Combined Vertebral Augmentation for Vertebral Body Fracture With Contraindications for Traditional Techniques.

INTRODUCTION AND OBJECTIVE: A vertebral compression fracture (VCF) can be found in trauma, osteoporosis, and tumor pathology. The most frequent is the pathological fracture in osteoporotic vertebrae in the elderly. Percutaneous techniques of vertebral cementation allow treatment of A1-A2 AO spine fractures, improving pain control and spine stabilization and decreasing mobility and mortality. Traditionally, the selection of patients is fundamental for spine surgery success, with an absolute contraindication being posterior wall involvement (A3-A4 AO spine fractures) or VCF with a loss of height greater than 50%. In this report, we present a variant surgical technique combining percutaneous spine surgery with cementoplasty for patients with classical spine surgery contraindications. METHODS: Five patients with complex symptomatic VCF or A3-A4 AO spine fractures in pathologic bone with MRI short tau inversion recovery (STIR) sequence (+) were operated on with a combined technique (percutaneous kyphoplasty (KP) and vesselplasty). The visual analog scale (VAS) was used to measure postoperative pain. RESULTS: The procedure was performed within 60 days of the fracture in all patients. The mean hospital stay was two days. No patient developed major complications. All the patients had a satisfactory clinical (improvement in pain control) and radiological response at the perioperative period and at a 30-day follow-up. CONCLUSIONS: The combined percutaneous technique allows surgical resolution of cases previously considered contraindicated, especially in elderly patients and those with comorbidities, without involving higher cost, complications, surgical time, and hospital stay. We suggest a novel, safe, and effective variation of the vertebral cementoplasty technique.

Actualización en el tratamiento del síndrome de hipertensión intracraneana / Update on the management of intracranial hypertension syndrome

Elevated intracranial pressure (ICP) is a devastating complication, with great impact on neurological status and high morbidity and mortality. Intracranial hypertension (ICH) has multiple etiologies. The natural history of this condition can lead to brain death. The successful management of patients with elevated ICP (> 20-25 mmHg) requires fast and timely recognition, judicious use of invasive monitoring and therapies aimed to reversing its underlying cause. Therefore, it must be managed as a neurological emergency. The objective of this review is to present in a friendly way the diagnostic approach and the management of ICH, focused on general practitioners.

Deep Brain Stimulation Surgery for Parkinson Disease Coexisting With Communicating Hydrocephalus: A Case Report.

We report a successful bilateral globus pallidus internus-deep brain stimulation (GPi-DBS) for a Parkinson disease (PD) patient with idiopathic normal pressure hydrocephalus (INPH) and an unusually long anterior commissure-posterior commissure (AC-PC) line. A 54-year-old man presented with a history of 3 months of severe shuffling gait, rigidity, slow movements of the left side limbs, and difficulty managing finances. A brain MRI revealed marked ventriculomegaly (Evans index = 0.42). The patient was diagnosed with INPH and a ventriculoperitoneal shunt was placed. Cognitive impairment improved, but walking disturbances, slowness, and rigidity persisted. Then treatment with levodopa was added, and the patient experienced a sustained improvement. He was diagnosed with PD. After 7 years, the patient developed gait freezing and severe levodopa-induced dyskinesia. The patient underwent bilateral GPi-DBS. We used MRI/CT fusion techniques for anatomical indirect targeting. Indirect targeting is based on standardized stereotactic atlas and on a formula-derived method based on AC-PC landmarks. The AC-PC line was 40 mm (the usual length is between 19 and 32 mm). Intraoperative microelectrode recording was a non-expendable test, but multiple recordings were avoided to reduce the surgical risk of ventricular involvement. There was a 71% decrease in the UPDRS III score during the on-stimulation state (28 to 8). The patient's dyskinesias resolved dramatically with a UdysRS of 15 (88% improvement) during the on-stimulation condition. The observed motor benefits and the improvement of his daily activities have persisted 6 months after surgery. Deep brain stimulation surgery in PD with ventriculomegaly is a challenge. This procedure can result in a greater chance of breaching the ventricle, with risks of intraventricular hemorrhage and migration of cerebrospinal fluid into the brain parenchyma with target displacement. Furthermore, clinical judgment is paramount when recent onset of shuffling gait coexists with ventriculomegaly because the most common dilemma is differentiating between PD and INPH. For these reasons, neurologists and surgeons may refuse to operate on PD patients with ventriculomegaly. However, DBS should be considered for PD patients with motor complications when responsiveness to levodopa is demonstrated, even in the context of marked ventriculomegaly.

Manejo de la espasticidad en pacientes con lesión medular con infusión de baclofeno intratecal mediante bomba implantable / Treating spasticity in medullar lesion patients with intrathecal baclofen

Presentamos 3 casos con lesión medular traumática alta, secuelados con tetraplejia y espasticidad de difícil manejo, en los que se evalúa la seguridad y eficacia del uso de baclofeno intratecal. Para evaluar la respuesta a baclofeno intratecal, previo a la implantación de la bomba, los pacientes fueron sometidos a una prueba terapéutica con bolos de baclofeno en dosis de 25, 50, 75 y 100 gamas, administradas por punción lumbar, con lo que se obtuvo una significativa disminución de la rigidez y espasticidad por más de 8 horas en todos los casos, evaluados con las escalas de Ashworth y de espasmos de Penn. A estos 3 pacientes se les implantó una bomba programable con un catéter intratecal para infusión de baclofeno a nivel dorsal. Los pacientes se controlaron neurológicamente cada 3 meses. Se logró mantener una respuesta clínicamente satisfactoria, debiéndose ajustar progresivamente dosis de baclofeno. No se han observado complicaciones significativas