[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.

[Biological cement extravasation into the spinal canal following kyphoplasty. Long-term follow-up. Report of one case and review of the literature]. / Fuga intrarraquídea de cemento biológico tras cifoplastia. Evolución a largo plazo.Presentación de un caso y revisión de la literatura.

BACKGROUND: Vertebroplasty and kyphoplasty are minimally invasive percutaneous techniques indicated in the treatment of some somatic vertebral fractures. Both are based on the introduction of a substance, called cement, inside the vertebral body. We can choose acrylic or biological cement. These techniques are not risk-free, cement extravasation being the main complication. Due to the short experience in the use of the biological cements, nowadays there are a lot of unresolved doubts about the long-term behaviour of these materials, especially in the case of leakage. PURPOSE: We report a case of biologic cement extravasation into the spinal canal during a kyphoplasty in a 23 year old man and its long-term follow-up (3 years), performing a review of the scientific literature related to the topic. CONCLUSIONS: Most of the papers in the literature discuss the behaviour of the reinforcement material inside a bony environment, but they do not refer to the evolution of the cement outside the vertebral space. We have appreciated in our case that the leaked cement is not being substituted for bone but it suffers a process of progressive resorption. The extravasation of the vertebral reinforcement material is an important and potentially serious complication of the vertebral augmentation techniques. To avoid this, a very precise chirurgical technique is necessary, under radiological guidance. Biocompatibility, biodegradability and osteoconductivity are the main advantages of biological cements. We base the choice of the cement on the balloon/trabeculae interaction.

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)

Fuga intrarraquídea de cemento biológico tras cifoplastia. Evolución a largo plazo. Presentación de un caso y revisión de la literatura / Biological cement extravasation into the spinal canal following kyphoplasty. Long-term follow-up. Report of one case and review of the literature

Introducción. La vertebroplastia y la cifoplastia son técnicas percutáneas mínimamente invasivas indicadas en el tratamiento de ciertas fracturas somáticas vertebrales. Ambas se basan en la introducción dentro del cuerpo vertebral de una sustancia llamada genéricamente cemento, el cual puede ser acrílico o biológico. Son técnicas no exentas de riesgos, destacando como principal complicación la extravasación del cemento. Dada la corta experiencia en el uso de cementos biológicos, existen hoy en día muchas dudas sin resolver acerca de su comportamiento a largo plazo, especialmente en caso de que se produzca una fuga del material de refuerzo vertebral.Objetivo. Presentamos un caso de extravasación intrarraquídea de cemento biológico durante una cifoplastia en un varón de 23 años y su evolución a largo plazo (3 años), realizando una revisión de la literatura publicada al respecto.Conclusiones. La mayoría de los estudios publicados tratan sobre la evolución del material de refuerzo dentro de un ambiente óseo, pero no hacen referencia a cómo evolucionaría el mismo fuera del espacio vertebral. Hemos apreciado, en nuestro caso, que el cemento extravasado no está siendo sustituido por hueso, sino que está sufriendo un proceso de reabsorción. La extravasación del material de refuerzo vertebral es una complicación importante y potencialmente grave de las técnicas de refuerzo vertebral percutáneo. Para evitarla se requiere una rigurosa técnica quirúrgica bajo control radioscópico. Los cementos biológicos tienen la ventaja de ser biocompatibles, biodegradables y osteoconductivos. La elección del cemento dependerá de las características de la interacción balón-trabécula (AU)

Background. Vertebroplasty and kyphoplasty are minimally invasive percutaneous techniques indicated in the treatment of some somatic vertebral fractures. Both are based on the introduction of a substance, called cement, inside the vertebral body. We can choose acrylic or biological cement. These techniques are not risk-free, cement extravasation being the main complication. Due to the short experience in the use of the biological cements, nowadays there are a lot of unresolved doubts about the long-term behaviour of these materials, especially in the case of leakage.Purpose. We report a case of biologic cement extravasation into the spinal canal during a kyphoplasty in a 23 year old man and its long-term follow-up (3 years), performing a review of the scientific literature related to the topic.Conclusions. Most of the papers in the literature discuss the behaviour of the reinforcement material inside a bony environment, but they do not refer to the evolution of the cement outside the vertebral space. We have appreciated in our case that the leaked cement is not being substituted for bone but it suffers a process of progressive resorption. The extravasation of the vertebral reinforcement material is an important and potentially serious complication of the vertebral augmentation techniques. To avoid this, a very precise chirurgical technique is necessary, under radiological guidance. Biocompatibility, biodegradability and osteoconductivity are the main advantages of biological cemnets. We base the choice of the cement on the balloom/trabeculae interaction (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)

[Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases]. / Regresión espontánea de hernias discales intervertebrales. A propósito de una serie de 37 casos.

INTRODUCTION: The intervertebral disc disease (IDD) is one of the most common muscle-skeletal disorders, causing both high work disability and elevated healthcare costs. There are two specific origins of disk disease that should be kept in mind: degenerative (DDD) and traumatic (TDD). Concerning the TDD, nowadays it has not been determined which patients could gradually improve and which ones will require surgery. Some studies indicate that about 85% of lumbar and 90% cervical acute disc herniation will get better in an average of 6 weeks. MATERIALS AND METHODS: We conducted an observational, prospective study, over a group of 858 patients, with the following inclusion criteria: 1. MRI imaging indicating TDD, 2. No signs or symptoms requiring urgent surgical treatment (cauda equina syndrome, progressive or serious motor deficit or unbearable pain) and 3. Development of progressively spontaneous symptoms remission. All of the patients included in our study were treated in our Department of Neurosurgery from 2006 to 2007. Patients were tested for disc herniation regression with a second MRI study. RESULTS: A spontaneous regression of their hernia was appreciated as follow: 33 cases of lumbar hernia (29 male, 4 female), 3 cervical hernia (1 male, 2 female) and 1 dorsal hernia (male). DISCUSSION: Research about other reported series was done, and the different factors that could take place in disc spontaneous regression were analyzed: a) lodgement of the herniated disc back into the intervertebral space; b) disappearance of the herniated fragment due to dehydration and retraction mechanisms; c) gradual resorption of the herniated tissue by phagocytosis and enzymatic degradation induced by an inflammatory reaction that appeared as the disc (acting the extrusion itself as an foreign body) and, d) pulsion of cephaloarchidian liquid against the herniated portion. CONCLUSIONS: Disc herniation can regress, or even disappear, in a number of patients, rendering the radiological findings not to be taken as the only surgical indication criterium. We consider that the best treatment is the one relying on a good doctor-patient relationship, suspended in a balance between conservative and surgical treatment. According to clinical data, the first one (conservative) should not exceed the estimated time beyond which the surgical result would be unsatisfactory. The second one (operative), excepting "need-to operate" situations (such as cauda equina compression, progressive or serious motor déficit, or unbearable pain), should be prudently supedited to MRI regresión control, in particular in patients in which a clinical improvement is observed. Thus, the disc herniation conservative healing, both clinical as radiological, do exist, being a concept to widespread among clinicians and patients also.

Regresión espontánea de hernias discales intervertebrales. A propósito de una serie de 37 casos / Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases

Introducción. La enfermedad discal intervertebral(EDI) es uno de los trastornos musculoesqueléticos máscomunes, que induce tanto una elevada proporción dediscapacidad laboral como un gran coste sanitario.Dentro de la EDI cabría considerar dos modalidades,la enfermedad discal de origen degenerativo (EDD) yla de origen traumático (hernias discales traumáticas- HDT). Con respecto a las HDT no se ha podido determinar,a día de hoy, qué pacientes son susceptiblesde mejorar espontáneamente y cuales lo harán si sesometen a tratamiento quirúrgico. Algunos estudioshan determinado, que hasta el 85% de los pacientescon una hernia discal lumbar aguda y hasta el 90% conuna hernia discal cervical aguda, mejorarán en el plazomedio de 6 semanas.Material y método. Durante el bienio 2006-2007,realizamos un estudio observacional, prospectivo en858 pacientes diagnosticados clínica y radiológicamentede HDT, que no cumplimentaban los criterios de unacirugía urgente -síndrome de la cola de caballo, déficitmotor progresivo/grave, o dolor incoercible-. Un grupode pacientes evolucionaron de forma progresiva a laremisión espontánea de la clínica que motivara su asistenciamédica. Se solicitó, en aquellos pacientes que asílo aceptaron, un nuevo estudio de neuroimagen.Resultados. Se ha apreciado una regresión espontáneade la herniación en 33 casos a nivel lumbar (29varones y 4 mujeres), en 3 casos a nivel cervical (1 varóny 2 mujeres) y en 1 caso a nivel dorsal (1 varón).Discusión. Se lleva acabo una revisión de otrasseries publicadas y se analizan los distintos factoresque pueden intervenir en la regresión espontánea delas mismas: a) el realojo del disco herniado en el espaciointervertebral; b) la desaparición del fragmento(..) (AU)

Introduction. The intervertebral disc disease (IDD)is one of the most common muscle-skeletic disorders,causing both high work disability and elevated healthcarecosts. There are two specific origins of disk diseasethat should be kept in mind: degenerative (DDD) andtraumatic (TDD). Concerning the TDD, nowadays ithas not been determined which patients could graduallyimprove and which ones will requiere surgery.Some studies indicate that about 85% of lumbar and90% cervical acute disc herniation will get better in anaverage of 6 weeks.Materials and methods. We conducted an observational,prospective study, over a group of 858 patients,with the following inclusion criteria: 1. MRI imaging (..) (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)

[Percutaneous vertebral augmentation: vertebroplasty and kyphoplasty: operative technique]. / Refuerzo vertebral percutáneo: vertebroplastia y cifoplastia: pocedimiento técnico.

The intravertebral injection of acrylic resin cement -usually polymethylmethacrylate (PMMA)- into a fractured vertebral body, constitutes the basis of the so called "vertebral augmentation techniques", "vertebroplasty" and "kyphoplasty", to manage pain and to strengthen and stabilize the compromised vertebra. In some ocassion, prior to the PMMA injection, an inflatable bone tamp was inserted into both pedicles of the fractured vertebra with the aim of restoring vertebral height to correct the kyphosis deformation. This procedure is called kyphoplasty (balloon-assisted vertebroplasty). The indications for vertebroplasty and kyphoplasty are evolving, from stabilization of painful osteoporotic vertebral fractures to vertebral collapse secondary to spinal metastases. In this paper we review the technical basis of both procedures, according to our experience in the treatment of vertebral fractures. Further studies are required to define the role for each technique in the spinal surgery's armamentarium.

Refuerzo vertebral percutáneo: vertebroplastia y cifoplastia. Procedimiento técnico / Percutaneous vertebral augmentation: vertebroplasty and kyphoplasty. Operative technique

Las técnicas de refuerzo vertebral, vertebroplastia y cifoplastia, consisten básicamente en la introducción de un cemento óseo -polimetilmetacrilato (PMMA)- en un cuerpo vertebral fracturado, para aliviar el dolor mediante la estabilización de la fractura vertebral. En ocasiones, previamente a la administración del cemento, a nivel de la vértebra colapsada, se inserta un balón que se insufla con la finalidad de restaurar la altura del cuerpo vertebral y reducir la deformidad cifótica; en estos casos hablamos de cifoplastia o de vertebroplastia mediante balón. Las indicaciones de la vertebroplastia y cifoplastia han ido evolucionando, pasando de la estabilización de una fractura vertebral osteoporótica dolorosa, al refuerzo de un colapso vertebral secundario a metástasis.En el presente trabajo se revisan los principales aspectos técnicos de la vertebroplastia y de la cifoplastia,a la luz de nuestra experiencia en el tratamiento de las fracturas vertebrales. Se necesitan más estudios que permitan definir el papel de cada procedimiento dentro del arsenal terapéuticode la cirugía de columna

The intravertebral injection of acrylic resin cement -usually polymethylmethacrylate (PMMA)- into a fractured vertebral body, constitutes the basis of the so called “vertebral augmentation techniques”, “vertebroplasty”and “kyphoplasty”, to manage pain and to strengthen and stabilize the compromised vertebra. In some ocassion, prior to the PMMA injection, an inflatable bone tamp was inserted into both pedicles of the fractured vertebra with the aim of restoring vertebralheight to correct the kyphosis deformation. This procedure is called kyphoplasty (balloon-assisted vertebroplasty).The indications for vertebroplasty and kyphoplasty are evolving, from stabilization of painful osteoporotic vertebral fractures to vertebral collapse secondary to spinal metastases. In this paper we review the technical basis of both procedures, according to our experience in the treatmentof vertebral fractures. Further studies are requiredto define the role for each techniques in the spinal surgery’s armamentarium

[Percutaneous vertebroplasty: technique and early results in 25 procedures]. / La vertebroplastia percutánea: técnica y resultados preliminares en 25 procedimientos.

Vertebroplasty procedure which involves percutaneous injection of bone cement into a collapsed vertebra using fluoroscopic guidance, has been introduced not only for treatment of osteoporotic patients, who have prolonged long lasting pain following vertebral fracture, but also for osteolytic vertebral compression fractures, to restore its loadbearing capacity and stiffness. Our result suggest that vertebroplasty is associated with pain relief in almost 100% of cases. Proper patient selection and a good technique should minimize complications.

La vertebroplastia percutánea: Técnica y resultados preliminares en 25 procedimientos / Percutaneous vertebroplasty: technique and early results in 25 procedures

La vertebroplastia es un procedimiento que precisa, bajo control radioscópico, de la inyección percutánea de cemento óseo en una vértebra colapsada. Se ha introducido para el tratamiento del dolor prolongado originado por una fractura vertebral secundaria, bien a osteoporosis o bien a procesos osteolíticos, con la finalidad de restaurar la capacidad de carga axial y la rigidez de la vértebra lesionada. Nuestros resultados sugieren que este procedimiento se acompaña de un alivio del dolor en prácticamente el 100 por ciento de los casos. Una adecuada selección de los pacientes y una técnica precisa suelen minimizar las complicaciones (AU)

[Primitive neuroectodermal tumor of the cauda equina. Report of a case]. / Tumor neuroectodérmico primitivo de la cola de caballo. A propósito de un caso.

Primitive neuroectodermal tumors are malignant neoplasms whose classification has been controversial. Spinal primitive neuroectodermal tumors are rare and at the cauda equina are even less common. We report the case of a 40 year-old man with a history of progressive back pain and gait difficulty. After the diagnosis of a primitive neuroectodermal tumor of the cauda equina, the patient presented seeding to the intracranial subarachnoid space followed by a poor outcome. We review the literature of primary spinal primitive neuroectodermal tumors.