spine utilizing the Medline (PubMed) and Google Scholar databases. RESULTS: We selected four articles describing the diagnosis/management of four cases of aggressive, asymptomatic hemangiomas in patients averaging 11.25 ± 2.36 years of age. Three of the four patients were females, and all were followed an average of 36.5 ± 25 months. Notably, two of four patients required emergency surgery. CONCLUSION: There is a paucity of the literature regarding the diagnosis and optimal therapeutic management of aggressive hemangiomas in asymptomatic patients, half of whom may present with acute neurological deterioration warranting emergency surgery.

Chiari malformation and types of basilar invagination with/without syringomyelia.

BACKGROUND: Craniometric studies document different subtypes of craniocervical junction malformations (CCJM). Here, we identified the different types and global signs and symptoms (SS) that correlated with these malformations while further evaluating the impact of syringomyelia. METHODS: Prospective data concerning SS and types of CCJM were evaluated in 89 patients between September 2002 and April 2014 using Bindal's scale. RESULTS: The mean Bindal's scores of each type of CCJM were Chiari malformation (CM) = 74.6, basilar invagination Type 1 (BI1) = 78.5, and BI Type 2 (BI2) = 78. Swallowing impairment and nystagmus were more frequently present in the BI patients. Symptomatic burdens were higher in patients with syringomyelia and included weakness, extremity numbness, neck pain, dissociated sensory loss, and atrophy. CONCLUSION: There were no statistically significant differences in SS between the different CCJM types. BI patients had more swallowing and nystagmus complaints versus CM patients, but there were no significant differences in clinical SS between BI1 and BI2 patients. Notably, those with attendant syringomyelia had a higher SS burden.

Symptomatic foramen of Magendie arachnoid cyst in an elderly patient: The second case report in the literature.

BACKGROUND: Arachnoid cysts are benign extra-axial lesions corresponding to 1% of intracranial expansive lesions. They are usually incidental findings in asymptomatic patients. Most cases are congenital, and when symptomatic are diagnosed in childhood or adolescence. Symptomatic arachnoids cyst in elderly patients is very rare. This report documents the second case in the literature of a symptomatic elderly patient with an arachnoid cyst located in the foramen of Magendie. CASE DESCRIPTION: A 68-year-old male had weakness in the lower limbs, imbalance, and gait disturbance for 3 years, associated with frequent falls. The patient complained of paresthesia in the upper right limb and right hemiface. An magnetic resonance imaging showed a massive cystic lesion in the posterior fossa in the foramen of Magendie. A median suboccipital craniectomy was performed, and the cyst was removed. CONCLUSION: This case report adds to the literature the second case of a patient with a symptomatic arachnoid cyst in the posterior fossa successfully treated by surgery.

Neuroendoscopia / Neuroendoscopy

O procedimento endoscópico tem sido bastante utilizado na neurocirurgia para tratamento de várias patologias. Atualmente, vários procedimentos são realizados de forma mais simples com melhores resultados para o paciente. Os autores deste artigo fazem uma revisão do tratamento neuroendoscópico para as hidrocefalias, tumores intraventriculares e os cistos de aracnoide...

Clinical complications in patients with severe cervical spinal trauma: a ten-year prospective study.

OBJECTIVE: To determine the complications due to severe acrescentar sigla após o nome (CST). METHODS: Between 1997 and 2006, 217 patients (191 men and 26 women) were prospectively evaluated. The mean age was 36.75±1.06 years. RESULTS: Forty-five percent of the patients had medical complications. The most important risk factor was alcoholic beverage use. The most important associated injury was head trauma (HT). Patients with American Spine Injury Association (ASIA) A or B had a 2.3-fold greater relative risk of developing complications. Thirty-three patients (15.2%) died. Patients with neurological deficit had a 16.9-fold higher risk of death. There was no influence of age and time between trauma and surgery on the presence of complications. CONCLUSIONS: Of the patients, 45% had clinical complications and 7.5% had associated injuries; pneumonia was the most important complication; patient age and time between trauma and surgery did not influence the development of medical complications; neurological status was the most important factor in determining morbidity and mortality.

Clinical complications in patients with severe cervical spinal trauma: a ten-year prospective study / Complicações clínicas em pacientes com trauma raquimedular cervical grave: estudo prospectivo de dez anos

OBJECTIVE: To determine the complications due to severe acrescentar sigla após o nome (CST). METHODS: Between 1997 and 2006, 217 patients (191 men and 26 women) were prospectively evaluated. The mean age was 36.75±1.06 years. RESULTS: Forty-five percent of the patients had medical complications. The most important risk factor was alcoholic beverage use. The most important associated injury was head trauma (HT). Patients with American Spine Injury Association (ASIA) A or B had a 2.3-fold greater relative risk of developing complications. Thirty-three patients (15.2%) died. Patients with neurological deficit had a 16.9-fold higher risk of death. There was no influence of age and time between trauma and surgery on the presence of complications. CONCLUSIONS: Of the patients, 45% had clinical complications and 7.5% had associated injuries; pneumonia was the most important complication; patient age and time between trauma and surgery did not influence the development of medical complications; neurological status was the most important factor in determining morbidity and mortality.

OBJETIVO: Identificar complicações decorrentes do trauma raquimedular cervical grave. MÉTODOS: Avaliação prospectiva de 217 pacientes (191 homens e 26 mulheres) entre 1997 e 2006, com média de idade de 36,75±1,06 anos. RESULTADOS: Houve complicações em 45% dos pacientes. O fator de risco mais importante foi ingestão de bebida alcoólica. Trauma craniano foi a associação mais frequente. Pacientes com classificação A ou B da American Spine Injury Association (ASIA) tiveram 2,3 vezes maior chance de complicações. Faleceram 33 pacientes (15,2%), sendo a chance de óbito 16,9 vezes maior naqueles com déficit neurológico. Não houve influência da idade ou do tempo decorrido entre o trauma e a cirurgia. CONCLUSÕES: Dos pacientes, 45% apresentaram complicações e 7,5% apresentaram traumas associados; pneumonia foi a principal complicação clínica; a idade dos pacientes e o tempo entre o trauma e a cirurgia não influenciaram na frequência de complicações; o status neurológico após o trauma foi o fator de risco mais importante na determinação de morbidade e mortalidade.

Epidemiology of severe cervical spinal trauma in the north area of São Paulo City: a 10-year prospective study. Clinical article.

OBJECT: The main objective was to study the epidemiological data obtained in patients with cervical spinal trauma (CST) in the north area of São Paulo City between 1997 and 2006. METHODS: All patients with severe CST in the north area of São Paulo City were studied. The data analyzed were age, sex, incidence, causes of trauma, level of trauma, morbidity, deaths, and complications. Analytical tests were performed to study risks of trauma and complications. The chi-square and analysis of variance tests were used for analytical data (significance level p < 0.05). RESULTS: The study population consisted of 217 patients who were hospitalized for CST. The average incidence rate was 21.6 cases annually or 1.8 cases monthly. The mean patient age was 36.75 years. The 20-40-year-old age bracket was found to be most highly represented, corresponding to 52.6% of total patients. Patients were predominantly male; 191 patients (88.01%) were male compared with only 26 female patients (11.99%). The ratio of men to women was 7.35:1. Injuries in the craniocervical region corresponded to 43 (19.8%) of the cases; injuries in the cervical subaxial region corresponded to 174 (80.2%) of the cases and were associated with worse neurological lesions. Additionally, 40.6% of patients presented with complications in other organs and systems; several patients presented with multiple complications, and 33 patients (15.02%) died. During the hospitalization period, 4 patients presenting as Grade A on the American Spinal Injury Association (ASIA) Scale evolved to Grade C, 1 patient presenting as ASIA Grade A evolved to Grade B, and 2 patients evolved to Grade E. Two patients who had been admitted without neurological lesions evolved to ASIA Grade C (1 patient postsurgery and 1 patient post-traction). Two patients presenting initially as ASIA Grade E evolved to Grade D, and another to central cord syndrome. On average, patients with incomplete lesions improved 1 grade in ASIA classification during hospitalization. CONCLUSIONS: Data from severe CST observed in the current study suggest many differences in the characteristics described in the majority of published epidemiological studies and those found in patients in the north area of São Paulo City. It is likely that these differences reflect the urban and cultural habits and behaviors of the population specific to this area.

Tumores de hipófise: considerações sobre 120 casos e revisão de literatura / Pituitary tumors: considerations about 120 cases and literature review

Objetivo: Estudo retrospectivo dos pacientes com adenoma hipofisário atendidos no Serviço de Neurocirurgia do Conjunto Hospitalar do Mandaqui de São Paulo, SP. Pacientes e métodos: Foram estudados, retrospectivamente, 120 casos de tumores de hipófise atendidos entre janeiro de 1993 e maio de 2006. Os dados analisados foram idade, sexo, queixa principal, apresentação clínica, classificação radiológica, tipo histológico e complicações. Resultados: A idade dos pacientes variou de 5 a 69 anos (média de 40,2 anos). Foram 89 pacientes do sexo feminino e 31 do sexo masculino. O déficit visual foi a queixa principal e presente em 52% dos pacientes. Com relação à classificação radiológica: 5,4%foram classificados como Hardy II; 8,1% como Hardy III; 86,5% como Hardy IV. A via de acesso foi transesfenoidal sublabial em 113 pacientes. Apenas três pacientes necessitaram reabordagem do tumor por craniotomia e sete pacientes foram submetidos à craniotomia sem tentativa transesfenoidal.Os tumores foram diagnosticados como não-secretores em 21,6% dos pacientes, prolactinomas em70,2% dos pacientes, secretor de GH em 5,4% e de ACTH e LH em 2,7% cada um. As principais complicações do tratamento cirúrgico foram diabetes insípido e fístula liquórica. Houve quatro óbitos no pós-operatório. Conclusões: A média etária foi de 40,2 anos; o sexo feminino foi mais acometido;a perda visual foi a principal queixa; a maioria dos pacientes se apresentou em grau IV da classificação de Hardy; o principal tipo histológico foi o prolactinoma; a via transesfenoidal sublabial foi suficiente para a maioria dos tumores.

Objective: Retrospective study of 120 cases of pituitary adenomas treated at Serviço de Neurocirurgiado Conjunto Hospitalar do Mandaqui de São Paulo, SP, Brazil. Patients and methods: 120 cases ofpituitary tumors treated between January, 1993 and May, 2006 were studied retrospectively. The data analyzed were: age, sex, main complaint, clinical presentation, radiological classification, type of hormone and complications. Results: The age of the patients varied between five to sixty-nine years (average of 40.2 years). The female/male ratio was 89:31. The visual deficit was the main complaint and present in 52% of the patients. According to Hardy’s classification, 5.4% were classified as Hardy II; 8.1% as Hardy III and 86.5% as Hardy IV. The surgical access was the transphenoidal in 113 patients. Three patients needed a second approach by craniotomy and seven patients were submitted to craniotomy as the first choice. The tumors were diagnosed as not secretor in 21.6% patients, prolactinomas in 70.2% patients, secretor of GH in 5.4% and ACTH and LH in 2.7% each one. The main complications of the surgical treatment were diabetes insipidus and cerebrospinal fluid leak. There were four deaths in the postoperative period. Conclusions: In this series the average age at presentations was 40.2 years;females were predominant; the visual loss was the main complaint; the majority of the patients were classified as Hardy IV; prolactinoma predominated; the transphenoidal surgical access was enough for the majority of the tumors.

Hematoma extradural intracraniano / Intracranial extradural hematomas

O hematoma extradural representa cerca de 1% a 5,5% daslesões intracranianas em pacientes com trauma cranincefes cranincefálico,podendo ser decorrentes de lesão arterial ou venosa. As relaçõesdos vasos com as proeminências ósseas do crânio e seiosdurais, as variáveis aderências da dura-máter ao crânio, osprogressivos mecanismos de desenvolvimento de hipertensãointracraniana na presença de um hematoma extradural, osmodelos de expansão e reabsorção e suas características nosmétodos de imagem, especialmente na tomografi a computadorizadasão discutidos. As indicações do tratamento cirúrgico eo eventual tratamento conservador são comentadas, assim comoo prognóstico quando relacionado à faixa etária do paciente.

Epidemiologia do trauma raquimedular cervical na zona norte da cidade de São Paulo / Epidemiology of cervical spine injury in the north area of Sao Paulo City

Objetivos: Estudar a epidemiologia do paciente vítima de trauma raquimedular cervical na zona norte da cidade de São Paulo, na área definida com DIR IV e na região de Franco da Rocha, entre 1996 e 2000. Métodos: Estudo parte retrospectivo, parte prospectivo, baseado em dados de protocolo padronizado para trauma raquimedular, consultas médicas e estudo de prontuários. Casuística: 95 pacientes consecutivos foram estudados entre abril de 1996 e dezembro de 2000. Conclusões: A incidência de casos de trauma raquimedular geral estimada foi de 22,63 milhão/ano e de trauma cervical foi de 8,6 milhão/ano. A média mensal foi 84 por cento maior no ano de 1999 em comparação a 1996. Predominaram as quedas ao solo como causa. A média de idade foi de 35 anos. Quarenta e cinco por cento da amostra apresentava-se com menos de 30 anos. Quarenta e dois por cento dos pacientes apresentaram complicações potencialmente graves. A média de internação foi de 25,86 dias. As lesões 0-C1-C2 causaram dano neurológico menos freqüentemente que as C3-C7 (11,6 por cento/61,04 por cento). As lesões que produziram deficit completo acima de C3 foram fatais. Mais de 60 por cento dos pacientes com traumatismo C3-C7 apresentaram deficits neurológicos e 41,5 por cento apresentaram paralisia, com nenhuma força evidente ao exame, com ou sem preservação sensitiva; 44 por cento destes morreram. Um paciente teve piora neurológica antes da cirurgia e outro teve seu quadro neurológico piorado pela cirurgia. O estado neurológico e o nível da lesão foram os fatores prognósticos mais importantes. Os 95 pacientes utilizaram 77 sistemas de fixação e/ou halo-coletes.

Subluxação atlanto-axial traumática: fixaçã com parafuso transarticular unilateral / Traumatic atlanto-axial rotatory dislocation: fixation with unilateral transarticular screw

É descrito o tratamento de uma paciente de 28 anos, que apresentava fratura vertebral cervical em dois níveis (fratura explosão de C6 e subluxação rotatória C1-C2). A massa lateral direita e a lâmina de C1 apresentavam-se fraturadas. Havia sido feita a traqueostomia precoce durante a admissão pelo grupo de emergência, o que duficultou o acesso pela via anterior. Foram realizadas a estabilização posterior C4-T1, com fixação segmentar (para estabilizar a lesão de C6) e a artrodese C-1-C2 com o parafuso transarticular, apenas em uma articulação, devido a fraturas na articulação C1-C2 contralateral. O objetivo foi o de estabilizar a coluna espinhal, para movimentaçã e cuidados respiratórios, e preservar a motilidade occipto-C1, C2-C3 e C3-C4. O controle, após 9 meses, mostrou estabilidade atlanto-axial mantida, com fusão interarticular, comprovando que, neste caso, a técnica transarticular unilateral foi suficiente para a fixação interna.

Abordagem lateral extracavitária: utilidade no tratamento do traumatismo raquimedular torácico, toracolombar e lombar / Lateral extracavitay approach for the treatment of thoracic, thoracolumbar and lumbar spinal trauma

Entre janeiro de 1996 e maio de 1997, foram tratados 33 pacientes nas Enfermarias do Complexo Hospitalar do Mandaqui e do Hospital do Servidor Público Estadual (HSPE), vítimas de trauma raquimedular torácico, toracolombar e lombar. Vinte e seis pacientes receberam tratamento cirúrgico, em 18 dos quais foi utilizada a abordagem lateral extracavitária. Esta abordagem propiciou a descompressao anterior ao saco dural (9 pacientes), a fusao com enxerto intersomático (7 pacientes), a implantaçao do parafuso cruzado pedículo-corpo vertebral (5 pacientes) e facilitou a colocaçao do parafuso transpedicular em 28 pedículos. Sao discutidas as contribuiçoes desta via.