Bloqueo del plano del erector espinal en L4 en cirugía de artrodesis lumbar: serie de casos / L4 erector spinal plane block after lumbar spine arthrodesi: a case-series

INTRODUCCIÓN: El bloqueo en el plano del erector espinal (erector spinae plane [ESP]) a nivel torácico se ha desarrollado en los últimos años en multitud de procedimientos quirúrgicos, incluido los pacientes tratados mediante artrodesis lumbar. Nos propusimos evaluar el efecto analgésico del ESP realizado a nivel lumbar L4 en el postoperatorio inmediato en pacientes intervenidos por artrodesis lumbar. MÉTODOS Y CASOS CLÍNICOS: Descripción de una serie de 8 casos clínicos intervenidos por artrodesis lumbar a quienes se les realizó un bloqueo del ESP lumbar bilateral en L4 con 20 ml de ropivacaína al 0,2% por lado. Se describió la intensidad del dolor durante las primeras 48 h del postoperatorio mediante escala visual analógica y la analgesia de rescate empleada. El dolor postoperatorio en reposo fue controlado en todos los pacientes (entre 0 y 3), si bien el dolor en movimiento fue considerado entre leve y severo según los pacientes (entre 0 y 8). El consumo de rescate fue entre 1 y 22mg de morfina. CONCLUSIONES: El ESP lumbar parece contribuir al control del dolor postoperatorio inmediato durante las primeras 48 h en pacientes intervenidos por artrodesis lumbar

INTRODUCTION: Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery. METHODS AND CASE SERIES: Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20 ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine. CONCLUSIONS: Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion

L4 erector spinal plane block after lumbar spine arthrodesi: A case-series. / Bloqueo del plano del erector espinal en L4 en cirugía de artrodesis lumbar: serie de casos.

INTRODUCTION: Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery. METHODS AND CASE SERIES: Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine. CONCLUSIONS: Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion.

Unusual twin pregnancy: complete hydatidiform mole with coexistent normal fetus.

The authors present a case of complete hydatidiform mole and coexisting fetus (CHMCF) in which mole gestation caused a placenta previa; with a posterior preterm premature rupture of membranes (PPROM) and ending in the 28h week of gestation due to acute chorioamnionitis, obtaining a live preterm newborn.

Primary tumour of the round ligament of the liver: a case presentation.

A 40-year-old Caucasian female patient presented to the outpatient General Surgery ward in "V. I. Lenin" Teaching Hospital complaining of a recurrent mesogastric pain that had lasted for 3 months. Physical examination showed a palpable mass confined to that area. She was then admitted with diagnosis of an abdominal tumour. Diagnostic work-up revealed that the process involved the round ligament of the liver, which is an exceptional localization, which motivated us to publish this case after surgical treatment by excision, having also taken into account the results of histopathology which revealed a PEComa, confirmed by inmunohistochemistry. After reviewing the available literature, the low incidence of these lesions, as well as the unusual histological variety, makes the present case one of interest.

[Accuracy of pedicle screw insertion in the thoracolumbar spine using image-guided navigation]. / Fiabilidad del navegador en la colocación de tornillos pediculares toracolumbares.

INTRODUCTION: Computer image guidance is one of the most significant technologic advancements in the spine surgery, because preoperative or intraoperative images can be used for multiplanar, three-dimensional intraoperative navigation. MATERIAL AND METHODS: We performed a prospective clinical study to assess the accuracy of pedicle screw insertion using an optoelectronic navigation system (SurgiGATE Spine 2.1 Medivision). The study population included 29 patients with diverse disorders of the thoraco- lumbar spine (degenerative 54%, spondylolisthesis 21%, fractures 14%, scoliosis 7% and spondylodiscitis 4%). One patient was excluded from the study because problems with the specific instruments or the computer system. Pre and post-operative axial computed tomography images were obtained for each patient and analyzed by two independent radiologists to placement accuracy. The correct location was defined accord to Heary scale in 5 grades. RESULTS: 163 image-guided thoraco-lumbar pedicle screws were placed 29 in the thoracolumbar spine and 134 in the lumbosacral spine. We achieved a completely intraosseous placement (Grade I) in 99.4% of lumbosacral spine screws and 100% of thoracolumbar spine screws. Only one misplaced screw (Grade III) in the pedicle of L III in the concavity of a scoliosis was reported. No implant related complications were noted. CONCLUSIONS: The low rate of misplaced screws in this prospective study compares favorably with previously published results. Our initial results indicate that Image-guided spinal surgery is a safe technique which improves surgical performance during posterior transpedicle stabilization.

Fiabilidad del navegador en la colocación de tornillos pediculares toracolumbares / Accuracy of pedicle screw insertion in the thoracolumbar spine using image-guided navigation

Introducción. La cirugía guiada por imagen es uno de los más importantes avances tecnológicos dentro de la cirugía del Raquis ya que permite al cirujano realizar una navegación multiplanar tridimensional en tiempo real en el interior de una vértebra. Material y métodos. Realizamos un estudio clínico prospectivo no randomizado sobre la fiabilidad en la colocación de tornillos pediculares mediante un sistema de navegación optoelectrónico (SurgiGATE Spine 2.1 Medivision). Se estudiaron veintinueve pacientes intervenidos por diferentes patologías en columna toracolumbar incluyendo: degenerativas (54%), espondilolistesis(21%), fracturas (14%), escoliosis (7%) y espondilodiscitis(4%). Un paciente fue eliminado del estudiodebido a un fallo técnico en el equipo de navegación.Se obtuvieron imágenes de TC pre y postoperatorias de cada paciente y éstas fueron evaluadas por dos neurorradiólogos independientes. La colocación correcta se definió de acuerdo a la escala de Heary en 5 grados.Resultados. Se colocaron 163 tornillos, 29 en la columnatoracolumbar y 134 en la columna lumbosacra.Hemos conseguido una colocación totalmente intraósea(Grado I) en el 99,4% de tornillos en la columnalumbosacra y en un 100% en la columna toracolumbar. Se comprobó el error de colocación (Grado III) en un pedículo de L3 en la concavidad de una escoliosis.No se observaron complicaciones relacionadas con los implantes.Conclusiones. El bajo porcentaje de tornillos mal colocados en este estudio se compara favorablemente con los resultados publicados en la literatura. Nuestros resultados indican que la cirugía guiada por imagen aplicada a la cirugía del raquis es una técnica segura para la fijación transpedicular (AU)

Introduction. Computer image guidance is one of the most significant technologic advancements in the spinesurgery, because preoperative or intraoperative images can be used for multiplanar, three-dimensional intraoperative navigation. Material and methods. We performed a prospective clinical study to assess the accuracy of pedicle screw insertion using an optoelectronic navigation system (SurgiGATE Spine 2.1 Medivision). The study population included 29 patients with diverse disorders of the thoracolumbar spine (degenerative 54%, spondylolisthesis 21%, fractures 14%, scoliosis 7% and spondylodiscitis 4%). One patient was excluded from the study because problems with the specific instruments or the computer system. Pre and post-operative axial computed tomography images were obtained for each patient and analyzed by two independent radiologists to place mentaccuracy. The correct location was defined accord to Heary scale in 5 grades. Results. 163 image-guided thoraco-lumbar pedicle screws were placed 29 in the thoracolumbar spine and 134 in the lumbosacral spine. We achieved a completely intraosseous placement (Grade I) in 99.4% of lumbosacral spine screws and 100% of thoracolumbar spinescrews. Only one misplaced screw (Grade III) in the pedicle of L III in the concavity of a scoliosis was reported. No implant related complications were noted. Conclusions. The low rate of misplaced screws in this prospective study compares favorably with previously published results. Our initial results indicate that Image-guided spinal surgery is a safe technique which improves surgical performance during posterior transpedicle stabilization (AU)

Glinidas. Revisión de su uso terapéutico en la diabetes mellitus tipo 2 / Glinides. A review of their therapeutic use in type 2 diabetes mellitus

Las glinidas representan una nueva familia de secretadores de insulina, químicamente heterogénea, caracterizados por un inicio de acción rápido y de corta duración. La repaglinida posee un efecto hipoglucemiantes uperponible al de las sulfonilureas convencionales. Algunos estudio sindican un descenso en el riesgo de hipoglucemias, sobre todo nocturnas, y en el caso de omisión de una comida principal. Este fármaco parece especialmente útil en estadios iniciales de la diabetes tipo 2 y en combinación con metformina. Puede emplearse en pacientes con insuficiencia renal moderada y está contraindicada en caso de insuficiencia hepática grave. La nateglinida presenta una menor duración de acción y un peor control de la hemoglobina glucosilada que la repaglinida. Algunos estudios experimentales sugieren que las glinidas pueden preservar mejor que las sulfonilureas la función de la célula betapancreática y que el mejor control de las excursiones glucémicas posprandiales podría tener un efecto beneficioso en la reducción del riesgo cardiovascular de estos pacientes (AU)

Glinides are a new, chemically heterogeneous class of insulin-secreting agents characterized by rapid onset and short duration of action. Repaglinide has an equivalent hypoglycemic effect to conventional sulfonylureas. Several studies have reported a decreased risk of hypoglycemias, particularly nocturnal hypoglycemic episodes or those occurring after a main meal has been missed. This drug seems to be particularly useful in the early stages of type 2 diabetes or in combination with met formin. Repaglinide can be used in patients with moderate renal insufficiency, but is contraindicated in severe hepatic dysfunction. Nateglinide has a shorter duration of action and is less effective in HbA1c control than repaglinide. Several experimental studies have suggested that glinides could be more effective in preserving beta-cell function than sulfonylureas, and that improvement of postprandial glucose levels could exert a protective cardiovascular effect (AU)

Escoliosis degenerativa del adulto: resultados del tratamiento quirúrgico / Adult degenerative scoliosis: surgical treatment results

Diseño del estudio. Estudio prospectivo del tratamiento en una serie clínica consecutiva de pacientes adultos con dolor y escoliosis, usando medidas pre- y postoperatorias. Objetivos. Evaluar los resultados del tratamiento quirúrgico, la mejoría del dolor y el aumento de la actividad física en los pacientes intervenidos por escoliosis degenerativa del adulto con clínica neurológica. Método. Quince pacientes adultos con escoliosis degenerativa y clínica neurológica que se trataron mediante descompresión y artrodesis instrumentada fueron seguidos de manera prospectiva durante dos años. El ángulo Cobb preoperatorio medio fue de 27,7° (11°-60°). Todos los pacientes se quejaban de dolor intenso (grado 2 en la escalera de dolor de la Organización Mundial de la Salud [OMS]). A los dos años de seguimiento los pacientes completaron un cuestionario sobre dolor, actividad física y situación laboral. La consolidación se valoró mediante radiología simple y tomografía axial computarizada (TAC). Resultados. El ángulo Cobb medio postoperatorio fue de 11,9° (1°-34°). El porcentaje de corrección medio fue del 60% (11%-87%). El dolor postoperatorio medio disminuyó en la mayoría de los pacientes (grado 1 en la escala de dolor de la OMS). La tasa de pseudoartrosis fue del 20%. Los pacientes mostraron su satisfacción con el tratamiento y se consiguió un aumento en la capacidad para desarrollar las actividades de la vida diaria. La tasa de reintervenciones fue del 20% (debido a pseudoartrosis, infección o síndrome suprafuncional) (AU)

Study design. Prospective study of treatment results, using pre- and postoperative measures, in a consecutive clinical series of adults patients with pain and scoliosis who underwent spinal fusion. Objective. To evaluate the outcome of surgical treatment of patients with painful adult scoliosis and neurological symptoms, reflected in decreased pain and increased activity. Methods. Fifteen adults with degenerative scoliosis and neurological symptoms treated with decompression and spinal fusion were followed prospectively for two years. Average preoperatively Cobb angle was 27'7° (11°-60°). All patients complained about pain (OMS pain scale grade 2). At two years of follow-up, patients completed a questionnaire including pain, activity level and work status. Bone healing was evaluated through X-ray and CT. Results. Average postoperatively Cobb angle was 11'9° (1°-34°). Average correction was 60% (11%-87%). Pain decreased in most of the patients (OMS pain scale grade 1). The nonunion rate was 20%. Patients reported satisfaction with the procedure and increased the ability for daily activities. Reintervention rate was 20% (due to pseudoarthrosis, infection or suprafunctional syndrome) (AU)

Modificación técnica al sistema USS fracturas para columna vertebral / Alternative design for a USS fractures

El sistema USS Fracturas permite reducir, fijar y aportarinjerto por vía transpedicular con buenos resultados en lasfracturas por flexión y compresión o por aplastamiento dela columna toracolumbar. La preparación de los pedículosde la vértebra fracturada para efectuar la espongioplastiaimpide el posterior agarre de los clavos roscados de Shanz.Por otro lado el diseño del fijador no permite colocar losclavos en la vértebra fracturada una vez montado el sistema.Hemos diseñado una modificación técnica que permitereducir la fractura, montar el sistema en los niveles superiore inferior de la vértebra fracturada, efectuar laespongioplastia con la fractura reducida y desplegada ysintetizar la vértebra lesional sin necesidad de desmontarla instrumentación. Los casos efectuados tras esta modificaciónno han demostrado aflojamientos de material niarrancamiento («pull out») de los tornillos

The USS Fracture Device allows to reduce, to fix and tobring graft by transpedicular way in wedge and burst typesof thoracolumbar fractures with good results. The cannulationof pedicles in a fractured vertebra for a graft avoida strong fixation of the Schanz nails. On the other side,the hardware design does not allow putting the nails in thefractured vertebra after locking the system. We havedesigned a technical modification to perform a reductionof the fracture, set the device above and below the lesionlevel and do a transpedicular bone grafting, including aosteosynthesis in the broken vertebra after hyperextensionmanoeuvre without hardware deconstruction. All the casesoperated after this alternative technical design show goodresults without device debreakings or pull out

Encuesta sobre la prescripción de genéricos en el ámbito de la atención primaria / Survey on the prescription of generic medicines in primary care

No disponible

Efectos de la erradicación de helicobacter pylori sobre el reflujo gastroesofágico patológico en pacientes con úlcera duodenal / Evolution of gastroesophageal reflux disease after eradication of helicobacter pylori in patients with duodenal ulcer

Background: Helicobacter pylori infection is not a risk factor for gastroesophageal reflux disease and it could even be a protector factor. Aim: To study the relationship between H pylori eradication and gastroesophageal reflux symptoms in patients with duodenal ulcer. Patients and methods: One hundred eleven patients with duodenal ulcer and treated for H pylori infection were studied. In 96 patients, H pylori was successfully eradicated and were evaluated every four months with endoscopy, during the first year. Thereafter, an annual clinical assessment was performed and endoscopy was repeated only if clinically indicated. Results: Patient were followed for a mean of 41 months (range 4 months to 6 years). Twelve patients (10.8 percent) had esophagitis at recruitment and in nine, H pylori was eradicated. The frecuency of gastroesophageal reflux symptoms or esophagitis in this group was similar to the rest of patients. During the first year, the frecuency of reflux symptoms ranged from 9 to 19 percent. The frecuency of esophagitis persisted at about 10 percent, although 81 percent of patients with esophagitis did not have it on recruitment. After the first year, the frecuency of reflux symptoms declined significantly to about 8 percent. Conclusions: In these patients with duodenal ulcer, gastroesophageal reflux disease had a variable evolution after H pylori eradication

[Spinal tuberculosis: early surgical treatment combined with medical treatment]. / Tuberculosis espinal: tratamiento quirúrgico temprano coadyuvante al tratamiento médico.

BACKGROUND: Spinal tuberculosis can produce kyphosis with neurologicaldeficit, despite antibiotic treatment. When there is no response to medical treatment, the recommended procedure is debridementand interbody fusion with bone autograft. The biological characteristicsof Mycobacterium tuberculosis do not prevent osteosynthesisof the infected bone from being performed. PATIENTS AND METHOD: Five patients with spinal tuberculosis and neurological deficitunderwent debridement, interbody fusion and anterior osteosynthesisin addition to medical treatment. In order to ensure stability, posterior fusion was also performed in three patients. All 5 patientsdisplayed weakness and paralysis of their lower extremities, two patients suffered an L4 radiculopathy, one developed paraparesiaand one was excluded due to a short follow-up. Mean value of vertebralkyphosis was 22,8 degrees and mean follow-up was 3,1 years. RESULTS: No patient had septic loosening or progression of the disease. Correction of kyphosis was 104,5% postoperatively and 80,5% atthe end of follow-up. All patients, apart from one with an L4radiculopathy, exhibited neurological recovery. CONCLUSIONS: Anterior instrumentation allows spinal decompression, septic focusdebridement, deformity correction and autologous bone grafting. In severe kyphotic flattening, it is advisable to associate alimited posterior arthrodesis. When pathological fractures appearor there is no response to antibiotic treatment, the combinationof medical and surgical treatment improves patients' outcome.

Tratamiento de la infección por helicobacter pylori en pacientes con úlcera duodenal: estudio de costo beneficio / Treatment of helicobacter pylori infection in patients with duodenal ulcer: a cost benefit study

Background: Epidemiological differences suggest that treatments for H. pylori eradication should be locally validated. Aim: To perform a cost benefit study of different treatment options for H. pylori infection. Patients and methods: One hundred and sixty-seven patients with active duodenal ulcer and H. pylori infection who completed a 2-week treatment with one of the following regimens were included: famotidine plus amoxycillin plus metronidazole (FAM), omeprazole plus amoxycillin plus tinidazole (OAT) or lansoprazole plus clarithromycin plus amoxycillin in 3 (LAC1) or 2 (LAC2) daily doses. We compared efficacy, adverse effects and cost. Results: Eradication rate was 74.6, 72.9, 96.4 y 91.7 percent for FAM, OAT, LAC1 and LAC2 respectively (p<0.05). Direct cost ranged from US$ 50 for FAM to US$ 220 for LAC1. A decision analysis was carried out in a model including direct and indirect costs and considering retreatment with antibiotics after the first treatment failure and one-year treatment with H2-blockers in case of a second failure. FAM was selected as the most cost-effective option, with an estimated cost of about US$ 300 ñ 148 per patient. However, cost associated to LAC2 was very similar (US$ 320 ñ 58) and the lower standard deviation suggests less variation. Sensitivity analyses, considering reasonable fluctuation in parameters such as eradication rate, cost and follow-up period suggest that a regimen containing a proton pump inhibitor, clarithromycin and amoxycillin may be the most cost-effective treatment. Conclusions: These results should be confirmed in other settings, specially in ordinary clinical practice, far from clinical research

Single-stage laparoscopic and endoscopic treatment for choledocholithiasis: a novel approach.

The transcystic approach is ideal for the management of choledocholithiasis detected during the course of laparoscopic cholecystectomy. When this approach is not possible or fails, current alternatives include laparoscopic choledochotomy, conversion to open common bile duct exploration, or postoperative endoscopic sphincterotomy (ES). Intraoperative ES is not routinely advised, as it is thought to be difficult to carry out in the operating room with the patient in the supine position. We challenged this concept and have performed ES intraoperatively when the transcystic approach had failed. Five consecutive patients in whom transcystic extraction of choledocholiths had failed underwent intraoperative ES. The laparoscopic procedure was terminated, the trocars were removed, the wounds were closed, and the patients were placed in the left lateral decubitus position. In this position, the endoscope was inserted, ES was performed under fluoroscopic guidance, and choledocholithiasis was treated. There were no difficulties or complications, and the postoperative course was similar to that of a simple laparoscopic cholecystectomy in all five patients. Intraoperative ES is a viable and effective treatment for choledocholithiasis when the transcystic approach fails. This novel approach to choledocholithiasis is well tolerated and may save the extra time and effort associated with all other current alternatives.