¿Cuál es la presión de drenaje óptima en hidrocefalias tumorales obstructivas? Análisis de factores subyacentes al sobredrenado valvular, revisión de casos y desarrollo de protocolo quirúrgico / What is the optimal drainage pressure in obstructive tumors hydrocephalus? Analysis of factors underlying valve overdrainage, case review and development of surgical protocol

Introducción: La hidrocefalia es una complicación frecuente dentro de la patología tumoral del SNC. La colocación de válvulas de derivación ventrículo-peritoneal (VDVP) en estos casos es, al día de la fecha, la práctica estándar para tratar esta patología y prevenir las complicaciones y comorbilidades que esta conlleva. Al momento, no existe un protocolo ni una presión valvular inicial establecida para estos pacientes, en los cuales hemos observado una tendencia al sobredrenado de líquido cefalorraquídeo (LCR). El objetivo de este trabajo es analizar nuestra experiencia en el tratamiento de hidrocefalias obstructivas secundarias a patología tumoral, determinar factores relacionados al advenimiento de sobredrenado, el manejo terapéutico del mismo y subsiguientemente protocolizar de manera sencilla y económica la colocación de este tipo de prótesis así como identificar una presión terapéutica que reduzca el riesgo de sobredrenado. Materiales y métodos: Estudio monocéntrico, analítico, retrospectivo de una cohorte de pacientes operados en nuestra institución por hidrocefalia obstructiva secundaria a patología tumoral entre los años 2013-2022.Se analizaron historias clínicas, imágenes y protocolos quirúrgicos. Se identificaron aquellos pacientes que desarrollaron sobredrenado. Subsiguientemente se analizaron mediante un modelo estadístico explicativo multivariado aquellas variables demográficas, clínicas y terapéuticas implicadas en el mismo.En una segunda etapa se propone un protocolo rápido, sencillo y económico a fin de determinar la presión óptima dentro de cada caso en particular. Resultados: Dentro de los 56 pacientes incluidos, 32 pacientes (57%) presentaron sobredrenado; 10 pacientes (18%) presentaron higromas en imágenes postoperatorias, y de estos, 3 pacientes (5.4%) requirieron intervenciones quirúrgicas. El 94% de los sobredrenados ocurrieron a presiones menores o igual a 160 mmH20. Así mismo, 8 de los 11 pacientes con VDVP de presión fija media (100-110 mmH20) no regulable presentaron sobredrenado.En un 27% de los pacientes debió aumentarse la presión valvular como consecuencia de hallazgos clínicos o radiológicos de sobredrenado. Conclusión: Las hidrocefalias secundarias a patología tumoral presentan un comportamiento distinto al de las normotensivas. La tasa de sobredrenado en estos pacientes es superior y por consiguiente debe ser tenida en cuenta como una posible complicación relevante. Dada la heterogeneidad de tumores, cada paciente presenta presiones de LCR distintas y por ende debe individualizarse el tratamiento. Proponemos el uso del protocolo de medición intraquirúrgica de presión a fin de colocar la VDVP a la presión óptima para cada paciente, y evitar de esta manera el sobredrenado de LCR

Background: Hydrocephalus is a common complication in CNS tumors pathology. The placement of ventriculoperitoneal shunt in these cases is, to date, the standard practice to treat this pathology and prevent the complications and comorbidities that it entails. At present, there is no protocol or initial valve pressure established for these patients, in whom we have observed a tendency toward overdrainage of cerebrospinal fluid (CSF).The objective of this work is to analyze our experience in the treatment of obstructive hydrocephalus secondary to tumor pathology, determine factors related to the occurrence of overdrainage, its therapeutic management and subsequently protocolize in a simple and economical way the placement of this type of prosthesis as well as identify a therapeutic pressure that reduces the risk of overdrainage. Methods: Monocentric, analytical, retrospective study of a cohort of patients operated on at our institution for obstructive hydrocephalus secondary to tumors, between the years 2013-2022.Medical records, images and surgical protocols were analyzed. Those patients who developed overdrainage were identified. Subsequently, the demographic, clinical and therapeutic variables involved in it were analyzed using a multivariate explanatory statistical model.In a second stage, a quick, simple, and economical protocol is proposed to determine the optimal pressure within each case. Results: Among the 56 patients included, 32 patients (57%) presented overdrainage; 10 patients (18%) presented hygromas on postoperative images, and of these, 3 patients (5.4%) required surgical interventions. 94% of overdrains occurred at pressures less than or equal to 160 mmH20. Likewise, 8 of the 11 patients with non-adjustable medium fixed pressure shunt (100-110 mmH20) presented overdrainage.In 27% of patients, valve pressure had to be increased because of clinical or radiological findings of overdrainage. Conclusion: Hydrocephalus secondary to tumors presents a different behavior than normotensive ones. The rate of overdrainage in these patients is higher and therefore must be considered as a possible relevant complication. Given the heterogeneity of tumors, each patient has different CSF pressures and therefore treatment must be individualized. We propose the use of the intrasurgical pressure measurement protocol to place the shunt at the optimal pressure for each patient, and thus avoid CSF overdrainage

[Endoscopic vs. microscopic techniques for the treatment of trigeminal neuralgia. Our experience at an Argentine care center]. / Descompresión microvascular endoscópica versus microscópica en neuralgia trigeminal en un Centro argentino.

INTRODUCTION: Trigeminal neuralgia is a highly invalidating pathology, whose natural course has been modified thanks to decompressive microvascular surgery. The intervention can be carried out either with a microscope or via an endoscopic technique. Our goal was to compare these two techniques for the treatment of this complex pathology. METHODS: Retrospective, analytical study of a cohort of patients treated by a single surgeon at our institution, in the period between 2015 and 2021. RESULTS: We identified 31 patients and divided them into two groups: 15 (49%) treated using the microscopic technique (group M), and 16 (51%) exclusively via an endoscopic one (group E). Differences were observed between the means of the size of the craniectomy in group M (3.7 cm) compared to group E (2.5 cm); The mean length of hospital stay for patients in group E was shorter (4.46 days compared to that of patients in group M, whose hospital stay averaged 2.43 days). There were no differences between the two groups regarding the length of the procedure. In both groups, the predominant compression was due to the superior cerebellar artery (SCA). Pain outcomes were equivalent, with every patient in both groups having an improved postoperative Barrow Neurological Institute Pain Intensity Score (BNI). DISCUSSION: Endoscopic microvascular decompression is an attractive option for the resolution of neurovascular conflict as it provides functional results similar to the microscope technique, without requiring an extensive craniectomy and associated to shorter in-hospital stay, which is beneficial for both the patient and the institution.

Introducción: La descompresión microvascular (DMV) en la neuralgia trigeminal es una técnica quirúrgica cuyo objetivo es revertir la compresión a la que se ve sometido un nervio por una estructura vascular. El objetivo de este estudio fue realizar una comparación directa entre la descompresión microvascular endoscópica (DMV-E) y la misma a través del uso del microscopio (DMV-M) en el tratamiento de la neuralgia del trigémino. Métodos: Se realizó un estudio de cohorte retrospectivo de pacientes operados de neuralgia de trigémino, por un mismo cirujano, entre 2015 y 2021 en nuestra institución, tanto por técnica microquirúrgica como endoscópica. Resultados: Se obtuvieron un total de 31 pacientes divididos en dos grupos: Grupo M correspondiente a 15 (49%) pacientes abordados con técnica microscópica y Grupo E, con 16 (51%) pacientes intervenidos con técnica endoscópica. Se identificaron diferencias en el tamaño de la craniectomía, más pequeña en el grupo E (2.50 cm vs 3.70 cm grupo M); y en el tiempo de internación, de 2.43 días en el grupo E vs. 4.46 días en el grupo M. El tiempo de cirugía fue similar para ambas técnicas quirúrgicas La principal compresión fue dada por la arteria cerebelosa superior (ACS) en ambos grupos. Todos los pacientes presentaron mejoría del Barrow Neurological Institute Pain Intensity Score (BNI) en el postoperatorio en ambos grupos. Discusión: La DMV-E constituye una alternativa quirúrgica interesante a la ya conocida DMV-M para el tratamiento de la neuralgia trigeminal, por requerir menores dimensiones en la incisión cutánea y tamaño de la craniectomía, acortando el tiempo de internación, lo cual no solo implica un beneficio para el paciente, sino que también representa menor costo de internación.

Descompresión microvascular endoscópica versus microscópica en neuralgia trigeminal en un centro Argentino / Endoscopic vs. microscopic techniques for the treatment of trigeminal neuralgia. Our experience at an Argentine care center

Resumen Introducción: La descompresión microvascular (DMV) en la neuralgia trigeminal es una técnica quirúrgica cuyo objetivo es revertir la compresión a la que se ve someti do un nervio por una estructura vascular. El objetivo de este estudio fue realizar una comparación directa entre la descompresión microvascular endoscópica (DMV-E) y la misma a través del uso del microscopio (DMV-M) en el tratamiento de la neuralgia del trigémino. Métodos: Se realizó un estudio de cohorte retrospec tivo de pacientes operados de neuralgia de trigémino, por un mismo cirujano, entre 2015 y 2021 en nuestra institución, tanto por técnica microquirúrgica como endoscópica. Resultados: Se obtuvieron un total de 31 pacientes divididos en dos grupos: Grupo M correspondiente a 15 (49%) pacientes abordados con técnica microscópica y Grupo E, con 16 (51%) pacientes intervenidos con técnica endoscópica. Se identificaron diferencias en el tamaño de la cra niectomía, más pequeña en el grupo E (2.50 cm vs 3.70 cm grupo M); y en el tiempo de internación, de 2.43 días en el grupo E vs. 4.46 días en el grupo M. El tiempo de cirugía fue similar para ambas técnicas quirúrgicas La principal compresión fue dada por la arteria ce rebelosa superior (ACS) en ambos grupos. Todos los pacientes presentaron mejoría del Barrow Neurological Institute Pain Intensity Score (BNI) en el postoperatorio en ambos grupos. Discusión: La DMV-E constituye una alternativa qui rúrgica interesante a la ya conocida DMV-M para el tratamiento de la neuralgia trigeminal, por requerir menores dimensiones en la incisión cutánea y tamaño de la craniectomía, acortando el tiempo de internación, lo cual no solo implica un beneficio para el paciente, sino que también representa menor costo de internación.

Abstract Introduction: Trigeminal neuralgia is a highly invali dating pathology, whose natural course has been modi fied thanks to decompressive microvascular surgery. The intervention can be carried out either with a microscope or via an endoscopic technique. Our goal was to compare these two techniques for the treatment of this complex pathology. Methods: Retrospective, analytical study of a cohort of patients treated by a single surgeon at our institution, in the period between 2015 and 2021. Results: We identified 31 patients and divided them into two groups: 15 (49%) treated using the microscopic technique (group M), and 16 (51%) exclusively via an endoscopic one (group E). Differences were observed between the means of the size of the craniectomy in group M (3.7 cm) compared to group E (2.5 cm); The mean length of hospital stay for patients in group E was shorter (4.46 days compared to that of patients in group M, whose hospital stay averaged 2.43 days). There were no differences between the two groups regarding the length of the procedure. In both groups, the predomi nant compression was due to the superior cerebellar artery (SCA). Pain outcomes were equivalent, with every patient in both groups having an improved postoperative Barrow Neurological Institute Pain Intensity Score (BNI). Discussion: Endoscopic microvascular decompression is an attractive option for the resolution of neurovas cular conflict as it provides functional results similar to the microscope technique, without requiring an exten sive craniectomy and associated to shorter in-hospital stay, which is beneficial for both the patient and the institution.

Posterior Fossa Calcifying Pseudoneoplasm of the Neuraxis (CAPNON): Presentation of Three Surgical Cases.

BACKGROUND: Calcifying pseudoneoplasm of the neuraxis (CAPNON) is an extremely rare entity with fewer than 150 cases reported in the literature and mostly with a supratentorial or spinal location. Posterior fossa CAPNON has been reported scarcely, and association with perilesional edema is a topic not yet approached which might play a significant role in treatment decision and clinical progression. Our objective is to report, to our knowledge, the first series of 3 posterior fossa CAPNON surgically treated in a single institution and assess features that help provide a systematic approach to diagnosis and timely treatment. METHODS: This was a monocentric, retrospective study of surgical patients diagnosed with a posterior fossa CAPNON in the last 5 years. A thorough bibliographic research was conducted. RESULTS: Three patients were included. Locations involved IV ventricle, right cerebellopontine angle with extension to foramen magnum, and cerebellar vermis. Two of them presented with symptoms linked to acute hydrocephalus, and the other one presented with progressive cranial nerve palsy and brainstem compression signs. The 3 of them showed radiological signs of perilesional edema on their preoperative magnetic resonance imaging. Gross total resection was accomplished in one case, with near and subtotal resections in the others. There were no complications. The outcome was favorable in all cases. CONCLUSIONS: It is essential to contemplate this infrequent diagnosis in cases of calcified lesions involving the posterior fossa. When symptoms manifest, surgery should be considered. Perilesional edema could be associated with symptomatic progression and hence a sign suggesting the need for surgical treatment.

Effectiveness of the Godelieve Denys-Struyf (GDS) method in people with low back pain: cluster randomized controlled trial.

BACKGROUND: The Godelieve Denys-Struyf method (GDS) is a motor learning intervention that may be applied in group or individualized sessions. OBJECTIVE: The study objective was to compare the effectiveness of routine physical therapy, group GDS (GDS-G) sessions, and group and individualized GDS (GDS-I) sessions. DESIGN: This was a cluster randomized controlled trial. SETTING: The study took place in 21 primary care physical therapy units ("clusters") of the Spanish National Health Service (SNHS). PARTICIPANTS: The participants were 461 people with subacute and chronic low back pain (LBP). INTERVENTION: Clusters were randomized into 3 groups. All participants received medical treatment and a 15-minute group education session on active management. Additional interventions were as follows: control (fifteen 40-minute sessions of transcutaneous electrical nerve stimulation, microwave treatment, and standardized exercises), GDS-G (eleven 50-minute group GDS sessions), and GDS-I (the same 11 sessions plus four 50-minute individualized GDS sessions). MEASUREMENTS: Primary outcomes at baseline and 2, 6, and 12 months later were LBP and pain referred down the leg (separate pain intensity numeric rating scales) and disability (Roland-Morris Questionnaire [RMQ]). Secondary outcomes were use of medication and self-reported health (mental and physical component summaries of the 12-Item Short-Form Health Survey [SF-12]). Separate linear mixed models for LBP, pain referred down the leg, and disability were developed to adjust for potential confounders. Randomization, outcome assessment, and data analyses were masked. RESULTS: At 12 months, disability improved 0.7 (95% confidence interval [CI]=-0.4, 1.8) RMQ point in the control group, 1.5 (95% CI=0.4, 2.7) RMQ points in the GDS-I group, and 2.2 (95% CI=1.2, 3.2) RMQ points in the GDS-G group. There were no differences in pain. LIMITATIONS: The amount of exercise was smaller in the control group, and GDS-I sessions were provided by junior physical therapists. CONCLUSIONS: The improvement in disability was slightly higher with group GDS sessions than with the program routinely used in clusters within the SNHS. Adding individualized GDS sessions eliminated this advantage. Further studies should compare the GDS with other types of exercise.