Stereotactic Lesion in the Forel's Field H: A 2-Years Prospective Open-Label Study on Motor and Nonmotor Symptoms, Neuropsychological Functions, and Quality of Life in Parkinson Disease.

BACKGROUND: Stereotactic lesion in the Forel's field H (campotomy) was proposed in 1963 to treat Parkinson disease (PD) symptoms. Despite its rationale, very few data on this approach have emerged. Additionally, no study has assessed its effects on nonmotor symptoms, neuropsychological functions and quality of life. OBJECTIVE: To provide a prospective 2-yr assessment of motor, nonmotor, neuropsychological and quality of life variables after unilateral campotomy. METHODS: Twelve PD patients were prospectively evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS), the Dyskinesia Rating Scale and the Parkinson's disease quality of life questionnaire (PDQ39) before campotomy, and after 6 and 24 mo. Nonmotor, neuropsychiatric, neuropsychological and quality of life variables were assessed. The impact of PD on global health was also rated. RESULTS: A significant reduction in contralateral rest tremor (65.7%, P < .001), rigidity (87.8%, P < .001), bradykinesia (68%, P < .001) and axial symptoms (24.2%, P < .05) in offmedication condition led to a 43.9% reduction in UPSDRS III scores 2 yr after campotomy (P < .001). Gait improved by 31.9% (P < .05) and walking time to cover 7 m was reduced by 43.2% (P < .05). Pain decreased by 33.4% (P < .01), while neuropsychiatric and neuropsychological functions did not change. Quality of life improved by 37.8% (P < .05), in line with a 46.7% reduction of disease impact on global health (P < .001). CONCLUSION: A significant 2-yr improvement of motor symptoms, gait performance and pain was obtained after unilateral campotomy without significant changes to cognition. Quality of life markedly improved in parallel with a significant reduction of PD burden on global health.

Geographic variations in clinical presentation and outcomes of decompressive surgery in patients with symptomatic degenerative cervical myelopathy: analysis of a prospective, international multicenter cohort study of 757 patients.

BACKGROUND CONTEXT: Degenerative cervical myelopathy (DCM) is a progressive degenerative spine disease and the most common cause of spinal cord impairment in adults worldwide. Few studies have reported on regional variations in demographics, clinical presentation, disease causation, and surgical effectiveness. PURPOSE: The objective of this study was to evaluate differences in demographics, causative pathology, management strategies, surgical outcomes, length of hospital stay, and complications across four geographic regions. STUDY DESIGN/SETTING: This is a multicenter international prospective cohort study. PATIENT SAMPLE: This study includes a total of 757 symptomatic patients with DCM undergoing surgical decompression of the cervical spine. OUTCOME MEASURES: The outcome measures are the Neck Disability Index (NDI), the Short Form 36 version 2 (SF-36v2), the modified Japanese Orthopaedic Association (mJOA) scale, and the Nurick grade. MATERIALS AND METHODS: The baseline characteristics, disease causation, surgical approaches, and outcomes at 12 and 24 months were compared among four regions: Europe, Asia Pacific, Latin America, and North America. RESULTS: Patients from Europe and North America were, on average, older than those from Latin America and Asia Pacific (p=.0055). Patients from Latin America had a significantly longer duration of symptoms than those from the other three regions (p<.0001). The most frequent causes of myelopathy were spondylosis and disc herniation. Ossification of the posterior longitudinal ligament was most prevalent in Asia Pacific (35.33%) and in Europe (31.75%), and hypertrophy of the ligamentum flavum was most prevalent in Latin America (61.25%). Surgical approaches varied by region; the majority of cases in Europe (71.43%), Asia Pacific (60.67%), and North America (59.10%) were managed anteriorly, whereas the posterior approach was more common in Latin America (66.25%). At the 24-month follow-up, patients from North America and Asia Pacific exhibited greater improvements in mJOA and Nurick scores than those from Europe and Latin America. Patients from Asia Pacific and Latin America demonstrated the most improvement on the NDI and SF-36v2 PCS. The longest duration of hospital stay was in Asia Pacific (14.16 days), and the highest rate of complications (34.9%) was reported in Europe. CONCLUSIONS: Regional differences in demographics, causation, and surgical approaches are significant for patients with DCM. Despite these variations, surgical decompression for DCM appears effective in all regions. Observed differences in the extent of postoperative improvements among the regions should encourage the standardization of care across centers and the development of international guidelines for the management of DCM.

Multimaterial 3D printing preoperative planning for frontoethmoidal meningoencephalocele surgery.

INTRODUCTION: Surgical correction of frontoethmoidal meningoencephalocele, although rare, is still challenging to neurosurgeons and plastic reconstructive surgeons. It is fundamental to establish reliable and safe surgical techniques. The twenty-first century has brought great advances in medical technology, and the 3D models can mimic the correct tridimensional anatomical relation of a tissue organ or body part. They allow both tactile and spatial understanding of the lesion and organ involved. The 3D printing technology allows the preparation for specific surgery ahead of time, planning the surgical approach and developing plans to deal with uncommon and high-risk intraoperative scenarios. CASE PRESENTATION: The present report describes a case of frontoethmoidal encephalocele, (nasofrontal subtype) of a 19-month-old girl, whose surgical correction was planned using 3D printing modeling. CONCLUSION: The 3D model allowed a detailed discussion of the aspects of the surgical approach by having tissues of different consistencies and resistances, and also predicting with millimetric precision the bilateral orbitotomy measurements. Moreover, it was a fundamental and valuable factor in the multidisciplinary preoperative discussion. This approach allowed reducing the time of surgery, accurately planning the location of the osteotomies and precontouring the osteosynthesis material. 3D models can be very helpful tools in planning complex craniofacial operative procedures.

A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multicenter AOSpine international study on 479 patients.

STUDY DESIGN: Prospective, multicenter international cohort. OBJECTIVE: To evaluate outcomes of surgical decompression for cervical spondylotic myelopathy (CSM) at a global level. SUMMARY OF BACKGROUND DATA: CSM is a degenerative spine disease and the most common cause of spinal cord dysfunction worldwide. Surgery is increasingly recommended as the preferred treatment strategy for CSM to improve neurological and functional status and quality of life. The outcomes of surgical intervention for CSM have never been evaluated at an international level. METHODS: Between October 2007 and January 2011, 479 symptomatic patients with image evidence of CSM were enrolled in the prospective, multicenter AOSpine CSM-International study from 16 global sites. Preoperative and postoperative clinical status, functional impairment, and quality of life were evaluated using the modified Japanese Orthopaedic Assessment Scale, Nurick Scale, Neck Disability Index, and Short-Form-36v2. Preoperative and 12- and 24-month postoperative outcomes were compared using mixed-model analysis of covariance for repeated measurements. RESULTS: The study cohort consisted of 310 males and 169 females, with a mean age of 56.37 ± 11.91 years. There were significant differences in age, etiology, and surgical approaches between the regions. At 24 months postoperatively, the mean modified Japanese Orthopaedic Assessment Scale score improved from 12.50 (95% confidence interval [CI], 12.24-12.76) to 14.90 (95% CI, 14.64-15.16); the Neck Disability Index improved from 36.38 (95% CI, 34.33-38.43) to 23.20 (95% CI, 21.24-25.15); and the SF36v2 Physical Component Score and Mental Composite Score improved from 34.28 (95% CI, 33.46-35.10) to 40.76 (95% CI, 39.71-41.81) and 39.45 (95% CI, 38.25-40.64) to 46.24 (95% CI, 44.94-47.55), respectively. The rate of neurological complications was 3.13%. CONCLUSION: Surgical decompression for CSM is safe and results in improved functional status and quality of life in patients around the world, irrespective of differences in medical systems and sociocultural determinants of health. LEVEL OF EVIDENCE: 3.

A systematic review of randomized trials on the effect of cervical disc arthroplasty on reducing adjacent-level degeneration.

OBJECT: Anterior cervical discectomy and fusion had been considered a safe and effective procedure for radiculopathy and myelopathy in the cervical spine, but degeneration in adjacent spinal levels has been a problem in some patients after fusion. Since 2002, cervical disc arthroplasty has been established as an alternative to fusion. The objective of this study was to review data concerning the role of cervical arthroplasty in reducing adjacent-level degeneration. METHODS: A systematic review was performed using the MEDLINE, EMBASE, Cochrane, and LILACS databases, focusing on a structured question involving the population of interest, types of intervention, types of control, and outcomes studied. RESULTS: No study has specifically compared the results of arthroplasty with the results of fusion with respect to the rate of postoperative development of adjacent-segment degenerative disease. One paper described a rate for adjacent-level surgery. The level of evidence of that paper was classified 2b, and although its authors found a statistically significant between-groups difference (arthroplasty vs fusion) using log-rank analysis, re-analysis according to number needed to treat (in the current paper) did not reveal statistical significance. CONCLUSIONS: Adjacent-level degeneration has not been adequately studied in a review of the available randomized controlled trials on this topic, and there is no clinical evidence of reduction in adjacent-level degeneration with the use of cervical arthroplasty.

[Effectiveness of methylprednisolone in the acute phase of spinal cord injuries--a systematic review of randomized controlled trials]. / Efetividade da metilprednisolona na fase aguda do trauma raquimedular--revisão sistemática dos ensaios clínicos randomizados.

UNLABELLED: Steroid therapy has been tested as a protector in spinal cord injury. Multicenter studies evaluating the methylprednisolone (MP) in post traumatic neurological recovery have shown promising results according to NASCIS. A large number of critical studies related to the NASCIS results have been published. OBJECTIVE: To review literature related to use of methylprednisolone compared with placebo. METHODS: This analysis added the average improvement achieved in groups of patients who used MP and placebo (PL) to the average scores of groups at baseline, before treatment, resulting in the final neurological outcome for both groups. RESULTS: The motor score of the MP group was only 2.5 points higher than the PL in a one year follow-up. In neurologically intact patients, the total score is 70 points. Improvement in sensitive scores was also discrete (1.1 and 1.7 points for the pinprick and light touch respectively). A high rate of complications was observed in a group of patients about 60 years old who used MP. CONCLUSION: Differences in the clinical magnitude of benefit obtained (not confirmed by other studies) with the use of MP or PL are not significant, in comparison with the potential for complications when using methylprednisolone.

Efetividade da metilprednisolona na fase aguda do trauma raquimedular: revisão sistemática dos ensaios clínicos randomizados / Effectiveness of methylprednisolone in the acute phase of spinal cord injuries: a systematic review of randomized controlled trials

A corticoterapia tem sido testada como protetor neuronal no trauma. Os estudos multicêntricos avaliando a metilprednisolona (MP) na recuperação neurológica após trauma revelaram-se promissores (NASCIS). Porém, várias, críticas às suas metodologias foram publicadas. OBJETIVO: Revisar a literatura relacionada ao uso da metilprednisolona comparada com placebo. MÉTODOS: A análise feita somou a média da melhora obtida nos grupos de pacientes que usaram MP e placebo (PL) à média dos escores dos grupos na linha de base, antes de tratamento, obtendo-se o resultado neurológico final de ambos os grupos. RESULTADOS: O escore motor do grupo MP foi apenas 2,5 pontos maior que o PL em um ano de seguimento. O escore motor em indivíduos intactos é de 70 pontos. A melhora nos escores sensitivos foi igualmente discreta (1,1 e 1,7 pontos para sensibilidade a picadas e tato respectivamente). A taxa de complicações observada em grupo de pacientes em torno de 60 anos foi alta com o uso de MP. CONCLUSÃO: As diferenças na magnitude do benefício clínico obtido (não confirmado por outros estudos) com o uso da MP e com o PL não são significativas em confronto com o potencial de complicações do uso da medicação.

Steroid therapy has been tested as a protector in spinal cord injury. Multicenter studies evaluating the methylprednisolone (MP) in post traumatic neurological recovery have shown promising results according to NASCIS. A large number of critical studies related to the NASCIS results have been published. OBJECTIVE: To review literature related to use of methylprednisolone compared with placebo. METHODS: This analysis added the average improvement achieved in groups of patients who used MP and placebo (PL) to the average scores of groups at baseline, before treatment, resulting in the final neurological outcome for both groups. RESULTS: The motor score of the MP group was only 2.5 points higher than the PL in a one year follow-up. In neurologically intact patients, the total score is 70 points. Improvement in sensitive scores was also discrete (1.1 and 1.7 points for the pinprick and light touch respectively). A high rate of complications was observed in a group of patients about 60 years old who used MP. CONCLUSION: Differences in the clinical magnitude of benefit obtained (not confirmed by other studies) with the use of MP or PL are not significant, in comparison with the potential for complications when using methylprednisolone.

Avaliação de fatores prognósticos da deambulação em crianças com mielomeningocele / Prognostic factors influencing ambulation in children with myelomeningocele

Objetivo: caracterizar o grau de acometimento neurológico, estabelecendo uma correlação entre o nível funcional da lesão e a aquisição da marcha, além de identificar os fatores que interferem nessa capacidade. Método: foram avaliadas prospectivamente vinye e oito crianças portadoras de mielomeningocele operadas com idade igual ou superior a três anos. Foram determinados o nível funcional da lesão, a aquisição ou não da marcha e os fatores associados por meio das medidas do grau de força muscular nos membros inferiores, presença de deformidades articulares, ocorrência de contratura da musculatura flexora e trato iliotibial, eficácia da reação de equilíbrio e presença de hidrocefalia tratada. Resultados: todos os fatores avaliados, exceto a hidrcefalia, foram relacionados de forma significativa à aquisição da marcha. Conclusão: a aquisição da marcha em crianças portadoras de mielomeningocele sofre influência de vários fatores, além do nível de acometimento neurológico, o que deve ser considerado no prognóstico e na programação terapêutica.

[Classification of thoracolumbar spine fractures based on a complete imaging investigation in 33 patients]. / Classificação das fraturas tóraco-lombares baseada em investigação por imagem: avaliação de 33 casos.

The thoracolumbar spine fractures constitute a wide spectrum of resultant lesions, with distinct injury mechanisms. In order to reduce the controversies concerning about the management of these fractures, a universally accepted classification is necessary. In this study we evaluated retrospectively 33 patients with thoracolumbar spine fracture, with the goal of categorize and evaluate the factors related to this pathology. A complete radiological investigation, complaining of plain radiography, computed tomography and magnetic resonance imaging, was used to classify these fractures. Fall was the more common mechanism, present in 24 cases. In 57.6% of the patients, the fractures located at thoracolumbar transition (T12-L1) and the more frequent neurological presentation was total deficit, present in 45.45%. The neurological presentation was more serious in patients with thoracic lesions regarding lumbar lesions (Fischer's test, p=0.039). A positive correlation was observed between severity of the neurological presentation and gravity of the lesion according to Magerl's classification (Pearson's method, r=0.85, p<0.001). In conclusion, thoracolumbar spine fractures are serious lesions considering the initial neurological presentation; a wide and accurate classification, as we used, is necessary to describe these injuries and may help resolve some of the controversies concerning the management of these lesions.

Classificação das fraturas tóraco-lombares baseada em investigação por imagem: avaliação de 33 casos / Classification of thoracolumbar spine fractures based on a complete imaging investigation in 33 patients

As fraturas das regiões torácica e lombar da coluna vertebral constituem amplo espectro de diferentes tipos de lesões resultantes de mecanismos fisiopatológicos distintos. A fim de se reduzir as controvérsias existentes a respeito da conduta destas lesões é necessária a utilização de uma classificação que permita a sua correta caracterização. Neste estudo avaliamos retrospectivamente 33 pacientes portadores de fraturas tóraco-lombares com o objetivo de categorizar e avaliar os fatores relacionados a esta patologia. O mecanismo de trauma mais freqüente foi queda de altura, presente em 24 casos. Na maioria dos pacientes (57,6 por cento) as fraturas localizaram-se na transição tóraco-lombar (T12-L1) e o quadro neurológico mais freqüente foi o déficit sensitivo-motor completo abaixo da lesão, em 45,45 por cento dos casos. A apresentação neurológica foi mais grave nos pacientes com lesões torácicas em relação às lesões lombares (teste de Fischer, p=0,039). Uma correlação positiva foi observada entre a severidade do quadro neurológico e a gravidade da lesão segundo a classificação de Magerl (r de Pearson=0,85, p<0,001). Concluímos que as fraturas tóraco-lombares são lesões graves considerando a apresentação neurológica inicial e que é necessária a utilização de uma classificação ampla e adequada como a utilizada no presente estudo.

The thoracolumbar spine fractures constitute a wide spectrum of resultant lesions, with distinct injury mechanisms. In order to reduce the controversies concerning about the management of these fractures, a universally accepted classification is necessary. In this study we evaluated retrospectively 33 patients with thoracolumbar spine fracture, with the goal of categorize and evaluate the factors related to this pathology. A complete radiological investigation, complaining of plain radiography, computed tomography and magnetic ressonance imaging, was used to classify these fractures. Fall was the more common mechanism, present in 24 cases. In 57.6 percent of the patients, the fractures located at thoracolumbar transition (T12-L1) and the more frequent neurological presentation was total deficit, present in 45.45 percent. The neurological presentation was more serious in patients with thoracic lesions regarding lumbar lesions (Fischer's test, p=0.039). A positive correlation was observed between severity of the neurological presentation and gravity of the lesion according to Magerl's classification (Pearson's method, r=0.85, p<0.001). In conclusion, thoracolumbar spine fractures are serious lesions considering the initial neurological presentation; a wide and accurate classification, as we used, is necessary to describe these injuries and may help resolve some of the controversies concerning the management of these lesions.

Tumor neuroectodérmico primitivo periférico originado em ramo do nervo ciático / Peripheral primitive neuroectodermal tumor arising in a branch of the sciatic nerve

Os autores relatam caso de tumor neuroectodérmico primitivo periférico originado de ramo do nervo ciático, em paciente de 17 anos, do sexo feminino. O tumor foi extirpado cirurgicamente e o tratamento foi complementado com rádio e quimioterapia. A lesão apresentava tanto um aspecto histológico característico, com células pequenas e arredondadas formando pseudo-rosetas, como um perfil imunoistoquímico compatível. Os tumores neuroectodérmicos primitivos de nervos periféricos são lesões raras, descritas em 36 casos da literatura. Neste relato são discutidas as principais características dessa lesão e enfatizada a importância de um tratamento cirúrgico agressivo associado à terapêutica adjuvante apropriada.

Naso-ethmoid schwannoma with intracranial extension: case report

Intranasal schwannomas are rare lesions, specially when they present with an intracranial extension. The fifth case in the medical literature of a naso-ethmoid schwannoma with extension into the anterior cranial fossa is presented. The magnetic resonance findings and the details of the combined intracranial / transfacial operative approach used are described. The possible origin and the clinical characteristics of this rare lesion are reviewed.

Tumor dermóide intramedular associado a diastematomielia: relato de caso / Intraspinal dermoid tumor associated with diastematomyelia: case report

A associaçao de tumor dermóide intramedular e diastematomielia é rara, descrita anteriormente em 8 casos. Descrevemos novo caso, de um adulto portador desta associaçao que apresentou paraparesia crural progressiva e síndrome sensitiva nos membros inferiores, além de cifoescoliose tóraco-lombar. A exploraçao cirúrgica confirmou a ocorrência de um tumor dermóide intramedular além da diastematomielia identificados na ressonância magnética. Discutemos aspectos fisiopatológicos e clínicos e as características radiológicas destas patologias destacando a importância do diagnóstico precoce

Clipes de titânio no tratamento de aneurismas saculares intracranianos / Titanium clips in the treatment of intracranial saccular aneurysms

Este trabalho descreve a utilização de 25 clipes de titânio no tratamento de 20 pacientes com hemor ragia subaracnóide aneur ismática. Todos os pacientes apresentavam hemorragias de graus I e II na escala de Hunt e Hess, provocadas por aneurismas da circulação anterior. O resultado do tratamento cirúrgico foi bom, não ocorrendo qualquer complicação, precoce ou tardia, que pudesse ser atribuída aos clipes de titânio. As dimensões médias dos artefatos provocados pelos clipes na tomografia computadorizada (TC) (comprimento) e ressonância magnética (RM)(volume) foram de 17,65 mm e 1,64 cm3 , respectivamente. Os clipes de titânio demonstraram ser cirurgicamente seguros e efetivos e, quando comparados com os clipes de liga de cobalto disponíveis no comércio, produziram artefatos bem menores nas imagens obtidas pela TC e RM, devido a sua menor susceptibilidade magnética. Com base nessas importantes vantagens, acreditamos que os clipes de titânio devam ser considerados como a opção ideal para uso rotineiro em cirurgiasde aneurismas.

This report describes the clinical use of 25 titanium clips in the treatment of 20 patients with aneurysmal subarachnoid hemorrhage. All patients had Hunt and Hess Grade I-II hemorrhages from aneurysms of the anterior circulation. The surgical outcome was good in the entire series, with no immediate or delayed complication related to the t i tanium cl ips. The average cl ip ar t i facts on the postoperat ive computerized tomography (CT) (lenght) and magnetic resonance imaging (MRI) (volume) was 17.65 milimeters and 1.64 cubic centimeters, respectively. The titaniumaneurysm clips seem to be surgically safe and effective and to reduce the clip artifacts on CT and MRI studies, when compared with commercially available cobalt alloy clips. Based on these important advantages over conventional clips, titanium clips should be considered as the ideal option for routine use in aneurysm surgery.

Tratamento cirúrgico dos neurinomas de trigêmio / Surgical treatment of trigeminal neurinomas

Os neurinomas do trigêmeo sao tumores raros que podem se originar isoladamente da raiz do nervo, do gânglio de Gasser ou de um de seus ramos terminais. Durante o crescimento, é relativamente freqüente a expansao além de seus segmentos de origem, ocupando também áreas adjacentes na base do crânio. Sua apresentaçao clínica mais freqüente é sob a forma de sinais e sintomas de disfunçao do nervo trigêmeo. De acordo com a origem e localizaçao preferencial, os neurinomas do trigêmeo podem ser classificados em quatro tipos: neurinomas de raiz, neurinomas do gânglio de Gasser, neurinomas dos ramos trigeminais e neurinomas que combinam dois ou mais dos tipos citados. Cada um desses tipos apresenta achados clínicos e radiológicos específicos. Com base nessa relaçao localizaçao/sintomatologia é possível sistematizar a escolha da melhor via de acesso cirúrgico. No presente estudo é analisada uma série com 7 doentes, dos quais 6 foram tratados cirurgicamente (ressecçao completa em 5 casos e subtotal em l caso) e 1 recusou a opçao de tratamento operatório. Sao enfatizados os aspectos clínicos e de imagem, os tipos de vias de acesso cirúrgico empregados e os resultados obtidos.

Abordagem transcondilar lateral extrema aos tumores da porçäo anterior da transiçäo occipito-cervical / The extreme lateral transcondylar approach to tumors of the anterior portion of the craniocervical junction

Os tumores localizados ao nível da transiçäo occipito-cervical em posiçäo ventral à medula cervical alta e à medula oblonga säo de difícil abordagem e remoçäo. Essas lesöes têm sido mais comumente tratadas por uma via anterior transoral ou por uma via postero-lateral suboccipital, ambas com as desvantagens sobrepujando as vantagens. Para contornar essas dificuldades, recentemente, foi idealizada uma via cirúrgica alternativa para essa regiäo: a abordagem transcondilar lateral extrema. Contudo, as informaçöes nem sempre claras ou completas contidas nas publicaçöes sobre esta abordagem, a tornam um procedimento de alta complexidade para a maioria dos neurocirurgiöes. A despeito de treinamento laboratorial prévio, encontramos inúmeras dificuldades durante a realizaçäo de 8 dessas abordagens à transiçäo da técnica e de estimular sua maior utilizaçäo, decidimos descrever em detalhes os aspectos anatômicos e técnicos desta via de acesso, com algumas pequenas modificaçöes, enfatizando os pontos críticos para sia realizaçäo adequada