Characterization of spinal hemangioblastomas in patients with and without von Hippel-Lindau, and YAP expression.

INTRODUCTION: Hemangioblastoma (HB) is a benign tumor of the central nervous system, associated with von Hippel-Lindau disease (VHL), or sporadic. The aim of this study was to compare and examine the clinical-pathological profile of patients with spinal hemangioblastoma and YAP expression. METHODS: A retrospective, descriptive, comparative study. All patients who underwent surgery for spinal HB between 2016 and 2023 were included. Clinical and radiological data were collected and analyzed. An immunohistochemistry panel including NeuN, neurofilaments (NF), and YAP-1, was performed. RESULTS: Nine patients were studied, six women and three men. Four patients had previously diagnosed VHL. The tumor location included: four cervical (44.44%), two thoracic (22.22%), two pontine with cervical extension (22.22%) and one patient with two lesions, one cervical and one thoracic (11.11%). Non-significant clinical differences were identified between VHL and sporadic patients. Imaging evidenced seven extramedullary and three intramedullary tumors. Histologically, intra-tumoral and perivascular axonal tracts were observed in all cases. One third of the tumors (two with VHL and one sporadic) presented extramedullary hematopoiesis. Seven cases (77.8%) expressed nuclear YAP (three with VHL and four sporadic HBs). The surgical outcome was good and only one patient with VHL undergoing subtotal resection had recurrence. CONCLUSIONS: Spinal HBs can be associated with VHL or be sporadic. To the best of our knowledge, this is the first study to describe YAP expression in HB. It is important to investigate the involvement of the Hippo pathway in HBs as a possible therapeutic target.

COVID-19 associated transverse myelitis: case report.

BACKGROUND: Transverse myelitis (TM) is a demyelinating inflammatory disease that presents with motor, sensory, and autonomic dysfunction, which may be acute or subacute. COVID-19-associated TM has been described in a scarce number of patients. CLINICAL CASE: A 15-year-old previously healthy male patient with respiratory disease before his neurological deterioration presented to the emergency room after developing a complete medullary syndrome located at the cervical-dorsal level, with ascending and symmetric paraparesis that rapidly progressed to paraplegia, with sensory dysfunction from the T3 level, sphincter dysfunction and sudden ventilatory deterioration that required mechanical ventilation. Magnetic resonance imaging was compatible with acute TM. Inflammatory and non-inflammatory etiologies were discarded. In addition, a positive severe acute respiratory syndrome coronavirus 2 test was obtained. Treatment included steroid pulses and plasmapheresis, with an insidious evolution. CONCLUSION: COVID-19 is an infrequent cause of TM and should be suspected when other etiologies have been ruled out.

INTRODUCCIÓN: La mielitis transversa (MT) es una enfermedad inflamatoria desmielinizante que se presenta con disfunción motora, sensitiva y autonómica, de forma aguda o subaguda. La MT asociada al COVID-19 se ha escrito en un escaso número de pacientes. CASO CLÍNICO: Se presenta el caso de un masculino de 15 años previamente sano, quien cursaba con un cuadro respiratorio y que desarrollo un deterioro neurológico súbito que involucro un síndrome medular completo localizado en el nivel cérvico dorsal, con paraparesia simétrica que progreso a la paraplejia, con disfunción sensitiva desde el nivel medular de T3, disfunción de esfínteres y deterioro ventilatorio que requirió manejo avanzado de la vía aérea. Su resonancia magnética fue compatible con mielitis transversa aguda. Se descartaron causas inflamatorias y no inflamatorias de la patología. Además, se obtuvo un resultado positivo de SARS-COV-2. Se inició tratamiento con pulsos de metilprednisolona y plasmaféresis, con una evolución insidiosa. CONCLUSIÓN: El COVID-19 es una causa infrecuente de MT y debe sospecharse cuando otras causas han sido descartadas.

SCIWORA. Una rara entidad clínica en la población pediátrica. Estudio ambispectivo / SCIWORA in children. A rare clinical entity: Ambispective study

Introducción: La lesión medular tipo SCIWORA es una entidad clínica con baja incidencia y alta repercusión funcional. El objetivo del estudio es la descripción epidemiológica de esta lesión y su evolución funcional con un seguimiento medio de 10 años. Material y métodos: Estudio analítico, longitudinal, de cohortes ambispectivo. Fueron evaluados 13 pacientes con el diagnóstico de SCIWORA en el periodo de estudio 2001-2022. Variables evaluadas: edad, sexo, días hasta la lesión medular, causa de lesión, imagen medular en la RM postraumatismo, nivel neurológico de lesión, ASIA ingreso/alta/5 años, SCIM III ingreso/alta/3 años, tipo de tratamiento empleado, empleo de terapia NASCIS III ingreso, tiempo de hospitalización, seguimiento medio. En octubre del 2022 fueron nuevamente evaluados en consultas externas mediante: cuestionario de discapacidad cervical (NDI)/Oswestry y cuestionario de calidad de vida validado en castellano para lesionados medulares (SV-QLI/SCI). Resultados: La mediana de edad fue de 4 años, 77% varones. El 54% de las lesiones corresponden a nivel cervical. El ASIA al ingreso fue del 31% A y del 31% C, nivel neurológico: C2 (22%) y T10 (15%), tráfico como causa de lesión (77%), SCIM III ingreso/alta: 28,5/42. La estancia media hospitalaria fue de 115 días. NDI: 11,6 y Oswestry: 15,3. Conclusión: El 77% de los SCIWORA se producen en menores de 8 años. Al año del alta hospitalaria un 31% de los pacientes fueron catalogados como ASIA D y a los 5 años el porcentaje se mantiene constante. No se encontraron diferencias significativas entre la causa de la lesión y tipo de alteración en RM (p = 0,872), ni entre la edad y el tipo de lesión medular objetivada en RM (p = 0,149).(AU)

Introduction: SCIWORA has a low incidence but a high functional repercussion. The aim of the present study was to characterize the epidemiology of this clinical-radiological condition and evaluate functional outcome with a mean of 10-years follow-up. Material and methods: Observational, longitudinal ambispective cohort study. Thirteen SCIWORA patients were admitted in the study period. Demographics, mechanism of injury, spinal cord MRI findings, neurological level of injury, time to SCI, neurological status (AIS) at admission/discharge/5 years, spinal cord independence measure (SCIM III) scale at admission and discharge, hospital length of stay and mean follow-up were recorded. On October 2022 patients were re-evaluated using NDI, Oswestry, and SV-QLI/SCI. Results: Median age was 4 years. The study population for this investigation was mostly men (77%). 54% of level of injury correspond to cervical spine. AIS at admission was A (31%) and C (31%). Neurological level of injury was C2 (22%) and T10 (15%). Motor vehicle-related injury was the most prevalent mechanism of injury (77%), SCIM III scale at admission and discharge: 28.5/42, hospital length of stay was 115 days. The NDI was 11.6, Oswestry: 15.3 and SV-QLI/SCI: 17. Conclusions: Seventy-seven percent of SCIWORA patients was detected under 8 years-old. At 1 year follow-up after discharge 31% patients were AIS grade D and with 5 years follow-up the percentage remain constant. No statistically significant differences in the mechanism of injury and MRI findings (P = 0.872), age and MRI spinal cord findings (P = 0.149) were found in SCIWORA patients.(AU)

SCIWORA in children. A rare clinical entity: Ambispective study. / SCIWORA. Una rara entidad clínica en la población pediátrica. Estudio ambispectivo.

INTRODUCTION: SCIWORA has a low incidence but a high functional repercussion. The aim of the present study was to characterize the epidemiology of this clinical-radiological condition and evaluate functional outcome with a mean of 10-years follow-up. MATERIAL AND METHODS: Observational, longitudinal ambispective cohort study. Thirteen SCIWORA patients were admitted in the study period. Demographics, mechanism of injury, spinal cord MRI findings, neurological level of injury, time to SCI, neurological status (AIS) at admission/discharge/5 years, spinal cord independence measure (SCIM III) scale at admission and discharge, hospital length of stay and mean follow-up were recorded. On October 2022 patients were re-evaluated using NDI, Oswestry, and SV-QLI/SCI. RESULTS: Median age was 4 years. The study population for this investigation was mostly men (77%). 54% of level of injury correspond to cervical spine. AIS at admission was A (31%) and C (31%). Neurological level of injury was C2 (22%) and T10 (15%). Motor vehicle-related injury was the most prevalent mechanism of injury (77%), SCIM III scale at admission and discharge: 28.5/42, hospital length of stay was 115 days. The NDI was 11.6, Oswestry: 15.3 and SV-QLI/SCI: 17. CONCLUSIONS: Seventy-seven percent of SCIWORA patients was detected under 8 years-old. At 1 year follow-up after discharge 31% patients were AIS grade D and with 5 years follow-up the percentage remain constant. No statistically significant differences in the mechanism of injury and MRI findings (P = 0.872), age and MRI spinal cord findings (P = 0.149) were found in SCIWORA patients.

[Translated article] SCIWORA in children. A rare clinical entity: Ambispective study.

INTRODUCTION: SCIWORA has a low incidence but a high functional repercussion. The aim of the present study was to characterize the epidemiology of this clinical-radiological condition and evaluate functional outcome with a mean of 10-years follow-up. MATERIAL AND METHODS: Observational, longitudinal ambispective cohort study. Thirteen SCIWORA patients were admitted in the study period. Demographics, mechanism of injury, spinal cord MRI findings, neurological level of injury, time to SCI, neurological status (AIS) at admission/discharge/5 years, spinal cord independence measure (SCIM III) scale at admission and discharge, hospital length of stay and mean follow-up were recorded. On October 2022 patients were re-evaluated using NDI, Oswestry, and SV-QLI/SCI. RESULTS: Median age was 4 years. The study population for this investigation was mostly men (77%). 54% of level of injury correspond to cervical spine. AIS at admission was A (31%) and C (31%). Neurological level of injury was C2 (22%) and T10 (15%). Motor vehicle-related injury was the most prevalent mechanism of injury (77%), SCIM III scale at admission and discharge: 28.5/42, hospital length of stay was 115 days. The NDI was 11.6, Oswestry: 15.3 and SV-QLI/SCI: 17. CONCLUSIONS: Seventy-seven percent of SCIWORA patients was detected under 8 years-old. At 1 year follow-up after discharge 31% patients were AIS grade D and with 5 years follow-up the percentage remain constant. No statistically significant differences in the mechanism of injury and MRI findings (P=0.872), age and MRI spinal cord findings (P=0.149) were found in SCIWORA patients.

Hidden neuraxial pathology in idiopathic scoliosis: original research / Patologia neuroaxial oculta na escoliose idiopática: pesquisa original / Patología neuroaxial oculta en la escoliosis idiopática: investigación original

ABSTRACT Objective: To evaluate the prevalence of hidden neuraxial pathology (NAP) revealed in idiopathic scoliosis (IS) in neurologically normal patients. Methods: We selected 401 patients with IS who visited our clinic. We identified patterns of NAP and its frequency. In addition to the main part of the study, we assessed the reliability of Magnetic Resonance Imaging (MRI) measuring of the pedicles to plan screw width and trajectory. Results: Among the 401 patients, 53 (13%) presented NAP. The proportion of males in this group was higher (42% vs. 21%, p=0.004), the age of onset of the deformity was lower (8.9±3.77 vs. 9.9±3.93 years old, p=0.045), the left-sided thoracic curve was more frequent (21% vs. 8%, p=0.016), thoracic kyphosis was more pronounced (p=0.070), and the percentage of revision surgeries for deformity progression or non-fusion was higher (13% vs. 5%, p=0.147). Conclusions: The spine MRI should be performed in the early stages of IS, as in some cases of NAP (Chiari, tethered spinal cord), there is the possibility of an early neurosurgical operation that will prevent the development of scoliosis. The main signs of hidden NAP in IS are early-onset IS, IS with left-sided thoracic curve, male gender, and thoracic kyphosis > 40°Cobb. Level of Evidence II; Retrospective Study.

Resumo: Objetivo: Avaliar a prevalência das patologias neuroaxiais ocultas (PNO) reveladas na escoliose idiopática (EI) em pacientes neurologicamente normais. Métodos: Foram selecionados 401 pacientes com EI que visitaram nossa clínica. Identificamos padrões de PNO e sua frequência. Além disso, avaliamos a confiabilidade da medição por ressonância magnética (RM) dos pedículos para planejar a largura e a trajetória do parafuso. Resultados: Entre os 401 pacientes, 53 (13%) apresentaram PNO. A proporção de homens neste grupo foi maior (42% contra 21%, p=0,004), a idade de início da deformidade foi menor (8,9±3,77 contra 9,9±3,93 anos, p=0,045), a curva torácica do lado esquerdo foi mais frequente (21% contra 8%, p=0,016), a cifose torácica foi mais pronunciada (p=0,070) e a porcentagem de cirurgias de revisão para progressão da deformidade ou não fusão foi maior (13% contra 5%, p=0,147). Conclusões: A ressonância magnética da coluna deve ser realizada nos estágios iniciais da EI, pois em alguns casos de PNO (Chiari, medula espinhal amarrada) existe a possibilidade de uma operação neurocirúrgica precoce que impedirá o desenvolvimento de escoliose. Os principais sinais de PNO oculta na EI são: EI de início precoce, EI com curvatura torácica à esquerda, sexo masculino e cifose torácica > 40°Cobb. Nível de Evidência II; Estudo Retrospectivo.

Resumen: Objetivo: Evaluar la prevalencia de las patologías neuroaxiales ocultas (PNO) reveladas en la escoliosis idiopática (EI) en pacientes neurológicamente normales. Métodos: Se seleccionaron 401 pacientes con EI que visitaron nuestra clínica. Se identificaron patrones de PNO y su frecuencia. Además, evaluamos la fiabilidad de la medición por resonancia magnética (RM) de los pedículos para planificar la anchura y la trayectoria del tornillo. Resultados: Entre los 401 pacientes, 53 (13%) presentaron PNO. La proporción de hombres en este grupo fue mayor (42% vs 21%, p=0,004), la edad de aparición de la deformidad fue menor (8,9±3,77 vs 9,9±3,93 años edad, p=0,045), la curva torácica del lado izquierdo se encontró con más frecuencia (21 % frente a 8 %, p=0,016), la cifosis torácica fue más pronunciada (p=0,070) y el porcentaje de cirugías de revisión por progresión de la deformidad o falta de fusión fue mayor (13% vs 5%, p=0,147). Conclusiones: La resonancia magnética de la columna debe realizarse en las primeras etapas de la EI, ya que en algunos casos de PNO (Chiari, médula anclada) existe la posibilidad de una operación neuroquirúrgica temprana que prevendrá el desarrollo de la escoliosis. Los principales signos de PNO oculta en EI son: EI de inicio temprano, EI con curvatura torácica izquierda, sexo masculino y cifosis torácica > 40°Cobb. Nivel de Evidencia II; Estudio Retrospectivo.

Falla en la extubación en el paciente con trauma raquimedular: parálisis diafragmática. Una entidad por considerar

La parálisis diafragmática es una entidad con epidemiologia no constatada, sin embargo, debe considerarse en el paciente con antecedente de trauma raquimedular asociado que presente signos tempranos de dificultad respiratoria, para de esta forma investigar y ofrecer manejos oportunos en esta condición clínica. Se presenta caso de varón de 65 años con debilidad diafragmática crónica por antecedente de herida por arma de fuego a nivel de la columna cervical.

Diaphragmatic paralysis is an entity with an unproven epidemiology. However, it should be considered in patients with a history of associated spinal cord trauma who present early signs of respiratory difficulty, to investigate and offer timely management to this clinical condition. We present the case of a 65-year-old man with chronic diaphragmatic weakness due to a history of gunshot wounds at the level of the cervical spine.

Orthostatic support in paraplegic and amputee patients: a controlled trial / Suporte ortostático em paraplégicos e amputados: um ensaio controlado

ABSTRACT Introduction: Functional incapacity caused by physical alterations leads to significant limitations in daily activities and has a major impact on the return of people with disabilities to the social space and the workplace. This calls for an evaluation of the long-term influence of the use of a device specially developed for orthostatic posture on the physiological, biomechanical and functional parameters of amputees and spinal cord patients. Objective: The objective was evaluate the effect of postural support device use on function, pain, and biomechanical and cardiologic parameters in spinal cord injury and amputees patients compared to a control group. Methods: The orthostatic device was used by the participants for a period of ten consecutive days, for three cycles of 50 minutes each day, and a 15-day follow-up. Participants were positioned and stabilized using adjustable straps on the shoulders, trunk, and hips. The primary outcome was brief pain inventory. Fifteen participants were included the control group, 15 in the amputee group, and 15 in the spinal cord group. Results: Our results demonstrate that the use of the device allows the orthostatic position of amputees and spinal cord patients evaluated for ten days, leading to improved functionality and pain in the spinal cord and amputee groups compared to the control group. In addition, no changes were observed for secondary outcomes, indicating that the use of the device did not cause harm interference to patients. Conclusion: The long-term use of the orthostatic device is beneficial for improving functionality, reduce pain in amputees and spinal cord injury patients. Level of evidence II; Therapeutic Studies - Investigating the results of treatment.

RESUMO Introdução: A incapacidade funcional causada por alterações físicas leva a limitações significativas nas atividades diárias e gera um grande impacto no retorno das pessoas com deficiência ao espaço social e ao local de trabalho, demandando a avaliação da influência em longo prazo do uso de um dispositivo especialmente desenvolvido para a postura ortostática nos parâmetros fisiológicos, biomecânicos e funcionais de pacientes amputados e com medula espinhal. Objetivo: O objetivo foi avaliar o efeito do uso do dispositivo de suporte postural na função, dor e parâmetros biomecânicos e cardiológicos em pacientes com lesão medular e amputados em comparação com um grupo controle. Métodos: O aparelho ortostático foi utilizado pelos participantes por um período de dez dias consecutivos, em três ciclos de 50 minutos diários, com acompanhamento de 15 dias. Os participantes foram posicionados e estabilizados por meio de alças ajustáveis nos ombros, tronco e quadris. O desfecho primário foi o questionário Breve Inventário de Dor. Quinze participantes foram incluídos no grupo controle, 15 no grupo amputado e 15 no grupo medular. Resultados: Nossos resultados demonstram que o uso do dispositivo permite a posição ortostática de amputados e pacientes com lesão medular avaliados por dez dias, levando a melhora da funcionalidade e dor nos grupos de amputados e medula espinhal em relação ao grupo controle. Além disso, não foram observadas alterações nos resultados secundários, indicando que o uso do dispositivo não causou interferência prejudicial aos pacientes. Conclusão: O uso prolongado do dispositivo ortostático é benéfico para melhorar a funcionalidade, reduzir a dor em amputados e pacientes com lesão medular. Nível de Evidência II; Estudos Terapêuticos - Investigação dos resultados de tratamento.

High-intensity interval training in people with spinal cord injury: a systematic review / Entrenamiento por intervalos de alta intensidad en personas con lesiones medulares: una revisión sistemática / Treinamento intervalado de alta intensidade em pessoas com lesão da medula espinhal: revisão sistemática

ABSTRACT Objective: Analyze the effects of high-intensity interval training (HIIT) on cardiometabolic parameters, and cardiorespiratory fitness to compile the most used HIIT training types in adults with spinal cord injury (SCI). Methods: This is a systematic review of searches performed in the electronic databases PubMed / Medline, Science Direct, and Google Scholar. Studies included I) needed to apply HIIT training II) adults with SCI to analyze III) cardiometabolic aspects and cardiorespiratory fitness. Two independent reviewers selected the articles for inclusion, extracted their data, and assessed their methodological quality. Results: 654 studies were found. Thus, 12 studies, 11 pre- and post-intervention, and one control group (CG) with 106 participants were analyzed. Pre- and post-HIITT intervention results revealed significant improvement in cardiorespiratory fitness and cardiometabolic aspects (VO2peak, LDH, HDL, insulin resistance). In addition, GC results revealed significant improvement in cardiorespiratory fitness observed in the intervention group (HIIT) compared to the moderate-low intensity (GC) group. Seven studies used the arm ergometer as the primary exercise modality. Two studies described functional electrical stimulation (FES) performed with the arm ergometer plus electrical stimulation in the lower limbs. None reported heart rate dynamics during the study period. Conclusion: High-intensity interval training improves physical fitness and cardiometabolic health in adults with SCI. Evidence level II; Systematic Review of level II studies.

RESUMEN Objetivo: Analizar los efectos del entrenamiento interválico de alta intensidad (HIIT) sobre los parámetros cardiometabólicos, fitness cardiorrespiratorio y recopilar los tipos de HIIT más utilizados en el entrenamiento en adultos con lesión medular (LME). Métodos: Se trata de una revisión sistemática, para lo cual se realizaron búsquedas en bases de datos electrónicas PubMed/Medline, Science Direct y Google Scholar. Se incluyeron estudios que I) necesitaban aplicar entrenamiento HIIT en II) adultos con SCI y analizar III) aspectos cardiometabólicos y aptitud cardiorrespiratoria. Dos revisores independientes seleccionaron los artículos para su inclusión, extrajeron sus datos y evaluaron su calidad metodológica. Resultados: De los 654 estudios encontrados, se analizaron 12 estudios, 11 pre y post intervención y 1 grupo control (GC) con un total de 106 participantes. Los resultados previos y posteriores a la intervención HIIT revelaron una mejora significativa en la aptitud cardiorrespiratoria y los aspectos cardiometabólicos (VO2pico, LDH, HDL, resistencia a la insulina). Los resultados de GC revelaron una mejora significativa en la aptitud cardiorrespiratoria observada del grupo de intervención (HIIT) en comparación con el grupo de intensidad moderada-baja (GC). Siete estudios utilizaron el ergómetro de brazo como la modalidad principal de ejercicio. Dos estudios describieron la estimulación eléctrica funcional (EEF) realizada con el ergómetro de brazo más la estimulación eléctrica en los miembros inferiores. Ninguno informó la dinámica de la frecuencia cardíaca durante el período de estudio. Conclusiones: El entrenamiento intervalos de alta intensidad mejora la condición física y la salud cardiometabólica en adultos con LME. Evidencia de nivel II; Revisión sistemática de estudios de nivel II.

RESUMO Objetivo: Analisar os efeitos do treinamento intervalado de alta intensidade (HIIT) nos parâmetros cardiometabólicos, aptidão cardiorrespiratória e compilar os tipos de HIIT mais utilizados no treinamento em adultos com lesão da medula espinhal (LME). Métodos: Trata-se de revisão sistemática, para a qual foram realizadas pesquisas nas bases de dados eletrônicas PubMed / Medline, Science Direct e Google Scholar. Foram incluídos estudos em que I) o treinamento HIIT era aplicado em II) adultos com LME e analisaram III) os aspectos cardiometabólicos e aptidão cardiorrespiratória. Dois revisores independentes selecionaram os artigos para a inclusão, extraindo seus dados e avaliarando a sua qualidade metodológica. Resultados: 654 estudos foram encontrados. Desses, 12 estudos, 11 pré e pós intervenção e 1 grupo controle (GC) com um total de 106 participantes foram analisados. Resultados pré e pós intervenção de HIIT revelaram significante melhora na aptidão cardiorrespiratória e aspectos cardiometabólicos (VO2pico, LDH, HDL, resistência à insulina). Resultados do GC revelaram uma significativa melhoria na aptidão cardiorrespiratória observada no grupo de intervenção (HIIT) em relação ao grupo de intensidade moderada-baixa (GC). Sete estudos usaram o ergômetro de braço como modalidade de exercício primária. Dois estudos descreveram a estimulação elétrica funcional (EEF) realizada com o ergômetro de braço adicionando estimulação elétrica nos membros inferiores. Nenhum relatou a dinâmica da frequência cardíaca durante o período do estudo. Conclusão: O treinamento intervalado de alta intensidade melhora a aptidão física e a saúde cardiometabólica em adultos com LME. Nível de evidência II; Revisão sistemática de Estudos de Nível II.

Three-level thoracic disc herniation: transthoracic decompression without fixation / Hernia discal dorsal de tres niveles: descompresión transtorácica sin fijación

Abstract Thoracic disc herniation is a rare pathology com pared to the rest of the herniated discs. Due to their difficult access to the area of compromise and proximity to the spinal cord they represent a real challenge for the spine surgeon. The objective is to report an atypical case with three symptomatic dorsal disc herniations which required surgical treatment. Surgery was performed in two times with a lapse of 12 months between interven tions. It was done a minimally invasive transthoracic decompression and intersomatic arthrodesis without instrumentation. The patient presented good neurologi cal recovery without any serious sequelae.

Resumen La hernia de disco dorsal es una afección poco fre cuente en comparación con el resto de las hernias discales. Por su difícil acceso a la zona de compromiso y cercanía de la médula espinal representan un verda dero desafío para el cirujano de columna. El objetivo del trabajo es presentar un caso atípico con tres hernias de disco dorsales sintomáticas en forma sincrónica que requirió tratamiento quirúrgico. La cirugía se hizo en dos tiempos con un lapso de 12 meses entre las intervenciones. Se realizó descompresión transtorácica mínimamente invasiva y artrodesis intersomática sin instrumentación en cada nivel. El paciente presentó buena recuperación neurológica sin ninguna secuela grave.

Situation-Specific Theory from Autonomic Dysreflexia Nursing Diagnosis Based on Roy's Adaptation Model

Introduction: Autonomic dysreflexia (AD) is a condition developed secondary to a spinal cord injury, which manifests with the loss of coordinated autonomic responses and cardiovascular control. For the care of the person, the nurse has the nursing diagnosis of AD, which allows the precise interpretation of the human responses of each individual. However, it is necessary to strengthen and update the diagnosis to the new disciplinary knowledge that evolved with nursing practice. For this, proposing a situation-specific theory is essential to explain the phenomenon of interest and guide practice. Objective: To construct a situation-specific theory for the nursing diagnosis of AD derived from the adaptation model of Sor Callista Roy. Materials and methods: Theoretical study developed in five stages: defining the approach to construct the theory, defining key concepts, developing a pictorial diagram, building propositions, and establishing causal relationships and evidence for practice. Results: The situation-specific theory included defining key concepts, developing a pictorial diagram, building propositions, and establishing causal relationships and evidence for practice. We described the concepts and their relationships through seven propositions and identified 19 ineffective behaviors and 43 environmental stimuli. Of them, 39 are focal, and four are contextual stimuli. Conclusions: This situation-specific theory offers a substantiated and comprehensive explanation of the human response to AD for supporting nursing care.

Introducción: La direflexia autónoma (DA) es una afección secundaria a una lesión en la médula espinal que se manifiesta en la pérdida de respuestas autónomas coordinadas y de control cardiovascular. Para el cuidado del paciente, las enfermeras cuentan con el diagnóstico de la DA, que permite interpretar adecuadamente las respuestas humanas de cada individuo. Sin embargo, es necesario fortalecer y actualizar el diagnóstico a los nuevos conocimientos disciplinarios que evolucionan con la práctica de la enfermería. Para esto es esencial una teoría de situación específica que explique el fenómeno de interés y guíe la práctica. Objetivo: Construir una teoría de situación específica para el diagnóstico en enfermería de la DA derivada de la adaptación del modelo de Sor Callista Roy. Materiales y métodos: Estudio teórico desarrollado en cinco etapas: definición del enfoque para construir la teoría, definición de los conceptos clave, desarrollo de un diagrama pictórico, construcción de las proposiciones y establecimiento de las relaciones causales y la evidencia para la práctica. Resultados: La teoría de situación específica incluyó la definición del enfoque para construir la teoría, la definición de los conceptos clave, el desarrollo de un diagrama pictórico, la construcción de las proposiciones y el establecimiento de las relaciones causales y la evidencia para la práctica. Se describen los conceptos y sus relaciones por medio de 7 proposiciones y se identificaron 19 comportamientos ineficaces y 43 estímulos ambientales. De ellos, 39 son focales y 4 contextuales. Conclusiones: Esta teoría de situación específica proporciona una explicación informada y completa de la respuesta humana a la DA para apoyar el cuidado en enfermería.

Introdução: a disreflexia autonômica (DA) é uma condição secundária à lesão da medula espinhal que se manifesta na perda de respostas autonômicas coordenadas e no controle cardiovascular. Para o atendimento ao paciente, os profissionais de enfermagem contam com o diagnóstico de DA que permite a interpretação adequada das respostas humanas do indivíduo. No entanto, há necessidade de fortalecer e atualizar o diagnóstico para o novo conhecimento disciplinar que evolui com a prática de enfermagem. Para isso, é essencial uma teoria situacional específica que explique o fenômeno de interesse e oriente a prática. Objetivo: Construir uma teoria situacional específica para o diagnóstico de enfermagem da DA derivada da adaptação do modelo de Sor Callista Roy. Materiais e método: estudo teórico desenvolvido em cinco etapas: definição da abordagem para construir a teoria, definição de conceitos-chave, desenvolvimento de um diagrama pictórico, construção de proposições e estabelecimento de relações causais e evidências para a prática. Resultados: a teoria específica da situação incluiu a definição da abordagem para a construção da teoria, a definição dos principais conceitos, o desenvolvimento de um diagrama pictórico, a construção de proposições e o estabelecimento de relações causais e evidências para a prática. Os conceitos e suas relações são descritos por meio de 7 proposições e foram identificados 19 comportamentos ineficazes e 43 estímulos ambientais. Destes, 39 são focais e 4 são contextuais. Conclusões: essa teoria específica da situação fornece uma explicação informada e abrangente da resposta humana à DA para apoiar a assistência de enfermagem.

Activity-based locomotor training: improving the movement in children with spinal cord injury.

OBJECTIVE: The objective of this study was to investigate the effects of activity-based locomotor training (ABLT) on motor function and walking ability in children with spinal cord injury (SCI). MATERIALS AND METHODS: The Chinese National Knowledge Infrastructure, WanFang, VIP, PubMed, and Web of Science databases were searched for related studies, with two reviewers subsequently evaluating the literature quality using the Cochrane Handbook. RESULTS: A total of 11 studies were eligible, while only one met the ABLT standard program criteria. Overall, ABLT significantly improved the lower limb motor function, increased walking speed and distance, and improved the daily living ability of children with SCI. CONCLUSIONS: The ABLT strategy is of great significance to the motor function and walking ability of children with SCI. At present, there exist few studies on the application of ABLT for pediatric SCI. Further control studies with a larger sample size are required to improve the ABLT program guidelines for children with SCI.

OBJETIVO: Discuta el impacto del entrenamiento ejercicio basado en la actividad en la lesión de la médula espinal en la función de movimiento de los niños y la capacidad de caminar. MATERIALS Y MÉTODOS: Según China Zhiwang, Wanfang, VIP, PubMed, Science Network y otros documentos relacionados como fuente de datos. Dos revisores usan calidad de evaluación manual de Cochrane. RESULTADOS: Un total de 11 estudios cumplen con las condiciones. Solo hay un estudio que cumple con los proyectos estándar de ABLT. General, ABLT mejora significativamente la función de los niños con lesiones de la médula espinal, aumenta la velocidad y la distancia de caminar y mejora la capacidad de la vida diaria. CONCLUSIÓN: La estrategia ABLT es de gran importancia para la función de movimiento de los niños de la médula espinal y la capacidad de caminar. En la actualidad, ABLT tiene menos investigación en lesión pediátrica de la médula espinal. Es necesario mostrar la cantidad de muestra y controlar la investigación para mejorar las pautas del plan ABLT para el daño de la médula espinal a los niños.

Mielopatía cervical por déficit de cobre secundario a sobrecarga de zinc dental. A propósito de un caso / Cervical myelopathy due to copper deficiency secondary to dental zinc overload: A case report

Se presenta el caso de un varón de 68años con un cuadro progresivo de hipoestesia braquial y crural con ataxia de la marcha, sugiriendo una mielopatía subaguda de cordones posteriores, demostrada en RM. Tras analítica sanguínea se diagnostica de déficit de cobre tras intoxicación por zinc, secundario al uso de un pegamento para dentaduras postizas que contenía zinc. Se inició tratamiento con cobre, retirándose el pegamento dental. Se inició tratamiento rehabilitador con fisioterapia, hidroterapia y terapia ocupacional. Se consiguió una mejoría funcional, pasando de una lesión medular ASIAD nivel C4 a otra ASIAD nivel C7. Deberían estudiarse los niveles de cobre en todas aquellas mielopatías no compresivas, de aparición subaguda, si existe una clara afectación de los cordones posteriores. El déficit de cobre en análisis establecería el diagnóstico. El tratamiento rehabilitador, el aporte de cobre suplementario y la retirada del zinc es fundamental para la prevención de daño neurológico irreversible.(AU)

We present the case of a 68-year-old man with progressive brachial and crural hypoaesthesia with gait ataxia suggesting subacute myelopathy of the posterior cords, demonstrated by MRI. After blood tests, a diagnosis of copper deficiency was made following zinc intoxication, secondary to the use of denture glue containing zinc. Treatment was started with copper and the dental glue was removed. Rehabilitation treatment was started with physiotherapy, hydrotherapy and occupational therapy. Functional improvement was achieved, going from an ASIAD level C4 to an ASIAD level C7 spinal cord injury. Copper levels should be studied in all non-compressive myelopathies of subacute onset if there is clear involvement of the posterior cords. Copper deficiency in analysis would establish the diagnosis. Rehabilitative treatment, supplementary copper supplementation and zinc withdrawal are essential to prevent irreversible neurological damage.(AU)

The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes / El enfoque de NOMS para los tumores metastásicos: integración de nuevas tecnologías para mejorar los resultados

Los paradigmas de tratamiento para pacientes con metástasis de columna vertebral han evolucionado significativamente en las últimas dos décadas. El cambio más transformador de estos paradigmas ha sido la integración de la radiocirugía estereotáctica espinal (sSRS). La sSRS permite la administración de dosis de radiación lítica con preservación de los órganos cercanos en riesgo, particularmente la médula espinal. La evidencia apoya la seguridad y la eficacia de la radiocirugía, ya que actualmente ofrece un control tumoral local duradero con bajas tasas de complicaciones, incluso para tumores que anteriormente se consideraban radiorresistentes a la radioterapia convencional de haz externo. El papel de la intervención quirúrgica sigue siendo consistente, pero se ha observado una tendencia hacia técnicas menos agresivas, a menudo mínimamente invasivas. Utilizando tecnologías modernas e instrumentación mejorada, los resultados quirúrgicos continúan mejorando con una morbilidad reducida. Además, los agentes dirigidos, como los productos biológicos y los inhibidores de puntos de control, han revolucionado la atención del cáncer al mejorar tanto el control local como la supervivencia del paciente. Estos avances han dado lugar a la necesidad de nuevas herramientas de pronóstico y a una revisión más crítica de los resultados a largo plazo. La naturaleza compleja de los esquemas de tratamiento actuales requiere un enfoque multidisciplinario que incluya cirujanos, oncólogos médicos, oncólogos radioterápicos, intervencionistas y especialistas en dolor. Esta revisión recapitula los datos actuales basados en la evidencia sobre el tratamiento de las metástasis espinales e integra estos datos en un marco de decisión, NOMS, que se basa en cuatro pilares centinela de la toma de decisiones en tumores metastásicos de la columna vertebral: estado neurológico, comportamiento oncológico del tumor, estabilidad mecánica, y carga sistémica de la enfermedad y comorbilidades médicas.(AU)

Spinal metastases are a common oncologic challenge as 20–40% of cancer patients are affected during the course of their illness and up to 20% of those will become symptomatic from spinal cord compression.1–5 The magnitude of this problem is expected to grow commensurate with the exponential rise in the use of targeted therapies which have demonstrated markedly improved survivals for virtually all malignant tumors. Additionally, the increased availability of advanced diagnostic imaging such as magnetic resonance imaging and 18-FDG PET scans will also serve to increase detection of spine metastatic disease. Despite extended survivals conveyed by biologics and checkpoint inhibitors, the treatment goals for patients with spine metastases remain palliative and focused on the preservation or restoration of neurological function and spinal stability, improved pain control and health related quality of life (HRQOL), and durable tumor control. Scoring systems such as the Tomita score6 and Tokuhashi revised score7 historically have been used to estimate survival and dictate treatment but increasingly have become obsolete due to their inability to incorporate and account for advances in all domains of cancer treatment.(AU)

El enfoque de NOMS para los tumores metastásicos: integración de nuevas tecnologías para mejorar los resultados / The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes

Los paradigmas de tratamiento para pacientes con metástasis de columna vertebral han evolucionado significativamente en las últimas dos décadas. El cambio más transformador de estos paradigmas ha sido la integración de la radiocirugía estereotáctica espinal (sSRS). La sSRS permite la administración de dosis de radiación lítica con preservación de los órganos cercanos en riesgo, particularmente la médula espinal. La evidencia apoya la seguridad y la eficacia de la radiocirugía, ya que actualmente ofrece un control tumoral local duradero con bajas tasas de complicaciones, incluso para tumores que anteriormente se consideraban radiorresistentes a la radioterapia convencional de haz externo. El papel de la intervención quirúrgica sigue siendo consistente, pero se ha observado una tendencia hacia técnicas menos agresivas, a menudo mínimamente invasivas. Utilizando tecnologías modernas e instrumentación mejorada, los resultados quirúrgicos continúan mejorando con una morbilidad reducida. Además, los agentes dirigidos, como los productos biológicos y los inhibidores de puntos de control, han revolucionado la atención del cáncer al mejorar tanto el control local como la supervivencia del paciente. Estos avances han dado lugar a la necesidad de nuevas herramientas de pronóstico y a una revisión más crítica de los resultados a largo plazo. La naturaleza compleja de los esquemas de tratamiento actuales requiere un enfoque multidisciplinario que incluya cirujanos, oncólogos médicos, oncólogos radioterápicos, intervencionistas y especialistas en dolor. Esta revisión recapitula los datos actuales basados en la evidencia sobre el tratamiento de las metástasis espinales e integra estos datos en un marco de decisión, NOMS, que se basa en cuatro pilares centinela de la toma de decisiones en tumores metastásicos de la columna vertebral: estado neurológico, comportamiento oncológico del tumor, estabilidad mecánica, y carga sistémica de la enfermedad y comorbilidades médicas.(AU)

Spinal metastases are a common oncologic challenge as 20–40% of cancer patients are affected during the course of their illness and up to 20% of those will become symptomatic from spinal cord compression.1–5 The magnitude of this problem is expected to grow commensurate with the exponential rise in the use of targeted therapies which have demonstrated markedly improved survivals for virtually all malignant tumors. Additionally, the increased availability of advanced diagnostic imaging such as magnetic resonance imaging and 18-FDG PET scans will also serve to increase detection of spine metastatic disease. Despite extended survivals conveyed by biologics and checkpoint inhibitors, the treatment goals for patients with spine metastases remain palliative and focused on the preservation or restoration of neurological function and spinal stability, improved pain control and health related quality of life (HRQOL), and durable tumor control. Scoring systems such as the Tomita score6 and Tokuhashi revised score7 historically have been used to estimate survival and dictate treatment but increasingly have become obsolete due to their inability to incorporate and account for advances in all domains of cancer treatment.(AU)

Transição após a lesão medular na fase aguda. Vivência dos processos de eliminação vesical / Transition after spinal cord injury in the acute phase. Experiencing bladder elimination processes

A Lesão Medular é um evento devastador para a pessoa que a vivencia. Pode surgir em qualquer fase do ciclo vital e tem consequências na sua vida pessoal, familiar e social. Manifesta-se por alterações motoras e sensitivas abaixo do nível da lesão e tem repercussões na função gastrointestinal, na sexualidade e na eliminação vesical. Objetivo: Perceber como vivenciam as pessoas com LM na fase aguda, a transição dos processos de eliminação urinária durante o internamento hospitalar. Métodos: Estudo qualitativo com abordagem fenomenológica, através de entrevistas semiestruturadas a dezasseis pessoas com LM que tiveram um internamento em neurocirurgia. A informação transcrita foi validada pelos participantes, organizada e submetida à análise de conteúdo tendo como referência para categorização o modelo conceptual de enfermagem de Afaf Meleis. O tratamento de dados realizou-se com auxílio da ferramenta AtlasTi. Resultados: Dos 16 participantes, 13 apresentavam alterações da sua eliminação vesical. Nas narrativas das vivências, foram identificadas as categorias: Viver uma Transição, Fatores Facilitadores e Inibidores da Transição, Padrões de resposta (indicadores de processo e resultado) e Terapêuticas de Enfermagem. A transição saúde/doença foi vivenciada pelos participantes. A consciencialização, os pontos e eventos críticos, foram propriedades identificadas na transição. A volição, o conhecimento prévio, a família e os recursos da comunidade foram fatores influenciadores da gestão da eliminação vesical. Os indicadores Coping, o Sentir-se Ligado, a Mestria e Reformulação da Identidade, foram facilmente identificados nas narrativas. As Terapêuticas de Enfermagem foram valorizadas pelos participantes, onde a ligação, o suporte emocional dado por estes profissionais e o ensino das técnicas, foram determinantes na gestão dos processos de eliminação vesical. Conclusão: As pessoas com LM no internamento em fase aguda, vivenciam uma transição de saúde/doença em que as terapêuticas de enfermagem e os fatores facilitadores foram as categorias determinantes para uma transição saudável e uma boa gestão da eliminação vesical.

Spinal cord injury is a devastating event for the person who experiences it. It can occur at any stage of life and has consequences for personal, family and social life. It is manifested by motor and sensory alterations below the level of the injury and has repercussions on gastrointestinal function, sexuality and bladder elimination. Aim: Understand how people with SCI experience in the acute phase, the transition of urinary elimination processes during hospitalization. Methods: Qualitative study with a phenomenological approach, through semi- structured interviews with sixteen people with SCI who had been hospitalized in neurosurgery. The transcribed information was submitted to thematic-categorical content analysis, in the light of Afaf Meleis conceptual nursing model, using the content analysis technique and the AtlasTi tool. Results: Of the 16 participants, 13 had alterations to their bladder elimination. In the narratives of the experiences, were identified the following categories: Living a Transition, Transition Facilitating and Inhibiting Factors, Response Patterns (process and outcome indicators) and Nursing Therapies. The health/illness transition was experienced by the participants. Awareness, critical points and events were properties of the transitions manifested. Volition, prior knowledge, family and community resources was facilitating factors of bladder elimination management. Indicators Coping, Feeling Connected, Mastery and Identity Reformulation were easily identified in the narratives. Nursing Therapies were valued by the participants, where the connection, emotional support given by these professionals and the teaching of techniques were decisive in the management of bladder elimination processes. Conclusion: People with SCI in acute hospitalization experience a health/illness transition in which nursing therapies and facilitating factors were the determining categories for a healthy transition and good bladder elimination management.

Percursos de cuidados para a autonomia da pessoa portadora de lesão medular no autocuidado andar ­ vivências da fase aguda / Care pathways for the autonomy of people with spinal cord injuries in self-care for walking - experiences of the acute phase

A lesão medular na fase aguda exige cuidados imediatos especializados em unidades hospitalares, conduzindo a uma interrupção dos projetos de vida pessoais. Este contexto poderá agravar-se com a perda de mobilidade da pessoa e afetar a sua autonomia e independência no autocuidado andar. Objetivo: Compreender como percecionam as pessoas com LM na fase aguda a situação de dependência adquirida no autocuidado andar e o processo assistencial que suporta a sua independência e autonomia. Métodos: Estudo qualitativo de abordagem fenomenológica, com recurso a entrevistas semiestruturadas a dezasseis pessoas com LM internadas num serviço de neurocirurgia, com uma amostra do tipo intencional. As categorias criadas têm como referência o modelo conceptual de enfermagem de Dorothea Orem. A análise de conteúdo foi realizada pela metodologia de Bardin e com auxílio da ferramenta AtlasTi. Resultados: Os dezasseis participantes relataram vivências sobre o autocuidado andar, revelando a importância deste autocuidado durante internamento. Identificaram-se vinte categorias que se agruparam em: Requisitos Universais de Autocuidado, Fatores Condicionantes Básicos de Autocuidado, Requisitos de Autocuidado no Desvio de Saúde, Intervenções de Enfermagem e Sistemas de Enfermagem. A participação nas recomendações de reabilitação e a ativação dos três sistemas de enfermagem, com destaque para o apoio-educativo, são assumidos como elementares para a recuperação. É encontrada motivação na esperança sempre presente de recuperar. O recurso a auxiliares de marcha contribuiu para aumentar a autonomia com manifesta satisfação. Conclusão: Na fase aguda da LM, as pessoas identificam necessidades específicas de cuidados para dar resposta à dependência adquirida no autocuidado andar, o que leva à procura de cuidados de saúde diferenciados. As intervenções de enfermagem de reabilitação são reconhecidas como fundamentais e dão resposta às questões funcionais, proporcionando apoio em ambientes favorecedores do desenvolvimento pessoal.

Spinal cord injury acute phase requires immediate specialized care in hospital units, leading to an interruption of personal life projects. This context may worsen with the person's loss of mobility and affect their autonomy and independence in walking self-care. Objective: To understand how people with SCI in the acute phase perceive the situation of dependence acquired in self-care walking and the healthcare process that supports their independence and autonomy. Methods: Qualitative study with a phenomenological approach, using semi-structured interviews with sixteen people with SCI admitted to a neurosurgery ward, with an intentional sample. The categories created are based on Dorothea Orem's conceptual nursing model. Content analysis was performed using Bardin's methodology and the AtlasTi tool. Results: The sixteen participants reported walking self-care experiences, revealing the importance of this self-care during hospitalization. Twenty categories were identified and grouped into Universal Self-Care Requisites, Basic Conditioning Factors, Health- Deviation Self-Care Requisites, Nursing Interventions and Nursing Systems. Participation in rehabilitation recommendations and activation of the three nursing systems, emphasizing educational support, are assumed to be essential for recovery. Motivation is found in the ever-present hope of recovery. The use of walking aids contributed to increase autonomy with manifest satisfaction. Conclusion: In the acute phase of SCI, people identify specific care needs to respond to the dependency acquired in walking self-care, which leads to the search for differentiated health care. Rehabilitation nursing interventions are recognized as fundamental and respond to functional issues, providing support and environments that favour personal development.

Síndrome de compresión medular de etiología infecciosa

El síndrome de compresión medular es una urgencia neuroquirúrgica debido a que un diagnóstico precoz y un tratamiento temprano podría revertir las incapacitantes secuelas ocasionadas por esta enfermedad. Las causas de este síndrome pueden ser traumática, metastásica, infecciosa y vascular (hematomas). La etiología infecciosa no es frecuente y el principal germen involucrado suele ser Staphylococcus aureus. A continuación presentamos el caso de una paciente de 58 años con síndrome de compresión medular de etiología infecciosa quien fue ingresada en el Servicio de Clínica Médica del Centro Médico Nacional.

Spinal cord compression syndrome is a neurosurgical emergency because early diagnosis and early treatment could reverse the disabling consequences caused by this disease. The causes of this syndrome can be traumatic, metastatic, infectious, and vascular (hematomas). Infectious etiology is not frequent and the main germ involved is usually Staphylococcus aureus. Below we present the case of a 58-year-old patient with spinal cord compression syndrome of infectious etiology who was admitted to the Medical Clinic Service of the National Medical Center.

Associação de estimulação por ondas de choque a toxina botulínica e baclofeno durante a reabilitação de paciente com lesão medular e trauma cranioencefálico: relato de caso / Association of extracorporeal shockwave stimulation to botulinum toxin and baclofen during an in-patient rehabilitation in spinal cord injury and traumatic brain injury: case report

Recentemente, a terapia por ondas de choque extracorpóreas (TOCE) mostraram-se ser uma promissora tecnologia não invasiva para neuromodulação e recuperação funcional devido a melhora em brotamento neuronal, neuroproteção, controle de neuroplasticidade e reorganização neuronal, além de atuar em fatores de neurogênese. Objetivo: Descrever um caso que usa TOCE como um adjuvante na reabilitação de trauma medular. Relato de caso: LPS, 25 anos, estudante de medicina, sofreu uma queda de altura indeterminada com fratura de C5 e lesão medular associada a trauma cranioencefálico. Na fase aguda, ele se recuperou adequadamente, tendo sido submetido a descompressão e fixação de coluna e hospitalizado por 5 meses devido a disautonomias e infecções urinárias. Após esse período, ele iniciou um programa de reabilitação intensiva para tetraplegia espástica com classificação inicial segundo o ASIA (American Spinal Injury Association) nível C5 motor e C6 sensório. O tratamento incluiu 10 sessões de TOCE, realizadas com Duolith SD1 (Storz Medical, Suíça) com uma densidade de energia de 0,25mJ/mm², 5 cm e 3 cm de profundidade de foco, 2000 pulsos aplicados na linha média de coluna níveis C5 a T1 e 2000 pulsos a 5 cm de profundidade aplicados em região plantar bilateral. Bloqueio com toxina botulínica e fenol foram realizados com resposta parcial apesar da dose otimizada de baclofeno.

Recently, extracorporeal shockwaves (ESWT) have shown as a promising non-invasive technology for neuromodulation and functional recovery, due to improving neuronal budding, neuroprotection, control of neuroplasticity and neuronal reorganization, in addition to acting on neurogenesis factors. Objective: To describe a case that uses ESWT as an adjuvant to the rehabilitation of spinal cord trauma. Case Report: LPS, 25 years old, medical student, suffered a fall from an undetermined height with C5 fracture and spinal cord injury, associated with a cranioencephalic trauma. In the acute phase, he was rescued properly, performed decompression and spinal cord fixation and remained hospitalized for 5 months due to dysautonomia and urinary infections. After this period, he started an intensive in-patient rehabilitation program for spastic tetraplegia with initial classification according to ASIA C5 (motor) and C6 (sensory). The treatment included 10 sessions of ESWT, made with Duolith SD1 (Storz Medical, Switzerland) with an Energy flux density 0,25 mJ/mm2, at 5cm and 3cm depth focus, 2000 pulses each over the spinal cord at the midline of levels from C5 to T1, and 2000 pulses at 5cm depth focus applied at plantar region bilaterally.

The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes. / El enfoque de NOMS para los tumores metastásicos: integración de nuevas tecnologías para mejorar los resultados.

Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: neurological status, Oocologic tumor behavior, mechanical stability and systemic disease burden and medical co-morbidities.