High incidence of dural tears with 3-column osteotomies: a systematic review of adult spinal deformity surgery literature for the past decade.

PURPOSE: Dural tear (DT) is a well-known complication of spinal surgery. We aimed to systematically review the literature from the past decade and determine the incidence and risk factors for DT in the adult spinal deformity (ASD) population to improve both the surgical strategy and counseling of patients undergoing ASD correction. METHODS: A systematic review from 2013 to 2023 utilizing PRISMA guidelines was performed. The MEDLINE database was used to collect primary English language articles. The inclusion criterion for patients was degenerative ASD. Pediatric studies, animal studies, review articles, case reports, studies investigating minimally invasive surgery (MIS), studies lacking data on DT incidence, and articles pertaining to infectious, metastatic or neoplastic, traumatic, or posttraumatic etiologies of ASD were excluded. RESULTS: Our results demonstrate that the incidence of DT in ASD surgery ranges from 2.0% to 35.7%, which is a much broader range than the reported incidence for non deformity surgery. Moreover, the average rate of DT during ASD surgery stratified by surgical technique was greater for osteotomy overall (19.5% +/- 7.9%), especially for 3-column osteotomy (3CO), and lower for interbody fusion (14.3% +/- 9.9%). Risk factors for DT in the ASD surgery cohort included older age, revision surgery, chronic severe compression, higher-grade osteotomy, complexity of surgery, rheumatoid arthritis (RA), and higher Anesthesiology Society of America (ASA) grade. CONCLUSION: To our knowledge, this is the first systematic review discussing the incidence of and risk factors for DT in the ASD population. We found that the risk factors for DT in ASD patients were older age, revision surgery, chronic severe compression, a greater degree of osteotomy, complexity of surgery, RA, and a higher ASA grade. These findings will help guide spine surgeons in patient counseling as well as surgical planning.

The Use of Cranial Aneurysm Clips for Repair of Incidental Lumbar Durotomy: Operative Technique and Case Series.

BACKGROUND: Incidental durotomy is a common complication of posterior lumbar spine surgery; however, effective and durable methods for primary repair remain elusive. Multiple existing techniques have previously been reported and extensively described, including sutured repair and the use of nonpenetrating titanium clips. The use of cranial aneurysm clips for primary repair of lumbar durotomy serves as a safe and effective alternative to obtain watertight closure of a dural tear. METHODS: We performed a retrospective review of patients at a single institution who underwent primary repair of an incidental lumbar durotomy with the use of an aneurysm clip during open posterior lumbar surgery between 2012 and 2023. Patient demographics, operative details, and postoperative metrics were collected and examined to evaluate the safety and efficacy of the novel technique. RESULTS: A total of 51 patients were included for analysis. Four patients underwent durotomy repair with an aneurysm clip alone, 27 patients were repaired with an aneurysm clip and fibrin glue, and 20 patients underwent repair with an aneurysm clip, fibrin glue, and a collagen dural substitute. Three patients (5.9%) reported headaches: 2 (3.9%) with pseudomeningocele and 1 (2%) with wound leakage. Two patients (3.9%) had treatment failure with a return to the operating room for repair of a cerebrospinal fluid leak. CONCLUSIONS: To the best of our knowledge, we report the largest series of patients undergoing primary repair of incidental durotomy with the use of an aneurysm clip. Use of an aneurysm clip is noted to be a safe, quick, and effective method of primary repair compared with existing repair techniques such as sutured repair or nonpenetrating titanium clips.

Incidental dural tears during pediatric posterior spinal fusions.

PURPOSE: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up. METHODS: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes. RESULTS: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery. CONCLUSIONS: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up. LEVEL OF EVIDENCE: Level IV.

Enhanced technique of dural closure using autologous fat graft and Gelfoam for effective management of dural tear following interlaminar endoscopic lumbar spine surgery.

BACKGROUND: Incidental dural tears are common complications in lumbar spine surgery, particularly in endoscopic procedures where primary closure via suturing is challenging. The absence of a standardized approach for dural closure in endoscopic spine surgery necessitates exploring alternative techniques. OBJECTIVE: This study introduces a surgical technique for dural closure utilizing fat graft and Gelfoam, offering an effective alternative to standard approaches in endoscopic spine surgery. METHODS: Surgical data from patients who underwent interlaminar endoscopic discectomy or stenosis decompression at Lerdsin Hospital from October 2014 to October 2021 were analyzed. RESULTS: Among 393 cases, dural tears occurred in 2% (8 patients). Our technique achieved successful closure in all these cases, with no incidents of cerebrospinal fluid leakage or wound complications. The majority of patients showed favorable clinical outcomes, except for one case involving concomitant nerve root injury. CONCLUSION: This study demonstrates that using fat graft and Gelfoam for dural closure is a simple, reliable, and safe technique, particularly effective for challenging-to-repair areas in interlaminar endoscopic lumbar spine surgery.

Economic Implications of Dural Tears in Lumbar Microdiscectomies: A Retrospective, Observational Study.

OBJECTIVE: Dural tears (DTs) are a frequent complication after lumbar spine surgery. We sought to determine the incidence of DTs and the related impact on health care expenditures after lumbar discectomies. METHODS: In this retrospective cohort study, all patients with first-time single-level lumbar discectomies at our institution who underwent minimally invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index, costs, revenues, length of stay, American Society of Anesthesiologists score, Charlson Comorbidity Index, and operative time (OT) were assessed. Exclusion criteria were age <18 years, previous spine surgery, multiple or traumatic disc herniations, and malignant and infectious diseases. RESULTS: The follow-up time was at least 12 months postoperatively. Of 358 patients identified with lumbar discectomies, 230 met the inclusion criteria. Incidence of DTs was 3.5%. Mean costs (P < 0.001), economic loss (P < 0.01), and OT (P < 0.0001) were found to be significantly higher in the DT group compared with the control group of patients without a DT. The revenues were not statistically different between the 2 groups (P > 0.05). Further analysis of the control group by profit and loss revealed significantly higher body mass index (P < 0.05), length of stay (P < 0.0001), and OT (P < 0.0001) in the loss group. CONCLUSIONS: DTs represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The impact of DTs on health care expenses is primarily based on significantly higher OT and a higher mean length of stay.

Trans-Defect Underlay Watertight Duraplasty for Traumatic Anterior Skull Base Dural Defect: Technical Report.

BACKGROUND: Watertight duraplasty is essential for surgical management of traumatic anterior skull base (ASB) dural defect but challenging in the deep and narrow operative corridor. Here, the authors report a trans-defect underlay watertight duraplasty (TDUWD) technique for traumatic ASB dural defect. METHODS: TDUWD was performed by inserting a free pericranium graft under the dural defect. The diameter of the pericranium graft was larger than the dural defect. The pericranium graft was sutured to the dural defect watertightly in an "inside-to-outside" direction, with the needle not penetrating the inner layer of pericranium graft. The pedicled pericranium flap was used as a second layer of reconstruction. The characteristics, complications, and outcomes of patients who received TDUWD are reported. RESULTS: A total of 29 patients received TDUWD. Immediate postoperative cessation of cerebrospinal fluid (CSF) leak occurred in 28 patients. One patient recovered after lumber drainage. No patient needed a second operation or reported delayed recurrence of CSF leak. No complication related to the surgical technique was observed. CONCLUSIONS: Use of TDUWD for traumatic ASB dural defect results in an immediate, 1-stage, and definitive correction of CSF leak and seems to be simple, safe, and reliable for large and deeply located dural defects.

Effects of surface profile on porcine dural mechanical properties.

BACKGROUND: Cerebrospinal fluid leakage through the spinal meninges is difficult to diagnose and treat. Moreover, its underlying mechanism remains unknown. Considering that the dura mater is structurally the strongest and outermost membrane among the three-layered meninges, we hypothesized that a dural mechanical tear would trigger spontaneous cerebrospinal fluid leakage, especially when a traumatic loading event is involved. Thus, accurate biomechanical properties of the dura mater are indispensable for improving computational models, which aid in predicting blunt impact injuries and creating artificial substitutes for transplantation and surgical training. METHOD: We characterized the surface profile of the spinal dura and its mechanical properties (Young's moduli) with a distinction of its inherent anatomical sites (i.e., the cervical and lumbar regions as well as the dorsal and ventral sides of the spinal cord). FINDINGS: Although the obtained Young's moduli exhibited no considerable difference between the aforementioned anatomical sites, our results suggested that the wrinkles structurally formed along the longitudinal direction would relieve stress concentration on the dural surface under in vivo and supraphysiological conditions, enabling mechanical protection of the dural tissue from a blunt impact force that was externally applied to the spine. INTERPRETATION: This study provides fundamental data that can be used for accurately predicting cerebrospinal fluid leakage due to blunt impact trauma.

Lesión dural asociada a fracturas de charnela toracolumbar y lumbares con compromiso del muro posterior: Relación con las variables del sistema de clasificación AOSpine / Thecal sac injury secondary to burst fractures of the thoracolumbar and lumbar spine, and its association with the AOSpine Classification System variables

Introducción: Las lesiones del saco dural con atrapamiento de la cauda equina entre los fragmentos óseos pueden estar asociadas con fracturas toracolumbares. Objetivo: Realizar un análisis retrospectivo de las variables clínico-radiográficas y el sistema de clasificación AOSpine y la posibilidad de lesión dural asociada en una serie de fracturas toracolumbares por estallido, tratadas en nuestro Centro. Materiales y Métodos: Estudio retrospectivo, observacional de una serie de pacientes con fracturas toracolumbares con compromiso del muro posterior operados en nuestra institución, entre enero de 2012 y diciembre de 2017. Resultados: Se incluyeron 46 pacientes, 16 casos con lesión del saco dural asociada. Las variables porcentaje de ocupación del canal, distancia interpedicular, ángulo del fragmento retropulsado y déficit neurológico asociado mostraron diferencias estadísticamente significativas según la comparación en función de la presencia o ausencia de lesión dural (p = 0,046, p = 0,007, p = 0,046 y p = 0,004, respectivamente). Conclusiones: Según nuestros resultados, la lesión dural traumática podría ser contemplada en la planificación del tratamiento de fracturas toracolumbares ante fragmentos voluminosos del muro posterior con ángulo agudo, compromiso severo del canal raquídeo, distancia interpedicular elevada y daño neurológico asociado, tal como se propone en la bibliografía. Nivel de Evidencia: IV

Introduction: Fractures of the thoracolumbar spine can trigger thecal sac injuries due to the impingement of the cauda equina between bone fragments. Objective: To carry out a retrospective analysis of clinical and radiological variables, the AOSpine Classification System and the possibility of secondary thecal sac injury in a series of thoracolumbar burst fractures treated at our center. Materials and Methods: A retrospective, observational study of a series of patients with thoracolumbar fractures with compromise of the posterior vertebral body wall, who underwent surgery at our center between January 2012 and December 2017. Results: Forty-six patients were included, 16 of which had secondary thecal sac injury. The differences in the variables-percentage of spinal canal involvement, interpedicular distance, angle of the retropulsed fragment, neurological deficit and type C fractures-were statistically significant according to the comparison made with the presence or absence of thecal sac injury (p=0.046, p=0.007, p=0.046, p=0.004, p=0,001 respectively). Conclusions: This study suggests that traumatic thecal sac injury could be suspected when managing burst fractures with prominent fragments in the posterior vertebral body wall, acute angle of the retropulsed fragment, severe compression of the spinal canal, wide interpedicular distance, neurological deficit and fracture displacement (fracture type C according to the AOSpine Classification System). Level of Evidence: IV

Muerte encefálica por neumoencéfalo y fístula dural en el postoperatorio de hernia discal lumbar / Brain death due to pneumocephalus and dural fistula in the post-operative period for a herniated lumbar disc

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Histological analysis of the repair of dural lesions with silicone mesh in rats subjected to experimental lesions / Análise histológica do reparo de lesões da dura com tela de silicone em ratos submetidos à lesão experimental

ABSTRACT Objective To evaluate inflammatory reaction, fibrosis and neovascularization in dural repairs in Wistar rats using four techniques: simple suture, bovine collagen membrane, silicon mesh and silicon mesh with suture. Methods Thirty Wistar rats were randomized in five groups: the first was the control group, submitted to dural tear only. The others underwent durotomy and simple suture, bovine collagen membrane, silicon mesh and silicon mesh with suture. Animals were euthanized and the spine was submitted to histological evaluation with a score system (ranging from zero to 3) for inflammation, neovascularization and fibrosis. Results Fibrosis was significantly different between simple suture and silicon mesh (p=0.005) and between simple suture and mesh with suture (p=0.015), showing that fibrosis is more intense when a foreign body is used in the repair. Bovine membrane was significantly different from mesh plus suture (p=0.011) regarding vascularization. Inflammation was significantly different between simple suture and bovine collagen membrane. Conclusion Silicon mesh, compared to other commercial products available, is a possible alternative for dural repair. More studies are necessary to confirm these findings.

RESUMO Objetivo : Avaliar reação inflamatória, fibrose e neovascularização da reparação da lesão dural em ratos Wistar, comparando quatro diferentes técnicas: pontos simples, membrana de colágeno bovino, tela de silicone e tela de silicone associada a pontos simples. Métodos : Trinta ratos Wistar foram randomizados em cinco grupos: o primeiro foi um grupo controle, submetido somente à durotomia. Os outros também foram submetidos à durotomia, porém sofreram sutura simples, reparo com membrana de colágeno bovino, tela de silicone e tela de silicone com sutura. Os animais foram sacrificados, e a coluna foi submetida à avaliação histológica com um escore (variando de zero a 3) para inflamação, neovascularização e fibrose. Resultados : A fibrose foi significativamente diferente, comparando-se sutura simples e tela de silicone (p=0,005) e sutura simples e tela com fio de sutura (p=0,015), demonstrando que a fibrose foi mais intensa quando um corpo estranho foi utilizado na reparação. Membrana bovina foi significativamente diferente da tela mais sutura (p=0,011) em relação à vascularização. A inflamação foi significativamente diferente entre os grupos submetidos à sutura simples e ao reparo com membrana de colágeno bovino. Conclusão : A tela de silicone, comparada com produtos similares com disponibilidade comercial, é uma possível alternativa como protetor de dura-máter. Mais estudos são necessários para comprovar esses resultados.

Fractura evolutiva: colocación de sistema derivativo cisto-peritoneal y corrección diferida: a propósito de un caso / Growing skull fracture: positioning system cisto-peritoneal derivative and correction deferred: report of a case

Describimos el caso de una paciente femenina de 5 años de edad, con antecedente de fractura craneal asociado a trauma directo en su segundo día de vida, posteriormente se diagnostica quistes porencefálico y aracnoideo frontoparietal izquierdo a los 3 meses de edad. Fue tratada en un primer momento con la colocación de sistema derivativo cistoperitoneal, y se le realizaron estudios de imágenes de seguimiento. A los 5 años de edad es traída a consulta de nuestro servicio de neurocirugía, por presentar deformidad calvarial en la superficie frontoparietal izquierda. El seguimiento con tomografía de cráneo demostró un cese relativo en la progresión en las dimensiones del quiste porencefálico y aumento del espacio entre los bordes óseos de la fractura. La paciente fue llevada a mesa operatoria, en la cual se realizó un abordaje hemicoronal izquierdo con resección de tejido gliótico, duroplastia con pericráneo y colocación de craneoplastía con tejido óseo craneal autólogo. El seguimiento al mes de la intervención correctiva mostró evolución satisfactoria y sin complicaciones. La cirugía correctiva de la fractura evolutiva, debe realizarse en el momento del diagnóstico para evitar su expansión. En concordancia con la teoría de Moss, se observa aumento del espacio entre los bordes de la fractura, aún con la disminución de la presión intracraneal al derivar el líquido cefalorraquídeo. En este caso, la intervención correctiva de la fractura, determinó una evolución satisfactoria, en ausencia de hidrocefalia o crisis convulsiva, posiblemente debida a la presión disminuida del quiste porencefálico sobre el parénquima subyacente.

We describe the case of a female patient of five years old, with a history of a skull fracture associated with direct trauma on his second day of life, then porencephalic left frontoparietal arachnoid cysts was diagnosed at 3 months of age. She was iniatially treated by plaing cystoeritoneal derivative system and follow-up imaging studies was performed. At 5 years of age is brought to clinic in our departmen of neurosurgery, for presenting calvarial deformity in the left frontoparietal area. The follow-p scan of the head showed a cease progression relative dimensions porencephalic cyst an increased space between the bone edges of the fracture. The patient was transferred to operating table, on which a hemicoronal left gliotico approach with resection of tissue was performed with dural graft placement craneoplasty bone tissue. Monitoring the month showed satisfactory corrective intervention and hassle evolution was performed with dural graft placement craneoplasty scalp and skull with autologous bone tissue. Corrective surgery of evolutionary fracture should be performed at the time of diagnosis to prevent its expansion. In agreement with the Moss theory, increasing the space between the edges of the fracture even with decreasing intracranial pressure deriving the cerebrospinal fluid was observed. In this case corrective intervention of the fracture produced a satisfactory outcome in the absence of hydrocephalus or seizure, possibly due to decreased pressure of porencephalic cyst on the underlying parenchyma.

Fractura compuesta de cráneo: reporte de casos y revisión de la literatura / Compound fracture of skull: case report and literature review

Introducción: Las fracturas son generalmente clasificados como simples (cerrada) o compuesta (abierta). En el caso de las fracturas de cráneo, pueden ser fracturas lineales, elevados, o triturado con la depresión. Fractura de cráneo compuesta rara vez se ha reportado en la literatura médica y cursa con una alta morbilidad y mortalidad. Los autores presentan seis casos de fracturas múltiples del cráneo, hablan sobre el tratamiento y pronóstico. Pacientes y métodos: Se analizaron seis casos de fractura compuesta del cráneo. Analizado por sexo, causa, localización, diagnóstico, tratamiento y pronóstico. Resultados: El sexo 5M / 1F. La edad media fue de 22 a. Las causas fueron: tres por agresión física, dos por accidente de coche y uno por explosión de neumático. Todos los pacientes fueron sometidos a TC. GCS medio al ingreso fue de 8. El tratamiento quirúrgico fue instituido en todos los casos. Tres pacientes desarrollaron infecciones (meningitis 2, empiema 1). Las secuelas fueron tres convulsiones, trastornos de la conducta 2. Hubo una muerte. Conclusión: La fractura compuesta del cráneo es rara y depende de la superficie del objeto y energía cinética. Las fracturas compuestas del cráneo con fragmentos de la depresión, son más frecuentes debido a la fuerza que se aplica hacia el cráneo. Su tratamiento inicial es quirúrgico y frecuentemente evoluciona con un mal pronóstico.

Introduction: Fractures are usually classified as simple (closed) or compound (open). In the case of skull fractures, they may be linear, high, or comminuted fracture with subsidence. The compound skull fracture has been rarely reported in medical literature and courses with high morbidity and mortality. The authors present six cases of compound fractures of the skull, discuss the treatment and prognosis. Patients and methods: We reviewed six cases of compound fracture of the skull. Analyzed according to gender, causes, location, diagnostic, treatment and prognosis. Results: The gender 5M / 1F. The mean age was 22 a. The two causes were physical aggression 3, car accident 2 and explosion of a tire 1. All patients underwent CT. Average score on ECG in admission 8. Surgical treatment was instituted all cases. Sequels were seizures 3 and behavioral disorders 2. There is one death. Conclusion: The compound fracture of the skull is rare and depends on the surface of blunt object and kinetic energy. The compound skull fractures with fragments of depression are more common, due to the force that is applied toward the skull. The initial treatment is surgical, and usually evolves with poor prognosis.

Incidencia de punción accidental de duramadre en un hospital universitario. Estudio prospectivo observacional / Incidence of accidental dura mater punctures in a university hospital: a prospective observational study

Objetivo. La punción accidental de duramadre es una complicación potencial durante el bloqueo epidural y se puede relacionar con múltiples factores. Nuestro objetivo fue determinar la prevalencia y factores de riesgo de punción dural accidental en un hospital terciario, evaluando las diferencias que existen en el número de complicaciones durante los distintos horarios de trabajo. Material y métodos. Se realizó un estudio observacional prospectivo de todas las mujeres que solicitaron analgesia regional a la Unidad de Analgesia Epidural y cumplían los criterios de inclusión, entre el 1 de enero de 2009 y el 1 de enero de 2011. La técnica empleada para el control del dolor del trabajo del parto fue la analgesia epidural. Resultados. Se incluyeron 12.480 embarazadas. La prevalencia de punción dural accidental fue de 0,4% (50 pacientes). De ellas, 28% correspondieron a médicos residentes. Se observaron más punciones durales accidentales en septiembre y en el turno de trabajo de tarde. Conclusiones. La prevalencia de PAD es similar a otras series. En nuestra serie, el cansancio o la falta de sueño parecen no influir en la incidencia de complicaciones en la analgesia para el trabajo de parto en una unidad de atención 24 horas, quizás por la distribución de lo turnos en las guardias no trabajando más de 6 horas seguidas(AU)

Objective. Accidental dura mater puncture is a potential complication during epidural block, and may be associated with multiple factors. Our objective was to determine the prevalence and risk factors of accidental dural puncture in a university hospital, evaluating the differences in the number of complications during different working hours. Material and methods. A prospective observational study was conducted on all women who requested regional anaesthesia in the Epidural Analgesia Unit between 1 January 2009 and 1 January 2011, and who fulfilled the inclusion criteria. The technique employed to control labour pains was epidural analgesia. Results. A total of 12,480 pregnant women were included. The prevalence of accidental dura mater puncture was 0.4% (50 patients). Of these, 28% were due to medical residents. More accidental dura mater punctures were observed during September and in the afternoon shift. Conclusions. The prevalence of accidental dura mater puncture is similar to other patient series. In ours, tiredness or lack of sleep did not influence the incidence of complications in analgesia for labour pains in a 24 hour care unit. This may be due to the distribution of on-call shifts not exceeding more than 6hours(AU)

Ectasia dural y dolor lumbar en pacientes con síndrome de Marfan / Ectasia and lumbar pain associated with marfan syndrome

Objetivo: Evaluar clínica y radiológicamente si la presencia y el volumen de la ectasia dural (ED) se asocia con dolor lumbar en pacientes con Síndrome de Marfan (SM). Material y Método: 92 pacientes diagnosticados de SM según los criterios de Gante fueron estudiados de forma prospectiva durante un año. Se les realizó una historia clínica, pruebas de imagen, incluyendo una resonancia magnética de columna lumbar volumétrica y se les entregaron 3 cuestionarios: SRS 22 (Scoliosis Research Society) y SF 36 v- 2 e Índice de discapacidad de Oswestry en función del que subdividimos la muestra en grupo I (pacientes con dolor lumbar moderado o grave) y grupo II (pacientes sin dolor lumbar). Resultados: Se realizó análisis multivariante de las variables relacionadas con el dolor lumbar, alcanzando la ED significación estadística. Estaba presente en el 75,9% de los pacientes del grupo I, y en el 49,2% del grupo II. La presencia de la ED se asocian con dolor lumbar en pacientes con SM (p= 0,016) y con la presencia de deformidad vertebral (p <0,001). Conclusiones: La presencia y el tamaño de la ED se asocian de forma significativa con dolor lumbar en el SM pero el scalloping no influye en la mayor intensidad del dolor (AU)

Objetive: Evaluate clinically and radiographically whether the presence and size of dural ectasia (ED) is associated with low back pain in patients with Marfan syndrome (MS). Material and method: 92 patients diagnosed with MS according to Ghent criteria were studied prospectively for one year. Underwent a medical history, imaging tests, including a lumbar spine MRI volumetric and 3 questionnaires were given: SRS 22 (Scoliosis Research Society) and SF 36 v-2 and Oswestry Disability Index subdivided according to the sample in group I (patients with moderate lower back pain and / or severe) and group II (patients without pain). Results: Multivariate analysis of variables related to low back pain, the ED reached statistical significance. ED was present in 75.9% of patients in group I, and 49.2% in group II. The presence of ED is associated with low back pain in patients with MS with an OR of 3.24 (1.21 to 8.68) p = 0.016 and the presence of vertebral deformity (scalloping) with an OR of 129, 83 (16.1 to 1047.74) p <0.001. Conclusion: The presence and size of ED was significantly associated with LBP in the SM but the «scalloping» does not affect the increased intensity of pain (AU)

Paquimeningitis craneal hipertrófica y estenosis traqueal idiopáticas: coincidencia o asociación? / Idiopathic hypertrophic cranial paquimeningitis and tracheal stenosis: coincidence or association?

La paquimeningitis hipertrófica idiopática crónica y la estenosis traqueal subglótica idiopática son raras condiciones de origen desconocido. En ambas existen un proceso inflamatorio fibrótico que afecta respectivamente, la duramadre y la traquea. La paquimeningitis hipertrófica idiopática crónica en forma típica, causa parálisis progresiva de nervios craneales, cefaleas, hipertensión intracraneal o disfunción cerebelosa. En la estenosis traqueal subglótica idiopática, usualmente limitada a la región subglótica y los dos primeros anillos traqueales, los sintomas son variables incluyendo disnea progresiva, sibilancias y estribor notables sobre el cuello. La paquimeningitis hipertrófica idiopática crónica ocurre en pacientes de todas las edades y el examen de elección para detectarla es la resonancia magnética cerebral, en tanto que la estenosis traqueal subglótica idiopática suele afectar mujeres jóvenes o maduras y es mejor evidenciada mediante tomografía computarizada. El diagnóstico es uno de exclusión. Deben descartarse enfermedades infecciosas como tuberculosis y lúes, y otras como sarcoidosis, carcinomatosis meníngea o vasculitis. Suelen responder inicialmente a los corticosteroides pero puede haber recurrencia al suspenderlos. La evolución a largo plazo es incierta. Este trabajo informa acerca de una paciente en quien ambas condiciones se dieron cita, discutiéndose sus manifestaciones clínicas, radiológicas y patológicas. Aunque considerada esencial para el diagnóstico, en nuestro caso no se realizó una biopsia meníngea. Planteamos la posibilidad de una asociación entre ambas condiciones, por su inicio simultáneo con recaídas, por su condición de inflamación crónica y recurrente y su respuesta a los corticosteroides.

Chronic idiopathic hypertrophic paquimeningitis and chronic subglottic tracheal stenosis are rare conditions of unknown origin. In both there is a fibrotic inflammatory process affecting, respectively the dura mater and the trachea. The chronic idiopathic hypertrophic paquimeningitis in its typical presentation causes progressive paralysis of cranial nerves, headaches, intracranial hypertensión or cerebellar dysfunction. In the chronic subglottic tracheal stenosis, usually limited to the subglottic region and the two first traqueal rings, its symptoms are variable including progressive shortness of breath, wheezing and stridor notable on the neck. The chronic idiopathic hypertrophic paquimeningitis occurs in patients of all ages and the test of choice for diagnosis it is the brain magnetic resonance image, while the chronic subglottic tracheal stenosis usually affect young or mature women and is best evidenced by computerizide tomography scan. The diagnósis is one of exclusion. Infectious diseases such as tuberculosis and lues, and others as sarcoidosis, meningeal carcinomatosis or vasculitides should be discarded. Often initially respond to corticosteroids but may have recurrences when stopped. The evolution in the long term is uncertain. This paper reports on a patient with both conditions, discussing their clinical, radiological and pathological manifestation. Although considered essential for the diagnosis, in our case was not performed a meningeal biopsy. We postulate the possibility of association between these two conditions, based in their simultaneous onset, the occurence of relapses in both diseases, its condition of recurrent and chronic inflammation, and its response to corticosteroids.

Quiste aracnoideo espinal epidural postraumático: presentación de un caso / Postraumatic epidural arachnoid spinal cyst: case report

Introducción. Los quistes aracnoideos extradurales espinales son lesiones poco frecuentes. Clínicamentese caracterizan por un cuadro mielopático progresivo,asociado o no a crisis radiculares. Para su diagnóstico radiológico las técnicas de resonancia magnética actuales posibilitan definirlos adecuadamente y conocer sulocalización topográfica. Los antecedentes patológicos del paciente son esenciales para establecer se etiología encontrándose en muchos casos una historia de traumaespinal, cirugía y menos frecuentemente anomalías con-génitas asociadas. El tratamiento en la mayoría de los casos es quirúrgico. Caso clínico. Presentamos el caso de un paciente de 35 años con antecedentes de una hemisección medular dorsal por arma blanca hace dos años. Evolutivamente se deterioran sus funciones motoras presentándose con una paraparesia espástica. Los estudios radiológicos mostraron la presencia de la lesión quística extradural comprimiendo el cordón medular a nivel dorsal (D3-D4). Se realizó cirugía descompresiva y se identificó un desgarro meníngeo a ese nivel que fue suturado. La evolución postoperatoria fue satisfactoria. Conclusiones. El tratamiento quirúrgico efectivo de estas lesiones está dado por la detección del defectomeníngeo y su cierre (AU)

Introduction. Extradural arachnoid spinal cysts are unfrequent lesions that are associated with spinal trauma, surgery and less frequently with congenital anomalies. The clinical manifestations are similar to those seen with other compressive spinal cord lesions. Magnetic resonance techniques allow to diagnose correctly this pathology and to define its thopographic situation. The pathologic history of the patient is essencial to establish the ethiology. Surgery is the elective treatment in most cases. Clinical case. The patient is a 35 years old man who has a medical history of penetrating spinal trauma two years ago. In that instance he suffered an unilateral spinal cord section at D2-D3 level with the corresponding Brown Sequard syndrome. A small wound was detected at the skin dorsal level and it was closed without difficulties. At the beginning, he improved his motor right leg function with rehabilitation and vita- mins. After two years of good recovery he came to our hospital suffering a neurological deterioration of six months of evolution. The physical examination revea- led an spastic paraparesis. Magnetic resonance was performed demonstrating a cystic extradural collection compressing the spinal cord at D3-D4 level. Surgical decompressive treatment allowed to excise the cyst and it was possible to define a dural tear that was closed successfully. The outcome was good with restoration of the initial motor function that he had after the spinal trauma. Conclusions. Surgical management of postraumatic epidural arachnoid spinal cyst allows to detect the meningeal tear and to close it, which is highly effective on these kinds of lesions (AU)

Peoría paradójica en fístulas carótido-cavernosas durales: cuando el cuerpo se enferma más para curarse / Paradoxical worsening in carotid-cavemous ductal fistulas: when the body get more sick in order to cure

Las fístulas carótido-cavernosas son comunicaciones arteriovenosas patológicas entre la arteria carótida interna intravenosa y el seno venoso-cavernoso que la rodea. Un sistema de flujo y presión elevados irrumpe sobre otro de bajo flujo y velocidad. Ello origina los síntomas y signos. La gran mayoría, son resultantes de traumatismos craneales siendo de alto flujo y alta velocidad-fístulas traumáticas o directas; menos comunes son las llamadas fístulas espontáneas o durales localizadas en la duramadre y alimentadas por ramas menígeas provenientes de las arterías carótidas externa, interna o ambas y de las arterias vertebrales. Estas últimas raras veces tienen implicaciones graves para la vida, pero la pérdida visual constituye el mayor riesgo; no obstante, con elevada frecuencia, ocurre la oclusión espontánea, por lo que se impone la observación hasta que la sintomatología justifique el tratamiento. En el curso evolutivo puede ocurrir la trombosis aguda de la fístula y más propiamente de la totalidad de la vena oftálmica superior la que produce un distintivo cuadro de notable agravamiento de los síntomas que en forma contradictoria ocurre antes de la mejoría y reversión de los síntomas, el síndrome de empeoramiento o peoría paradójica. Para ilustrar el síndrome se presentan los casos clínicos de los pacientes

Caroid-cavernous fistulas are pathological arteriovenous communications between the intracavernous internal carotid artery and the cavernous sinus. A system of high flow and pressure bursts over another system of low flow and slow velocity. This causes the symptoms and signs. The vast majority are related with head trauma being high flow and high speed fistulas: traumatic or direct. Less common are the so-called spontaneous or dural fistulas located in the duramater and fed by meningeal branches from the external, internal, or both carotic arteries and the vertebral arteries. These latest rarely have serious implications for life, but visual loss is the greatest risk; however, with high frequency spontaneously occlusion occurs, and then observation imposes until symptoms justified the treatment. During its evolution acute thrombosis of the fistula itself can occur along the entire length of the ophthalmic vein which produces a distinctive and paradoxical worserning and reversal of symptoms, which is called the syndrome of paradoxical worserning. Clinical cases of two patients are presented to illustrate the syndrome

Comparison of Oxiplex and Gore-Tex effectivity in an experimental peridural fibrosis model / Comparación entre la eficacia del Oxiplex y del Gore-Tex en un modelo experimental de fibrosis peridural

Objective. The authors conducted a study to compare the effectiveness of Oxiplex and Gore-tex in preventing postlaminectomy peridural fibrosis in rats. Peridural fibrosis is a common cause of pain in patients undergoing spinal surgery. To prevent scar formation numerous materials and methods have been employed such as non steroidal anti-inflammatory drugs (NSAIDs), Gelfoam, Oxiplex, Gore-tex, carboxymethil cellulose, Adcon-L, autogenous adipose grefting, mitomisin, and radiotherapy have been investigating for a long time, but only moderate success has been obtained. Methods. Laminectomies were performed at the fourth lumbar vertebra (L-4) in 30 rats. Oxiplex or Gore-Tex was applied over the dura mater with the aim to perform a blinded evaluation of their effects. In the control group, only a L-4 laminectomy was performed. Animals were sacrificed 28 days after the surgical procedure. The extent of peridural fibrosis was evaluated on spine specimens by histological analysis. Results. Both groups of animals treated with either Oxiplex or Gore-Tex showed a significant reduction in the degree of peridural fibrosis as compared to the control group. However no significant difference in the prevention of peridural fibrosis was observed between the Oxiplex and Gore-Tex groups. Conclusions. This experimental model has shown that Oxiplex and Gore-Tex are effective methods to prevent peridural fibrosis and dural adhesions at the postlaminectomy áreas (AU)

Objetivo. Los autores realizaron un estudio para comparar la eficacia de Oxiplex y Gore-tex en la prevención de fibrosis peridural tras laminectomías en ratas. La fibrosis peridural es una causa común de dolor en pacientes sometidos a cirugía de la columna vertebral. Para evitar la formación de cicatriz, se han empleado numerosos materiales y métodos como los antiinflamatorios no esteroideos (AINE), Gelfoam, Oxiplex, Gore-tex, carboxymethil celulosa, Adcon-L, injertos de grasa antóloga, mitomicina o la radioterapia, pero sólo se ha obtenido resultados exitosos en pocas ocasiones. Métodos. Se realizaron laminectomías en la cuarta vértebra lumbar (L-4) en 30 ratas. Se aplicaron Oxiplex o Gore-Tex sobre la duramadre con el objetivo de realizar una evaluación ciega de sus efectos. En el grupo control, sólo se realizó la laminectomía L4. Los animales fueron sacrificados 28 días después de la intervención quirúrgica. El grado de fibrosis peridural se evaluó sobre la columna vertebral de especímenes por análisis histológico. Resultados. Ambos grupos de animales tratados con Oxiplex o Gore-Tex mostraron una reducción significativa en el grado de fibrosis peridural en comparación con el grupo control. Sin embargo, ninguna diferencia significativa en la prevención de la fibrosis peridural se observó entre los grupos de Oxiplex y Gore-Tex. Conclusiones. Este modelo experimental ha demostrado que Oxiplex y Gore-Tex son métodos eficaces para prevenir la fibrosis peridural y adherencias en la duramadre tras laminectomías (AU)