Normal spino-pelvic parameters and correlation between lumbar lordosis (LL) and pelvic incidence (PI) in children and adolescents in Indian population.

PURPOSE: The purpose of this work is to describe normal spino-pelvic parameters for pediatric and adolescent Indian population (and compare it with a cohort of different ethnicity) and to find out the correlation of pelvis incidence (PI) and lumbar lordosis (LL) METHODS: 129 asymptomatic subjects (66 males, 63 females) with age 4-15 years were studied. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) were measured on lateral whole-spine standing radiographs using computer software and compared in relation to age, sex, and ethnicity. Using correlation and regression analysis, the association and predictability of LL with PI was studied within the entire sample and then among age groups 4-10 and 11-15 years. RESULTS: Mean PI was 42° ± 8.1°, whereas PT and SS were 12.9° ± 7.8° and 29.3° ± 9.62°, respectively. PI and SS were lower (p < 0.0001), but PT was higher than Caucasians. Overall PI remained unchanged in the age group > 10 years in comparison to the younger age. Mean PT was lower (p = 0.0020), but SS and LL were higher (p = 0.0027 and p = 0.0002 respectively). Angular spino-pelvic parameters were similar between sex groups. Overall correlation between PI and LL was 0.4 (p < 0.0001) which was 0.1 (p = 0.2345) and 0.5 (p < 0.0001) for ages 4-10 and 11-15 years, respectively. Overall, the prediction of PI based on LL is not very accurate with a simple linear term between PI and LL (R2 = 0.1) and only improve marginally with a restricted cubic spline function. CONCLUSIONS: In pediatric and adolescent' population, ethnicity and age-related variations of normal sagittal spino-pelvic parameters exist and should be considered in patient management.

Importance of intraoperative dynamic spinal cord mapping (DSCM) during complex spinal deformity surgery.

STUDY DESIGN: Case report and review of literature. OBJECTIVE: To illustrate the importance of "dynamic spinal cord mapping" (DSCM) in locating the site of neurophysiologic data loss during severe spinal deformity correction. During marked correction of severe spinal deformities, intra-operative neuromonitoring remains of paramount importance. This case illustrates the importance of a unique type of monitoring, particularly useful when obtaining correction at multiple sites. METHODS: A patient with symptomatic, progressive, severe kyphoscoliosis underwent multiple periapical posterior column osteotomies, partial T8 and complete T9 vertebral column resections and T2 to L3 posterior segmental instrumented fusion. During correction maneuvers, complete loss of spinous process descending neurogenic evoked potentials occurred. A flexible epidural catheter was placed at different spinal levels to dynamically stimulate the spinal cord and map out the site of data loss corresponding to the area of neural compromise. RESULTS: Using DSCM, the site of data loss was identified to the apex of the proximal thoracic region cephalad to the VCR site. This was rectified by releasing correction at the proximal end of the construct, and neurophysiologic data promptly returned to baseline. Postoperatively the patient was neurologically intact. CONCLUSION: Dynamic spinal cord mapping helps map areas of neurophysiologic data loss permitting focused attention to the site of compromise to reverse the offending agent. This improves the chance for return of baseline data, avoiding the potential for permanent neurologic catastrophe for the patient. LOE: IV.

Adult degenerative scoliosis: evaluation and management.

Degenerative scoliosis is a prevalent issue among the aging population. Controversy remains over the role of surgical intervention in patients with this disease. The authors discuss a suitable approach to help guide surgical treatment, including decompression, instrumented posterior spinal fusion, anterior spinal fusion, and osteotomy. These treatment options are based on clinical analysis, radiographic analysis of the mechanical stability of the deformity, given pain generators, and necessary sagittal balance. The high potential complication rates appear to be outweighed by the eventual successful clinical outcomes in patients suitable for operative intervention. This approach has had favorable outcomes and could help resolve the controversy.

Intermittent androgen deprivation for locally advanced and metastatic prostate cancer: results from a randomised phase 3 study of the South European Uroncological Group.

BACKGROUND: Few randomised studies have compared intermittent hormonal therapy (IHT) with continuous therapy for the treatment of advanced prostate cancer (PCa). OBJECTIVE: To determine whether intermittent therapy is associated with a shorter time to progression. DESIGN, SETTING, AND PARTICIPANTS: 766 patients with locally advanced or metastatic PCa received a 3-mo induction treatment. The 626 patients whose prostate-specific antigen (PSA) level decreased to <4 ng/ml or to 80% below the initial value were randomised. INTERVENTION: Patients received cyproterone acetate (CPA) 200mg for 2 wk and then monthly depot injections of a luteinising hormone-releasing hormone (LHRH) analogue plus 200mg of CPA daily during induction. Patients randomised to the intermittent arm ceased treatment, while those randomised to the continuous arm received 200mg of CPA daily plus an LHRH analogue. MEASUREMENTS: Primary outcome measurement was time to subjective or objective progression. Secondary outcomes were survival and quality of life (QoL). Time off therapy in the intermittent arm was also recorded. RESULTS AND LIMITATIONS: 127 patients from the intermittent arm and 107 patients from the continuous arm progressed, with a hazard ratio (HR) of 0.81 (95% confidence interval [CI]: 0.63-1.05, p=0.11). There was no difference in survival, with an HR of 0.99 (95% CI: 0.80-1.23) and 170 deaths in the intermittent arm and 169 deaths in the continuous arm. The greater number of cancer deaths in the intermittent treatment arm (106 vs 84) was balanced by a greater number of cardiovascular deaths in the continuous arm (52 vs 41). Side-effects were more pronounced in the continuous arm. Men treated with intermittent therapy reported better sexual function. Median time off therapy for the intermittent patients was 52 wk (95% CI: 39.4-65.7). CONCLUSIONS: IHT should be considered for use in routine practice because it is associated with no reduction in survival, no clinically meaningful impairment in QoL, better sexual activity, and considerable economic benefit to the individual and the community.

Temporal bone dissection for neurosurgery residents: identifying the essential concepts and fundamental techniques for success.

BACKGROUND: Many contemporary neurosurgery residents, cordoned by work hour restrictions and drawn to newer technologies such as endovascular therapy, lack the proper direction necessary to learn the essentials of temporal bone dissection. A thorough knowledge of temporal bone anatomy combined with guidance regarding proper surgical technique makes temporal bone dissection an efficacious and fundamental learning activity. There is currently no concise guide for neurosurgical training programs to use in teaching the essentials of this dissection. METHODS: Over several years, the authors worked with neurosurgery residents to determine the key concepts necessary to gain a fundamental working knowledge of temporal bone dissection. RESULTS: We have identified 5 essential surgical principles and developed a step-by-step dissection technique useful for neurosurgery residents. CONCLUSIONS: Using this template, neurosurgery residents can make the most of their time in the skull base laboratory, becoming familiar with relevant temporal bone anatomy in situ and becoming facile with the surgical techniques necessary for its safe dissection.

Extended transbasal approach to skull base tumors. Technical nuances and review of the literature.

A variety of novel surgical approaches have been developed in recent years to manage disease of the cranial base. Few offer the width and depth of exposure achievable with the extended transbasal approach. This approach combines a bifrontal craniotomy with an orbitonasal or orbitonasoethmoidal osteotomy, and potentially a sphenoethmoidotomy to provide broad access to malignancies of the anterior, middle, and posterior skull base. The approach enables the en bloc resection of tumors within the frontal lobes, orbits, paranasal sinuses, and sphenoclival corridors without brain retraction and may obviate the need for transfacial access. This can be combined with additional approaches, based on the tumor's epicenter. Reconstruction is accomplished with the use of pericranium, and in some instances, a temporalis muscle pedicle or a gracilis microvascular free flap. Complications include cerebral spinal fluid leakage, pneumocephalus, infection, and cranial neuropathies. However, the morbidity and mortality associated with this approach is low. The extended transbasal approach is a relatively novel exposure that enables the skilled cranial base surgeon to safely excise many malignant lesions previously felt to be unresectable.

Bronquiolite obliterante em crianças / Bronchiolitis obliterans in children

Objetivo: Apresentar uma revisão sobre os aspectos gerais da bronquiolite obliterante, com ênfase na bronquiolite obliterante pós-infeccciosa em crianças. Métotodos: Foram selecionadas as publicações mais relevantes sobre a bronquiolite obliterante, utilizando basicamente o banco de dados do Medline (janeiro de 1966 a setembro de 1999). Resultaddos: A presente revisão inclui os seguintes tópicos: introdução, aspectos gerais da broquiolite obliterante (terminologia, histopaatologia e classificação) e bronquiolite obliterante pós-infecciosa (agentes etiológicos, aspectos clínico-radiológicos, diagnóstico e investigação, e tratamennto). Comentários: A bronquiolite obliterante é uma síndrome clínica mais comum do que se imaginava na população pediátrica, merecendo atenção dos pediátras