Volumetric growth rate of incidental asymptomatic meningiomas: a single-center prospective cohort study.

BACKGROUND: Decision about treatment of incidentally found intracranial meningiomas is controversial and conditioned by the growth potential of these tumors. We aimed to evaluate the growth rate of a cohort of incidentally found asymptomatic meningiomas and to analyze their natural course and the need for eventual treatment. METHODS: A total of 193 patients harboring intracranial meningiomas (85 with 109 incidental and 108 with 112 symptomatic) were included between 2015 and 2019. In the prospective cohort of incidental meningiomas, we measured size at diagnosis, volumetric growth rate (by segmentation software), appearance of symptoms, and need for surgery or radiotherapy. Progression-free survival and risk factors for growth were assessed with Kaplan-Meier survival and Cox regression analyses. RESULTS: Among incidental meningiomas, 94/109 (86.2%) remained untreated during a median follow-up of 49.3 months. Tumor growth was observed in 91 (83.5%) and > 15% growth in 40 (36.7%). Neurological symptoms developed in 1 patient (1.2%). Volume increased an average of 0.51 cm3/year (95% CI, 0.20-0.82). Nine patients were operated (9.2%) and 4 underwent radiotherapy (4.7%). Treatment-related complication rates of incidental and symptomatic meningiomas were 0% and 35.4%, respectively. Persistent neurological defects occurred in 46 (40.7%) of symptomatic versus 2 (2.3%) of incidental meningiomas. Among covariates, only brain edema resulted in an increased risk of significant tumor growth in the female subgroup (Cox regression HR 2.96, 95% CI 1.02-8.61, p = 0.046). Size at diagnosis was significantly greater in the symptomatic meningioma group (37.33 cm3 versus 4.74 cm3, p < 0.001). CONCLUSIONS: Overall, 86% of incidentally found meningiomas remained untreated over the first 4 years of follow-up. The majority grew within the 20% range, yet very few developed symptoms. Treatment-related morbidity was absent in the incidental meningioma group.

Adscripción de un médico internista al servicio de neurocirugía: ventajas e implicaciones clínicas y profesionales / The appointment of an internal medicine practitioner to a neurosurgical department: Advantages, and clinical and professional implications

La mayor edad y creciente complejidad de los pacientes neuroquirúrgicos ingresados ha supuesto un incremento en las interconsultas con Medicina Interna. Esta colaboración presenta inconvenientes debido a la falta de continuidad asistencial y a la discrecionalidad de su uso. La adscripción de un internista al servicio de Neurocirugía a tiempo completo y con atribuciones asistenciales completas, salvo las estrictamente quirúrgicas, es una opción organizativa factible. Este sistema minimiza la necesidad de interconsultas, mejora la calidad asistencial percibida, permite que el cirujano se centre en tareas puramente quirúrgicas, aporta una visión global del paciente y de su enfermedad, enriquece al grupo con conocimientos especializados no neuroquirúrgicos y eleva el nivel científico del equipo. En nuestro servicio se dispone de una internista en plantilla desde hace 14 años. Describimos sus atribuciones de trabajo diarias, las ventajas asistenciales que proporciona al servicio y las implicaciones profesionales y laborales derivadas

The increasing age and complexity of in-hospital neurosurgery patients have raised the number of consultations with Internal Medicine. This type of collaboration is discretional and lacks temporal continuity. The full-time appointment of an internal medicine practitioner to a Neurosurgery Department, with complete care attributions except for strict surgical work, is a feasible organizational option. This method minimizes the need for medical consultation, improves the perceived quality of care, allows neurosurgeons to focus on purely surgical tasks, provides an integral vision of the patient's condition, enriches the group with specialized non-neurosurgical knowledge, and raises the scientific level of the team. In our Neurosurgery Department, an internal medicine practitioner has been working as part of the staff for 14 years. We describe her medical activity duties, the advantages our department gains from her daily work, and the professional and working implications derived

The appointment of an internal medicine practitioner to a neurosurgical department: Advantages, and clinical and professional implications. / Adscripción de un médico internista al servicio de neurocirugía: ventajas e implicaciones clínicas y profesionales.

The increasing age and complexity of in-hospital neurosurgery patients have raised the number of consultations with Internal Medicine. This type of collaboration is discretional and lacks temporal continuity. The full-time appointment of an internal medicine practitioner to a Neurosurgery Department, with complete care attributions except for strict surgical work, is a feasible organizational option. This method minimizes the need for medical consultation, improves the perceived quality of care, allows neurosurgeons to focus on purely surgical tasks, provides an integral vision of the patient's condition, enriches the group with specialized non-neurosurgical knowledge, and raises the scientific level of the team. In our Neurosurgery Department, an internal medicine practitioner has been working as part of the staff for 14 years. We describe her medical activity duties, the advantages our department gains from her daily work, and the professional and working implications derived.

Medidas de protección radiológica: implicaciones en el diseño de quirófanos de neurocirugía / Radiation protection measures: Implications on the design of neurosurgery operating rooms

Objetivo: Describir pros y contras de diversas medidas de protección radiológica y sus implicaciones en el diseño de un quirófano de neurocirugía. Material y métodos: Se realizó una reforma estructural del quirófano de neurocirugía a propósito de la adquisición y uso de un O-arm. Se ampliaron las medidas y blindajes del quirófano, y se instaló una mampara blindada y abatible en su interior. Se midieron dosis de radiación delante y detrás de la mampara. Resultados: La mampara proporciona una radioprotección integral para todo el personal de quirófano (dosis < 5μSv a 2,5 m del gantry por cada exploración con O-arm; 0,0μSv tras la mampara por cada exploración de O-arm; dosis acumulada anual tras la mampara, indetectable), obvia la necesidad de delantales plomados y dosímetros personales y minimiza la circulación de personal. El aumento del tamaño del quirófano permite almacenar los equipos dentro y minimiza el riesgo de colisión o contaminación. Los quirófanos rectangulares permiten aumentar la distancia al foco emisor de radiación. Conclusiones: El blindaje de paredes, techos y suelos, la forma rectangular y la superficie lo más amplia posible, la presencia de una mampara plomada y abatible, y los sistemas de seguridad que impiden una irrupción inesperada en el quirófano mientras se está irradiando son cuestiones relevantes a tener en cuenta en el diseño del quirófano de neurocirugía

Objective: To describe pros and cons of some radiation protection measures and the implications on the design of a neurosurgery operating room. Material and methods: Concurring with the acquisition and use of an O-arm device, a structural remodeling of our neurosurgery operating room was carried out. The theater was enlarged, the shielding was reinforced and a foldable leaded screen was installed inside the operating room. Radiation doses were measured in front of and behind the screen. Results: The screen provides whole-body radiation protection for all the personnel inside the theater (effective dose <5μSv at 2,5 m from the gantry per O-arm exploration; 0,0μSv received behind the screen per O-arm exploration; and undetectable cumulative annual radiation dose behind the screen), obviates the need for leaded aprons and personal dosimeters, and minimizes the circulation of personnel. Enlarging the size of the operating room allows storing the equipment inside and minimizes the risk of collision and contamination. Rectangular rooms provide greater distance from the source of radiation. Conclusion: Floor, ceiling and walls shielding, a rectangular-shaped and large enough theater, the presence of a foldable leaded screen, and the security systems precluding an unexpected irruption into the operating room during irradiation are relevant issues to consider when designing a neurosurgery operating theater

[Radiation protection measures: Implications on the design of neurosurgery operating rooms]. / Medidas de protección radiológica: implicaciones en el diseño de quirófanos de neurocirugía.

OBJECTIVE: To describe pros and cons of some radiation protection measures and the implications on the design of a neurosurgery operating room. MATERIAL AND METHODS: Concurring with the acquisition and use of an O-arm device, a structural remodeling of our neurosurgery operating room was carried out. The theater was enlarged, the shielding was reinforced and a foldable leaded screen was installed inside the operating room. Radiation doses were measured in front of and behind the screen. RESULTS: The screen provides whole-body radiation protection for all the personnel inside the theater (effective dose <5µSv at 2,5 m from the gantry per O-arm exploration; 0,0µSv received behind the screen per O-arm exploration; and undetectable cumulative annual radiation dose behind the screen), obviates the need for leaded aprons and personal dosimeters, and minimizes the circulation of personnel. Enlarging the size of the operating room allows storing the equipment inside and minimizes the risk of collision and contamination. Rectangular rooms provide greater distance from the source of radiation. CONCLUSION: Floor, ceiling and walls shielding, a rectangular-shaped and large enough theater, the presence of a foldable leaded screen, and the security systems precluding an unexpected irruption into the operating room during irradiation are relevant issues to consider when designing a neurosurgery operating theater.

Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos / Role of surgery in spontaneous spondylodiscitis: Experience in 83 consecutive patients

Objetivo: Describir y discutir el papel del tratamiento quirúrgico en la espondilodiscitis espontánea. Pacientes y métodos: Análisis retrospectivo de resultados y complicaciones de una cohorte de pacientes intervenidos por espondilodiscitis espontánea (no posquirúrgica) de cualquier nivel espinal y etiología. Resultados: En el período 1995-2014 se trataron 83 pacientes (45% mujeres, edad mediana 66 años) con diagnóstico de espondilodiscitis (confirmación microbiológica en el 67,4%). Existió déficit neurológico preoperatorio en el 44,5%. El nivel más frecuentemente afectado fue el dorsal (54,2%). Los principales gérmenes aislados fueron Mycobacterium tuberculosis (22,9%), Staphylococcus aureus (20,5%) y SARM (7,2%). Se intervinieron 81 pacientes mediante: laminectomía simple y/o biopsia (22,2%), laminectomía, desbridamiento y artrodesis posterior (43,2%), y desbridamiento y fijación anterior (34,5%). El 86,7% de los pacientes intervenidos obtuvieron buena evolución postoperatoria (mejoría sintomática o del déficit). Se estabilizaron 7 pacientes y empeoraron 2. Aparecieron complicaciones en 35 pacientes, fundamentalmente derrame pleural (9), anemia (7) y necesidad de reintervención y desbridamiento (7). La mediana de estancia postoperatoria fue de 14 días. Tras un seguimiento medio de 8,5 meses se consideraron curados 46 pacientes, 10 presentaron secuelas, se perdieron 22 pacientes y 5 fallecieron. La cirugía no motivó reingresos. Conclusiones: Aunque la antibioterapia específica y prolongada es el tratamiento estándar, la cirugía permite obtener muestra para estudio microbiológico e histopatológico, desbridar el foco infeccioso y estabilizar la columna. En nuestra experiencia la utilización de material metálico de fijación acelera la recuperación y no predispone a ulteriores infecciones o a cronificación de las mismas

Objective: To describe and discuss the role of surgery in the management of spontaneous spondylodiscitis. Patients and methods: Retrospective review on the outcome and complications of a cohort of patients undergoing surgery for spontaneous (non-postoperative) spondylodiscitis of any spinal level or aetiology. Results: From 1995 to 2014, 83 patients (45% females, median age 66) with spondylodiscitis were treated. Microbiological confirmation was obtained in 67.4%. Forty-four percent of patients presented with neurological defect. The most common affected level was thoracic (54.2%). The most frequent isolations were Mycobacterium tuberculosis (229%), Staphylococcus aureus (20.5%) and MRSA (7.2%). Eighty-one patients underwent surgery: simple laminectomy and/or biopsy (22.2%), debridement and posterior fixation (43.2%) and debridement and anterior fixation (34.5%). Improvement of pain or neurological defect was achieved in 86.7% of the patients; 7 patients stabilized and 2 worsened. Complications occurred in 35 patients, mainly pleural effusion (9), anaemia (7) and need for re-debridement (7). Median postoperative stay was 14 days. After a median follow up of 8.5 months, 46 patients were considered completely cured, 10 presented sequelae, 22 patients were lost and 5 patients died. No readmissions occurred because of the infectious episode. Conclusions: Although prolonged and specific antibiotic therapy remains the mainstay of treatment in spontaneous spondylodiscitis, surgery provides samples for microbiological confirmation and histopathologic study, allows debridement of the infectious foci and stabilizes the spine. In our experience, the use of internal metallic fixation material accelerates recovery and does not predispose to chronic infection

[Role of surgery in spontaneous spondylodiscitis: Experience in 83 consecutive patients]. / Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos.

OBJECTIVE: To describe and discuss the role of surgery in the management of spontaneous spondylodiscitis. PATIENTS AND METHODS: Retrospective review on the outcome and complications of a cohort of patients undergoing surgery for spontaneous (non-postoperative) spondylodiscitis of any spinal level or aetiology. RESULTS: From 1995 to 2014, 83 patients (45% females, median age 66) with spondylodiscitis were treated. Microbiological confirmation was obtained in 67.4%. Forty-four percent of patients presented with neurological defect. The most common affected level was thoracic (54.2%). The most frequent isolations were Mycobacterium tuberculosis (229%), Staphylococcus aureus (20.5%) and MRSA (7.2%). Eighty-one patients underwent surgery: simple laminectomy and/or biopsy (22.2%), debridement and posterior fixation (43.2%) and debridement and anterior fixation (34.5%). Improvement of pain or neurological defect was achieved in 86.7% of the patients; 7 patients stabilized and 2 worsened. Complications occurred in 35 patients, mainly pleural effusion (9), anaemia (7) and need for re-debridement (7). Median postoperative stay was 14days. After a median follow up of 8.5 months, 46 patients were considered completely cured, 10 presented sequelae, 22 patients were lost and 5 patients died. No readmissions occurred because of the infectious episode. CONCLUSIONS: Although prolonged and specific antibiotic therapy remains the mainstay of treatment in spontaneous spondylodiscitis, surgery provides samples for microbiological confirmation and histopathologic study, allows debridement of the infectious foci and stabilizes the spine. In our experience, the use of internal metallic fixation material accelerates recovery and does not predispose to chronic infection.

Spinal cord herniation repair with microstaples: case report.

Idiopathic spinal cord herniation (ISCH) is a relatively rare and frequently misdiagnosed condition. It preferentially affects women and causes progressive thoracic myelopathy that presents as a Brown-Séquard syndrome or as spastic paraparesis. Although its etiology and pathogenesis are controversial, ISCH is characterized by the presence of an anterior dural defect that allows the incarceration of a segment of the cord. Typically, a C-shaped ventral displacement and kinking of the cord are visible on sagittal MRI. Surgery aimed at stopping or reversing myelopathic symptoms is usually recommended for symptomatic patients. Surgical options include reduction of the hernia and direct suturing, or enlargement of the dural defect, with or without patching. Suturing under the cord in a very tight space can be troublesome and may lead to neurological deterioration. The authors present the case of a symptomatic ISCH in which nonpenetrating titanium microstaples were used to close the dural defect after cord reduction. The patient experienced a good outcome, and the follow-up MRI study showed adequate cord repositioning and stability of the suture. The use of microstaples, which allows for an easier and faster dural closure than conventional suturing, is a novel technical adjunct that has not been previously reported for this condition. In addition, microstaples produce minimal metallic artifact that does not hinder the quality of follow-up MR images.