Determination of Normal Values of the Basal Angle in the Era of Magnetic Resonance Imaging.

BACKGROUND: The flexion of the skull base (basal angle [BA]) is the inclination between the anterior fossae and the basilar ramp of the occipital and sphenoid bones. An increased BA, termed platybasia, is usually associated with basilar invagination. BA reference values in the magnetic resonance imaging (MRI) era and the diagnosis of platybasia are of clinical importance. The transnasal approach has been the surgical technique of choice to remove the odontoid process in cases of ventral brainstem compression in patients with platybasia. The knowledge of normal BA values has been influenced by technological image acquisitions. The aim of this study was to determine the normal BA values in normal subjects in the MRI era. METHODS: For the determination of normal BA values, the literature reporting these values in normal individuals was reviewed and a meta-analysis of pertinent studies was performed. RESULTS: A total of 8 articles were included in this study, evaluating a total of 667 individuals. A summary measure of the results was obtained. The data obtained in this analysis provided a final basal angle value of 116.5 degrees (95% confidence interval, 104.39-128.7). The normal basal angle ranges between 104 and 129 degrees. CONCLUSION: Platybasia can be defined as a value >129 from the basal angle.

Basilar Invagination: A Craniocervical Kyphosis.

BACKGROUND: For more than a century, odontoid process prolapse, which compresses cranial base structures, has been the hallmark of basilar invagination (BI). The angulation of the whole skull toward the cervical spine may be considered to contribute to BI and odontoid prolapse. The objective of this study was to evaluate the craniocervical angular craniometry of patients with BI compared with patients with Chiari malformation (CM) and normal subjects. METHODS: Angular craniocervical relationships among midline magnetic resonance imaging scans from patients with BI, patients with CM, and normal subjects were evaluated and compared. Angles were measured by Meazure 2.0 software from digitalized images. RESULTS: Using data from 121 images, 42 patients with BI (14 type I BI, 28 type II BI), 47 patients with CM, and 32 control subjects were evaluated. The BI group had a more acute kyphotic angle than the CM group (P < 0.01) and control group. The kyphosis difference was 17.57 ± 2.3° (P < 0.01) between the BI and CM groups and 21.19 ± 2.3° (P < 0.01) between the BI and control groups. Basal angles were significantly larger in the BI group compared with the other 2 groups. A strong correlation was found with kyphosis and CLV and the clivus-canal angle and cervical lordosis angle (P < 0.01). CONCLUSIONS: Craniocervical kyphosis in patients with BI was approximately 20° greater than in normal subjects and patients with CM. Craniocervical kyphosis should be considered a pathophysiologic condition in BI.

Invasive treatment to control neuropathic pain / Tratamento invasivo para o controle da dor neuropática

ABSTRACT BACKGROUND AND OBJECTIVES: Distress, allied to neuropathic pain persistence and its refractory nature, often leads patients to accept invasive procedures. Neuropathic pain control is a major medical challenge requiring approaches and decisions especially based on effectiveness, risks and costs. This study aimed at reviewing these aspects related to major invasive procedures. CONTENTS: Major invasive procedures to control neuropathic pain are presented. Initially, classically reversible anesthetic blocks; then invasive neuromodulation techniques using electric current application and the magnetic field generated by it becomes a target to be stimulated, inhibited or modified in the nervous system (central, peripheral or autonomic); and, finally, ablative procedures including anesthetic methods administering neurolytic agents rather than anesthetics and neurosurgeries using different methods to injure the nervous system to control painful neuropathic discomfort. CONCLUSION: Patients eligible to invasive procedures to control neuropathic pain have, in addition to pain itself, a mixed distress including the collection of repeated delusions at every treatment failure. They have reserved prognosis with regard to total cure and, unfortunately, relieve obtained with invasive treatment in general does not reach persistent and high rates. In such adverse situation, these partial results of decreasing original pain intensity may be interpreted as acceptable, provided the impact on final quality of life is positive. Maybe, the rare exceptions are good results obtained with typical idiopathic/cryptogenic neuralgias ironically excluded from the stricter interpretation of the new pathophysiologic classification of neuropathic pains.

RESUMO JUSTFICATIVA E OBJETIVOS: O sofrimento aliado à persistência e refratariedade da dor neuropática frequentemente leva seu portador a aceitar tratamentos invasivos. O controle da dor neuropática representa um desafio médico importante necessitando adoção de condutas e decisões baseadas, principalmente, em efetividade, riscos e custos. O escopo deste estudo foi a revisão desses aspectos relacionados aos principais procedimentos invasivos CONTEÚDO: São apresentados os principais procedimentos invasivos utilizados para o controle da dor neuropática. Inicialmente, os bloqueios anestésicos, classicamente reversíveis; depois as técnicas de neuromodulação invasiva que utilizam a aplicação de corrente elétrica e o campo magnético por ela gerado em alvos a serem estimulados, inibidos ou modificados, no sistema nervoso (central, periférico ou autônomo); e, finalmente, os procedimentos ablativos que incluem os métodos anestésicos que administram agentes neurolíticos ao invés de anestésicos, e, as neurocirurgias que utilizam métodos diversos de produção de lesões no sistema nervoso para o controle do desconforto doloroso neuropático. CONCLUSÃO: Os pacientes que se apresentam como candidatos a receberem indicações de procedimentos invasivos para controle de dores neuropáticas, possuem além do inerente à própria dor, sofrimento misto, que inclui a coleção de desilusões reiteradas a cada insucesso de tratamento. Possuem prognóstico reservado no que tange a plena cura, e, infelizmente, o alívio obtido com o tratamento invasivo, em geral, não atinge taxas persistentes e elevadas. Nessa situação tão adversa esses resultados parciais de redução da intensidade da dor original possam ser interpretados como aceitáveis desde que o impacto na qualidade de vida final seja positivo. Talvez, as raras exceções, recaiam sobre os bons resultados obtidos com as neuralgias típicas, idiopáticas/criptogenéticas, ironicamente, excluídas da interpretação mais rígida da nova classificação fisiopatológica das dores neuropáticas.

Paraplegia secundária a tratamento com quiropraxia em paciente com mieloma múltiplo não diagnosticado / Paraplegia following massage therapy intervention in a patient with undiagnosed multiple myeloma

Introdução: Devido à disponibilidade crescente de terapias alternativas para o tratamento de dor nas costas e acesso por vezesdifícil de avaliações médicas especializadas, há um amplo uso de terapias alternativas para o tratamento de dor nas costas.Descrição do Caso: Descrevemos um caso com uma consequência catastrófica de massagem terapêutica em um paciente comsintomas iniciais de dor nas costas, resultando em paraplegia definitiva e discutimos as necessidades de diagnóstico médico paraqualquer tratamento. Discussão e Conclusão: Discutir os danos potenciais ao paciente, ao iniciar um método de tratamentoquestionável, que são o diagnóstico retardado, dano físico direto, interferência com tratamentos tradicionais, prejuízosfinanceiros e perda de tempo. Os tratamentos alternativos são ferramentas valiosas para controlar os sintomas refratários,especialmente a dor. Mas reforçamos a necessidade do rastreio médico adequado antes de realizar terapias que podem trazer...

Introduction: Due to increased number of available alternative therapies to the treatment of back pain and sometimes a difficultaccess to specialized medical evaluations, there is a widespread use of alternative therapies for the treatment of back pain.Case Description: We describe a case with a catastrophic consequence of massage therapy in a patient with initial symptomsof back pain resulting in definitive paraplegia and discuss the needs for medical diagnosis for any treatment. Discussion andConclusion: We discuss the potencial harms to the patient when initiating a questionable treatment method, which are latediagnosis, direct physical harm, interference with tradiotional treatments, financial harm and time loss. Alternative treatmentsare valuable tools to control refractory symptoms, especially pain....