A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

[Progressive Brown-Sequard syndrome secondary to idiopathic spinal cord herniation: clinico-radiological and surgical correlations]. / Síndrome de Brown-Séquard progresivo secundario a hernia medular idiopática: correlación clinicorradiológica y quirúrgica.

INTRODUCTION: Idiopathic medullary herniation is an infrequent disease, which shows up in clinical form as a progressive mielopathy, most commonly known as the Brown-Sequard syndrome. Its anatomical base is a dural defect where a portion of anterior spinal cord gets progressively incarcerated. The MRI and myelo-CT scan show a bending of the spinal cord in the form of a «bell tent¼ towards the anterior dural sheath at the mid-dorsal portion mainly. CASE REPORT: A 37 year old male, who was diagnosed of idiopathic medullary herniation and surgically treated by our own developed technique, reporting its neuroradiological, anatomo-surgical and clinical correlation. CONCLUSION: Treatment should be individualized, as no standard surgical technique has been established up to the present.

TITLE: Síndrome de Brown-Séquard progresivo secundario a hernia medular idiopática: correlación clinicorradiológica y quirúrgica.Introducción. La hernia medular idiopática es una patología infrecuente que cursa clínicamente con una mielopatía progresiva, la mayoría de las ocasiones en forma de síndrome de Brown-Séquard. Su base anatómica es un defecto dural por el que se incarcera progresivamente una porción del cordón medular anterior. La resonancia magnética y la mielotomografía demuestran un acodamiento medular en «tienda de campaña¼ hacia la cara anterior del estuche dural, a nivel dorsal medio fundamentalmente. Caso clínico. Varón de 37 años, diagnosticado de hernia medular idiopática e intervenido quirúrgicamente mediante una técnica propia; se demuestra su correlación neurorradiológica, anatomoquirúrgica y evolutiva. Conclusión. El tratamiento debe ser individualizado, pues no existe una técnica quirúrgica universalmente establecida.

Costes indirectos asociados al glioblastoma. Experiencia en un centro / Indirect costs associated with glioblastoma: Experience at one hospital

Introducción: El glioblastoma es el tumor cerebral más frecuente. A pesar de los avances en su tratamiento, el pronóstico sigue siendo pobre, con una supervivencia media en torno a los 14 meses. Los costes directos, aquellos asociados al diagnóstico y el tratamiento de la enfermedad, han sido descritos ampliamente. Los costes indirectos, aquellos derivados de la pérdida de productividad debido a la enfermedad, han sido descritos en escasas ocasiones. Material y método: Realizamos un estudio retrospectivo, incluyendo a los pacientes diagnosticados entre el 1 de enero del 2010 y el 31 de diciembre del 2013 de glioblastoma en el Hospital Universitario Donostia. Recogimos datos demográficos, relativos al tratamiento ofertado y la supervivencia. Calculamos los costes indirectos a través del método del capital humano, obteniendo datos de sujetos comparables según sexo y edad, y de mortalidad de la población general a través del Instituto Nacional de Estadística. Los salarios pasados fueron actualizados a euros de 2015 según la tasa de inflación interanual y los salarios futuros fueron descontados en un 3,5% anual en forma de interés compuesto. Resultados: Revisamos a 99 pacientes, 46 mujeres (edad media 63,53 años) y 53 hombres (edad media 59,94 años). En 29 pacientes se realizó una biopsia y en los 70 restantes se realizó una cirugía resectiva. La supervivencia global media fue de 18,092 meses. Los costes indirectos totales fueron de 11.080.762 Euros (2015). El coste indirecto medio por paciente fue de 111.926 Euros (2015). Discusión: A pesar de que el glioblastoma es un tipo relativamente poco frecuente de tumor, que supone el 4% de todos los tipos de cáncer, su mal pronóstico y sus posibles secuelas generan una mortalidad y morbilidad desproporcionadamente altas. Esto se traduce en unos costes indirectos muy elevados. El clínico debe ser consciente del impacto del glioblastoma en la sociedad y los costes indirectos deben ser tenidos en cuenta en los estudios de coste-efectividad para conocer las consecuencias globales de esta enfermedad (AU)

Introduction: Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described. Material and method: We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries. Results: We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was Euros11 080 762 (2015). Mean indirect cost per patient was Euros 111 926 (2015). Discussion: Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease (AU)

Indirect costs associated with glioblastoma: Experience at one hospital. / Costes indirectos asociados al glioblastoma. Experiencia en un centro.

INTRODUCTION: Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described. MATERIAL AND METHOD: We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries. RESULTS: We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was €11 080 762 (2015). Mean indirect cost per patient was €111 926 (2015). DISCUSSION: Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease.

Metástasis de carcinoma escamoso de laringe en seno cavernoso. Presentación de un caso / Surgical management in metastatic squamous cell carcinoma of the larynx to the cavernous sinus. Case report

La afectación del seno cavernoso en el cáncer laríngeo supone la presencia de una enfermedad en estadio avanzado y de corta supervivencia. El objetivo del trabajo es presentar un caso de un paciente diagnosticado de carcinoma escamoso de laringe. Se realizó una revisión en las bases de datos Medline, DOYMA y Scielo con las palabras "metástasis en seno cavernoso". Encontramos publicados 10 casos de carcinoma escamoso de laringe con metástasis en seno cavernoso. La supervivencia media de los 10 casos publicados en la literatura fue 4,1 meses, en nuestro caso 9 meses. Los pacientes que recibieron radioterapia mejoraron sintomáticamente. El diagnóstico en algunos casos sólo se confirmó en la realización de una necropsia. En este tipo de lesiones, la cirugía se utiliza para diagnóstico más que como una herramienta terapéutica (AU)

The spread to the cavernous sinus in laryngeal cancer means the presence of a disseminated disease and short survival. The aim of this paper is to report a case of laryngeal squamous carcinoma of the larynx. A search was conducted in the databases of Medline and SciELO DOYMA using the words "cavernous sinus metastasis". We found 10 published cases of laryngeal squamous carcinoma with metastasis to the cavernous sinus. The average survival of the 10 cases reported in the literature was 4.1 months; in our case it was 9 months. Patients who received radiotherapy improved symptomatically. In some cases the diagnosis was confirmed only after necropsy. In this type of lesions, surgery is used for diagnosis rather than as a therapeutic tool (AU)

[Surgical management in metastatic squamous cell carcinoma of the larynx to the cavernous sinus. Case report]. / Metástasis de carcinoma escamoso de laringe en seno cavernoso. Presentación de un caso.

The spread to the cavernous sinus in laryngeal cancer means the presence of a disseminated disease and short survival. The aim of this paper is to report a case of laryngeal squamous carcinoma of the larynx. A search was conducted in the databases of Medline and SciELO DOYMA using the words "cavernous sinus metastasis". We found 10 published cases of laryngeal squamous carcinoma with metastasis to the cavernous sinus. The average survival of the 10 cases reported in the literature was 4.1 months; in our case it was 9 months. Patients who received radiotherapy improved symptomatically. In some cases the diagnosis was confirmed only after necropsy. In this type of lesions, surgery is used for diagnosis rather than as a therapeutic tool.

[Remote cerebellar haemorrhage after lumbar arthrodesis: case report and literature review]. / Hematoma cerebeloso como complicación de artrodesis lumbar. A propósito de uncaso y revisión de la literatura.

Remote cerebellar haemorrhage (RCH) is a rare complication of spinal surgery, less frequent than the RCH observed after an intracranial surgery. The patients principally complained of headache or were presented with deterioration in mental status. We report a case of RCH in a 55 years old woman that underwent lumbar arthrodesis with occult dural defect. We review the literature, analysing its causes and therapeutic implications.

Hematoma cerebeloso como complicación de artrodesis lumbar. A propósito de un caso y revisión de la literatura / Remote cerebellar haemorrhage after lumbar arthrodesis: Case report and literature review

El hematoma cerebeloso (HCD) como complicación en cirugía de raquis, es menos frecuente que el hematoma a distancia secundario a la cirugía intracraneal. Se manifiesta principalmente con cefalea o deterioro del nivel de consciencia y se ha asociado a la pérdida de LCR intra o postoperatoria. Presentamos un caso de HCD en una paciente de 55 años tras cirugía instrumentada de columna lumbar con fístula de LCR oculta, además de una revisión de la literatura con análisis de sus posibles causas, así como las implicaciones terapéuticas (AU)

Remote cerebellar haemorrhage (RCH) is a rare complication of spinal surgery, less frequent than the RCH observed after an intracranial surgery. The patients principally complained of headache or were presented with deterioration in mental status. We report a case of RCH in a 55 years old woman that underwent lumbar arthrodesis with occult dural defect. We review the literature, analysing its causes and therapeutic implications (AU)

Early mortality in spontaneous supratentorial intracerebral haemorrhage.

BACKGROUND: Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival. METHODS: Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU. FINDINGS: During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases. CONCLUSIONS: Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.

Early mortality in spontaneous supratentorial intracerebral haemorrhage

Background. Spontaneous supratentorial intracerebralhaemorrhage is a severe, frequent, and poorlyunderstood condition. Despite the publication of 12 randomisedcontrolled trials on this subject, the role of surgeryremains controversial and no treatment has proved to beeffective. We report on a ten year prospective cohort studybased on a defined population treated with or without surgeryand their outcome in terms of early survival.Methods. Population based, ten year prospective observationalstudy directed to patients consecutively admittedto the Intensive Care Unit (ICU) in a tertiary centre withspontaneous supratentorial intracerebral haemorrhage.Patients were distributed in five groups according to theGlasgow Coma Score (GCS) at admission. Haemorrhageswere classified as deep-seated or superficial. All patientreceived standard medical care, and additionally surgeryif it was found indicated by the duty neurosurgeon. Primaryendpoint was early mortality defined as dead occurredby any cause during the admission in the ICU.Findings. During the ten year period, 1.485 patientswere admitted to our centre with primary intracerebralhaemorrhage. Of these, 376 were admitted to theintensive care unit and 285 sustained supratentorialhaemorrhages. Low GCS was strong predictor of earlymortality. Despite the larger size of haematomas inpatients undergoing surgical evacuation, surgery wasassociated with lower early mortality in all GCS subgroups.Maximal benefit was observed in patient withadmission GCS of 4-8. Superficial haematomas wereoperated on more often, and were associated with lowermortality rate than deep-seated cases.Conclusions. Our findings suggest that craniotomyfor haematoma evacuation may reduce early mortalityin patients with primary supratentorial intracerebralhaemorrhage. Surgery seems specially useful in patientswith admission GCS between 4 and 8, and in those withsuperficial haemorrhages (AU)

Introducción. La hemorragia intracerebral supratentorialespontánea es un proceso frecuente, gravey poco comprendido. A pesar de la publicación de 12ensayos clínicos controlados sobre el tema, la indicaciónquirúrgica es controvertida y ningún tratamiento se hamostrado efectivo. Presentamos los resultados de unestudio prospectivo de cohortes desarrollado a lo largo dediez años en una población definida. Los pacientes recibierontratamiento quirúrgico o conservador y su evoluciónse describe en términos de mortalidad temprana.Material y métodos. Estudio prospectivo y observacionalbasado en una población definida en el que se incluyeronconsecutivamente todos los pacientes que ingresaron a lolargo de diez años en la Unidad de Cuidados Intensivos(UCI) de un centro terciario. Los pacientes fueron clasificadosen cinco grupos de acuerdo al puntaje en la escalade coma de Glasgow (GCS) al ingreso. Las hemorragiasfueron clasificadas en superficiales y profundas. Todoslos pacientes recibieron el tratamiento médico estándary cirugía de acuerdo con la indicación del neurocirujanode guardia. El punto final del análisis fue la mortalidadtemprana, definida como muerte por cualquier causaocurrida durante el ingreso en UCI.Resultados. Un total de 1.485 pacientes con hemorragiaintracerebral espontánea fueron ingresados ennuestro centro durante los diez años del estudio. De (..) (AU)

[Skull-base plasmacytoma with craniocervical instability]. / Plasmocitoma de base craneal con inestabilidad cráneo-cervical.

INTRODUCTION: Cranio-cervical instability is, in some cases, the main surgical concern in posterior skull base tumors. We report on a case in which a solitary plasmacytoma of the skull base presented with cranio-cervical instability. Vertebral artery was injured during surgery. The surgical anatomy is reviewed, with emphasis in vascular complications avoidance. CASE REPORT: A 66 year-old woman was diagnosed of a cranial base solitary plasmacytoma and treated with radio and chemotherapy with complete remission. After receiving that treatment, she presented with tetraparesis and a cranio-cervical instability was diagnosed. She was operated on, under cranial traction, of posterior occipito-cervical instrumentation with C1 to C2 transarticular Magerl screws. The right vertebral artery was injured during surgery without additional neurological deficit. Two years after the operation she remains independent for daily activities. CONCLUSIONS: Transarticular screws at the C1 to C2 level of the cervical spine may provide rigid fixation in posterior cranio-cervical instrumentation for osteolytic lesions, but there is a risk of injury to the vertebral artery, specially when some variations in the surgical anatomy exist.

Plasmocitoma de base craneal con inestabilidad cráneo-cervical / Skull base plasmacytoma with craniocervical instability

Introducción. La inestabilidad cráneo-cervicalconstituye, en ocasiones, el principal problema neuroquirúrgicoen la patología tumoral de la base cranealposterior. Presentamos un caso clínico en el que unplasmocitoma solitario originó inestabilidad cráneocervical.Durante la cirugía de estabilización, se lesionóla arteria vertebral. Revisamos la anatomía quirúrgicadesde el punto de vista de la prevención de las complicacionesvasculares.Caso clínico. Mujer de 66 años diagnosticada deplasmocitoma solitario de base craneal, tratada conradio y quimioterapia con remisión completa, quepresenta tetraparesia y disfagia. Tras el diagnóstico deinestabilidad cráneo-cervical, se indica estabilizaciónmediante instrumentación occipito-cervical. Es intervenidabajo tracción craneal con atornillado C1-C2 segúntécnica de Magerl y extensión occipital. Durante lacirugía se lesionó la arteria vertebral derecha sin repercusiónclínica. Dos años más tarde, la paciente es capazde llevar una vida independiente.Conclusiones. La instrumentación cráneo-cervicalcon tornillos transarticulares C1-C2, como parte delsistema de fijación C0-C1-C2, parece eficaz para corregirla inestabilidad en lesiones osteolíticas, a expensasde un riesgo considerable de lesión de la arteria vertebral,especialmente en presencia de algunas variacionesanatómicas (AU)

Introduction. Cranio-cervical instability is, in somecases, the main surgical concern in posterior skull basetumors. We report on a case in which a solitary plasmacytomaof the skull base presented with cranio-cervicalinstability. Vertebral artery was injured during surgery.The surgical anatomy is reviewed, with emphasis invascular complications avoidance.Case report. A 66 year-old woman was diagnosedof a cranial base solitary plasmacytoma and treatedwith radio and chemotherapy with complete remission.After receiving that treatment, she presented withtetraparesis and a cranio-cervical instability was diagnosed.She was operated on, under cranial traction, ofposterior occipito-cervical instrumentation with C1 toC2 transarticular Magerl screws. The right vertebralartery was injured during surgery without additionalneurological deficit. Two years after the operation sheremains independent for daily activities.Conclusions. Transarticular screws at the C1 to C2level of the cervical spine may provide rigid fixation inposterior cranio-cervical instrumentation for osteolyticlesions, but there is a risk of injury to the vertebralartery, specially when some variations in the surgicalanatomy exist (AU)

[Spinal cord compression due to a epidural lipoma]. / Compresión medular por lipoma epidural dorsal.

INTRODUCTION: The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and the functional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. CASE REPORT: A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. CONCLUSIONS: Spinal epidural lipoma is a benign tumour which initially presents itself with local or radicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved.

Compresión medular por lipoma epidural dorsal / Spinal cord compression due to a epidural lipoma

Introducción. El espacio extradural raquídeo se encuentra normalmente ocupado por tejido adiposo y por un rico plexo venoso, por lo que no es sorprendente que sea el asiento de tumores de estirpe lipídica que pueden al cazar un tamaño suficiente como para comprimir la médula espinal. Los lipomas epidurales son infrecuentes y se manifiestan clínicamente con un síndrome de compresión medular y/o radicular progresivo. La resonancia magnética del raquis suele serla clave en el diagnóstico, pues demuestra con claridad tanto la naturaleza como la localización del tumor y su extensión en relación al cordón medular. Con frecuencia se trata de lesiones accesibles para la extirpación quirúrgica y tienen un excelente pronóstico en cuanto a la recuperación funcional. Desde el punto de vista histopatológico se las describe como lesiones de aspecto similar al tejido graso maduro mezclados con numerosos canales vasculares, razón por la cual se los ha denominado angiolipomas. Caso ilustrativo. Mujer de 47 años que consulta por dolor submamario bilateral de dos años de duración acompañado de pérdida progresiva de sensibilidad y debilidad en las extremidades inferiores. El estudio por resonancia magnética llevó al diagnóstico de una compresión medular por una masa epidural a nivelD3-D7. Durante la intervención quirúrgica se identificó un tumor amarillento fácilmente disecable que se extirpó completamente. Un año más tarde la paciente se encuentra asintomática. Conclusión. Los lipomas extradurales raquídeos son tumores benignos que suelen presentarse como un síndrome radicular seguido de síndrome de compresión medular. El tratamiento de elección es la extirpación quirúrgica a través de una laminectomía. Probablemente se trata de los tumores técnicamente más fáciles de extirpar del raquis y que más satisfacciones produce al neurocirujano y al paciente ya que la recuperación funcional suele ser completa

Introduction. The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and thefunctional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. Case report. A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. Conclusions. Spinal epidural lipoma is a benign tumour which initially presents itself with local orradicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved

Secondary abdominoplasty.

BACKGROUND: Abdominoplasty is the most frequent excisional body contour procedure performed in aesthetic surgery. Secondary abdominoplasty refers to a new excisional procedure for a patient who has previously undergone an excisional abdominoplasty. In the authors' practice, more than 7% of abdominoplasties are secondary cases and deserve special consideration. METHODS: The authors present a retrospective analysis of their experience with 21 secondary cases among 298 abdominoplasties performed between 2001 and 2006. They have considered as secondary cases only those involving patients who have undergone excisional abdomen contour surgery previously. RESULTS: A total of 17 patients underwent surgery during the first year after the primary procedure, and 4 patients had surgery more than 5 years after that procedure. Following the principles described in this report, it was possible to solve the problem in each particular case and to obtain improvements in both trunk contour and patient satisfaction. CONCLUSIONS: In planning and designing the procedure, a precise diagnosis of the abdominal deformities is essential. The risks in secondary abdominoplasty are similar to those in the primary procedure.

[Effect of the administration of cholecystokinin on the cholestasis associated with total parenteral nutrition in experimental short bowel]. / Efecto de la administración de colescistoquinina sobre la colestasis asociada a la nutrición parenteral total en el intestino corto experimental.

INTRODUCTION: Total parenteral nutrition (TPN) is not free of complications. One of the most serious is cholestasis; the cause of this complication is unclear but it may be due to a lack of an enteral stimulus for cholecystokinin (CCK) production. CCK is essential for contraction of the gallbladder and also stimulates intrahepatic bile flow. Its absence may contribute to cholestasis. After any hepatic aggression, the Kupffer cells respond and release proinflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-alpha), which increase the hepatic damage. The objective of this experimental study has been to observe the effect that the exogenous administration of CCK could have on hepatic damage in experimental short bowel with and without TPN, determined using the serum levels of IL-1 and TNF-alpha. MATERIAL AND METHODS: A resection of 80% of the small bowel was performed on 53 Wistar rats and a continuous infusion of saline or TPN was initiated. The rats were divided into the following groups: SHAM (N = 14): normal saline infusion and free access to food and water. TPN (N = 15): Standard TPN. SHAM-CCK (N = 14): same as the SHAM group but with a daily dose of CCK. TPN-CCK (N = 10): same as the TPN group but with a daily dose of CCK. At the end of the experiment, the animals were sacrificed and blood samples were obtained to determine the IL-1 and TNF-alpha values by ELISA. RESULTS: The IL-1 and TNF-alpha levels were higher in the TPN group (7.537 and 5.899 pg/mL, respectively) than in the SHAM group (6.509 and 4.989 pg/mL, respectively) (p > 0.05). The TNF-alpha values were higher in the SHAM group (4.989 pg/mL) than in the SHAM-CCK group (4.583 pg/mL) (p < 0.001). The IL-1 and TNF-alpha levels were higher in the TPN group than in the TPN-CCK group (6.709 and 4.794 pg/mL, respectively) (p < 0.001 for TNF-alpha). CONCLUSIONS: 1. There is a rise in the serum levels of the pro-inflammatory cytokines IL-1 and TNF-alpha in animals with short bowel on TPN or enteral nutrition. 2. The administration of CCK causes a fall in the IL-1 and TNF-alpha levels, and could be used such as a further measure to prevent TPN-associated cholestasis.

Efecto de la administración de colescistoquinina sobre la colestasis asociada a la nutrición parenteral total en el intestino corto experimental / Effect of the administration of cholecystokinin on the cholestasis associated with total parenteral nutrition in experimental short bowel

Introducción. La nutrición parenteral total (NPT) no está libre de complicaciones. Una de las más serias es la colestasis, cuyo origen no es muy claro y puede deberse a la falta de estimulo enteral para la producción de colescistoquinina (CCQ). La CCQ es fundamental para la contracción de la vesícula biliar y como estimulante del flujo biliar intrahepático. Su falta puede contribuir a la colestasis. Ante toda agresión hepática, las células de Kupffer responden y liberan citoquinas proinflamatorias, como la interleukina-1 (IL-1) y el factor de necrosis tumoral alfa (TNF-α), que aumentan el daño hepático. El objetivo de este estudio experimental ha sido observar el efecto que la administración exógena de CCQ pudiera tener sobre el daño hepático en el intestino corto experimental con y sin NPT, medido por los niveles séricos de IL-1 y TNF-α. Material y métodos. Cincuenta y tres ratas Wistar fueron sometidas a una resección del 80% del intestino delgado y a una infusión continua de suero o NPT y se asignaron a los siguientes grupos: • SHAM (N=14): infusión de suero fisiológico y acceso libre a comida y agua. • NPT (N=15): NPT estándar. • SHAM-CCQ (N=14): como el grupo SHAM y una administración diaria de CCQ. NPT-CCQ (N=10): como el NPT y una administración diaria de CCQ. Al final del experimento, los animales fueron sacrificados y se obtuvieron muestra de sangre para determinar los valores IL-1 y TNF-α por ELISA. Resultados. Los niveles de IL-1 y TNF-α fueron mayores en el grupo NPT (7,537 y 5,899 pg/mL, respectivamente) que en el grupo SHAM (6,509 y 4,989 pg/mL, respectivamente) (p > 0,05). Los valores de TNF-α fueron mayores en el grupo SHAM (4,989 pg/mL) que en el grupo SHAM-CCQ (4,583 pg/mL), (p < 0,001). Los niveles de IL-1 y TNF-α fueron mayores en el grupo NPT que en el grupo NPT-CCQ (6,709 y 4,794 pg/mL, respectivamente) (p< 0,001 para TNF-α). Conclusiones. 1. En los animales con intestino corto bajo NPT o con nutrición enteral, se elevan los niveles séricos de las citoquinas proinflamatorias IL-1 y TNF-α. 2. La administración de CCQ, disminuye los niveles de IL-1 y TNF- α, pudiendo ser utilizada como una medida más para combatir la colestasis asociada a la NPT

Introduction. Total parenteral nutrition (TPN) is not free of complications. One of the most serious is cholestasis; the cause of this complication is unclear but it may be due to a lack of an enteral stimulus for cholecystokinin (CCK) production. CCK is essential for contraction of the gallbladder and also stimulates intrahepatic bile flow. Its absence may contribute to cholestasis. After any hepatic aggression, the Kupffer cells respond and release proinflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-α), which increase the hepatic damage. The objective of this experimental study has been to observe the effect that the exogenous administration of CCK could have on hepatic damage in experimental short bowel with and without TPN, determined using the serum levels of IL-1 and TNF-α. Material and methods. A resection of 80% of the small bowel was performed on 53 Wistar rats and a continuous infusion of saline or TPN was initiated. The rats were divided into the following groups: • SHAM (N=14): normal saline infusion and free access to food and water. • TPN (N=15): Standard TPN. • SHAM-CCK (N=14): same as the SHAM group but with a daily dose of CCK. • TPN-CCK (N=10): same as the TPN group but with a daily dose of CCK. At the end of the experiment, the animals were sacrificed and blood samples were obtained to determine the IL-1 and TNF-α values by ELISA. Results. The IL-1 and TNF-α levels were higher in the TPN group (7.537 and 5.899 pg/mL, respectively) than in the SHAM group (6.509 and 4.989 pg/mL, respectively) (p>0.05). The TNF-α values were higher in the SHAM group (4.989 pg/mL) than in the SHAM-CCK group (4.583 pg/mL) (p<0.001). The IL-1 and TNF-α levels were higher in the TPN group than in the TPNCCK group (6.709 and 4.794 pg/mL, respectively) (p< 0.001 for TNF-α). Conclusions. 1. There is a rise in the serum levels of the pro-inflammatory cytokines IL- 1 and TNF-α in animals with short bowel on TPN or enteral nutrition. 2. The administration of CCK causes a fall in the IL-1 and TNF-α levels, and could be used such as a further measure to prevent TPN-associated cholestasis