Assessing pediatric neurosurgery capacity in La Paz, Bolivia: an illustrative institutional experience of a lower-middle-income country in South America.

OBJECTIVE: The current pediatric neurosurgery capacity in lower-middle-income countries (LMICs) in South America is poorly understood. Correspondingly, the authors sought to interrogate the neurosurgical inpatient experience of the sole publicly funded pediatric hospital in one of the largest regional departments of Bolivia to better understand this capacity. METHODS: A retrospective review of all neurosurgical procedures performed at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2019 and 2023 was conducted after institutional approval using a recently implemented national electronic medical record system. RESULTS: A total of 475 neurosurgical admissions satisfied inclusion for analysis over the 5-year span. The majority of admissions were from within the La Paz Department (87%) via the emergency department (77%), without private insurance (83%). The most common indications for neurosurgical intervention were trauma (35%), followed by hydrocephalus (28%), congenital disease (12%), infection (5%), and craniosynostosis (3%). Overall, the median age at time of surgery was 2.0 years, and the median operating time was 1.5 hours with a minority of intraoperative complications (2%). The most common inpatient complication was unplanned return to the operating room (19%), most commonly seen in congenital indications. At final discharge, the median postoperative length of stay was 10 days. Twenty-seven (6%) of the 475 patients died during hospitalization, most commonly seen in tumor indications. Of the 448 patients who were discharged, 299 (67%) returned for at least one follow-up appointment. CONCLUSIONS: There is restricted breadth in neurosurgical indications and outcomes achievable at the Children's Hospital of La Paz, Bolivia. As such, the capacity of pediatric neurosurgery at institutions in LMICs in South America such as this one is very limited. Identifying and prioritizing actionable interventions to improve this capacity is institution- and LMIC-dependent, and as such, future efforts will need to be tailored appropriately.

Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization.

OBJECTIVE: A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome. METHODS: This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. RESULTS: A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. CONCLUSION: Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A Bibliographic Analysis of the Most Cited Articles in Global Neurosurgery.

OBJECTIVE: Global neurosurgery is the practice of neurosurgery with the primary purpose of delivering timely, safe, and affordable neurosurgical care to all who need it. The aim of this study is to identify the most frequently cited articles in global neurosurgery through a bibliographic review to characterize articles and trends around this growing topic. METHODS: The top most-cited articles in global neurosurgery were determined by searching the Web of Science database using a priori search terms. Articles with at least 5 citations were selected, and there were no time period or language restrictions. The data were extracted from each included article and all characteristics were summarized. RESULTS: A total of 932 articles were identified using the search terms; 69 articles fulfilled inclusion criteria and 17 articles were selected that had more than 5 citations. The articles' number of citations ranged from 6 to 98 for the most-cited article. Authors from, or affiliated with, 14 countries contributed to the 17 articles, and the country that had the greatest representation was the United States. The main topic discussed was surgical capacity, the second topic was the treatment of different neurosurgical conditions, and volunteerism was the third topic. CONCLUSIONS: There is currently a deficit in both the amount of literature surrounding the topic of global neurosurgery and how much that literature is cited. Developing innovative ways to increase academic productivity within, or in collaboration with, low-middle income countries is essential to contribute to global neurosurgery.

Factors attributable to the cancellation of programmed surgeries.

OBJECTIVE: To analyze the factors attributable to the cancellation of surgeries of a third level health institution in the city of Valledupar, Cesar / Colombia (2017-2018). MATERIAL AND METHODS: Descriptive, retrospective, cross-sectional study. Data from the hospital surgical unit adverse case file were collected for 6 surgical specialties. RESULTS: They showed that in 2017 there was a surgical suspension of 4% of the total of scheduled surgeries that were (3339), for 2018 the rate was 3% with a total of scheduled surgeries (1733). The reason for the suspension for both periods was the factor related to the patient's adverse conditions with 45.9 and 38.5% respectively. The specialty most affected for these cases was the specialty of general surgery with the same percentage value in both periods of 4%. CONCLUSION: The results give us an idea of the factors present for the cancellation of scheduled surgeries and the need to apply measures to guarantee patient safety.

OBJETIVO: Analizar los factores atribuibles a la cancelación de cirugías de una institución de salud de tercer nivel en la ciudad de Valledupar, Cesar, Colombia (2017-2018). MATERIAL Y MÉTODOS: Estudio descriptivo, retrospectivo, transversal. Se recopilaron datos del archivo de casos adversos de la unidad quirúrgica del hospital para 6 especialidades quirúrgicas. RESULTADOS: Mostraron que en 2017 hubo una suspensión quirúrgica del 4% del total de cirugías programadas que fueron (3339), para 2018 la tasa fue del 3% con un total de cirugías programadas (1733). La razón de la suspensión para ambos períodos fue el factor relacionado con las condiciones adversas del paciente con 45.9 y 38.5% respectivamente. La especialidad más afectada para estos casos fue la especialidad de cirugía general con el mismo valor porcentual en ambos períodos del 4%. CONCLUSIÓN: Los resultados nos dan una idea de los factores presentes para la cancelación de cirugías programadas y la necesidad de aplicar medidas para garantizar la seguridad del paciente.

Microsurgery for Unruptured Cerebral Arteriovenous Malformations in the National Inpatient Sample is More Common Post-ARUBA.

BACKGROUND: The ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) was the first randomized control trial to investigate unruptured cerebral arteriovenous malformation (cAVM) treatments and concluded that medical management was superior to interventional therapy for the treatment of unruptured cAVMs. This conclusion generated considerable controversy and was followed by rebuttals and meta-analyses of the ARUBA methodology and results. We sought to determine whether the ARUBA results altered treatment trends of cAVMs within the United States. METHODS: Using the National Inpatient Sample, the largest all-payer inpatient care database within the United States, we isolated patients who were admitted on an elective basis for cAVM treatment and determined the treatment modality undergone by these patients. The cohort was dichotomized separately at 2 ARUBA time points: the European Stroke Conference presentation in May 2013, and The Lancet publication in February 2014. RESULTS: We found that the overall treatment rate of unruptured cAVMs decreased after both time points. However, the rate of surgical excision alone, relative to other modalities, was significantly increased, and endovascular intervention demonstrated a nonsignificant decrease. CONCLUSIONS: Our findings suggest that the ARUBA trial has influenced unruptured cAVM treatment patterns within the United States. Although the overall treatment rate has decreased, unruptured cAVMs, when treated post-ARUBA, are most commonly approached with surgical excision alone.

Endoscopic versus Microscopic Pituitary Adenoma Surgery: A Single-center Study.

BACKGROUND: Transsphenoidal approach became the gold standard in the surgical treatment of pituitary adenomas in the past years, but the comparative efficacy of microscopic and endoscopic transnasal surgery has not been fully studied. AIMS: To compare the microscopic and endoscopic transnasal approaches for the treatment of pituitary adenomas. SETTINGS AND DESIGN: A retrospective analysis was performed, comparing adult patients with pituitary adenomas who had undergone transnasal microscopic surgery between January 2006 and December 2014 with the patients operated on with endoscopic surgery between March 2011 and December 2014 at Hospital Italiano de Buenos Aires. MATERIAL AND METHODS: Imaging, hormonal, and ophthalmological studies as well as complications were analyzed. STATISTICAL ANALYSIS: Due to the existence of dichotomous variables, Fisher's exact test was used for statistical analysis. RESULTS: In all, 259 patients who had undergone microsurgery and 140 patients operated on with endoscopy were included. The pathologies compared were microsurgically resected nonfunctioning adenomas: 38.2% (n = 99) versus endoscopically resected: 42.1% (n = 59), and microsurgically resected functioning adenomas: 61.8% (n = 160) versus endoscopically resected: 57.9% (n = 81). A higher number of patients with invasive macroadenomas were reported in the group operated on with endoscopy (35.5% vs. 56.4%). When the patients with invasive pathology of the cavernous sinus were compared, percentages of total resection and hormonal control were higher for endoscopic surgeries (35% vs. 46.8%; 33.3% vs. 64%); however, this difference was not statistically significant. No statistically significant differences were found when postoperative complications were individually analyzed. CONCLUSION: The microsurgical and endoscopic approaches are safe and effective techniques to treat pituitary adenomas. For invasive adenomas, the endoscopic approach may report better results.

Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil.

Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (ß1 = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.

A study to assess global availability of fetal surgery for myelomeningocele.

AIM: To establish the provision of fetal surgery for myelomeningocele (MMC) worldwide. METHODS: Through the International Society for Prenatal Diagnosis (ISPD) Fetal Therapy Special Interest Group and the North American Fetal Therapy Network (NAFTNet), fetal therapy centres were surveyed (September 2017-June 2018) regarding availability of fetal MMC surgical repair, patient inclusion criteria, repair techniques, number of cases, and outcome reporting. Responses were summarised on an interactive map on the ISPD website. RESULTS: Forty-four of 59 centres responded (74.6%) of which 34 centres (77.1%) currently offered fetal surgery for MMC and seven centres (15.9%) were awaiting a first case after service set up. Patient inclusion criteria were similar and based on the Management of Myelomeningocele (MOMS) trial. Five centres (14.7%) operated beyond 26 weeks' gestational age, outside the MOMS criteria. Open fetal surgery was provided in 23 centres (67.6%), fetoscopic surgery only in five (14.7%), and six centres offered both types (17.6%). Neurosurgical closure was similar for open surgery but highly variable in fetoscopy surgery. The median number of cases per centre was 21 (range 1-253). CONCLUSIONS: Fetal surgery for MMC is now offered globally. Two thirds of centres offer open repair via hysterotomy using criteria based on the MOMS trial.

Preventability of Pediatric 30-Day Readmissions following Ventricular Shunt Surgery.

OBJECTIVE: To compare the preventability of 30-day pediatric ventricular shunt readmissions using clinical and administrative data review. STUDY DESIGN: We performed a retrospective chart review of one hundred forty-seven 30-day ventricular shunt readmissions at a tertiary pediatric center from May 2009-April 2013 under 2 scenarios: scenario 1 considered all ventricular shunt failures preventable; and scenario 2 considered shunt failures with excellent/good catheter positioning and no contributing deficiencies in care not preventable. Three physician reviewers independently assessed readmissions to determine their preventability and whether deficiencies in care existed that contributed to the readmission. We also evaluated the degree of interrater agreement in adjudicating readmission preventability. RESULTS: Only 42% of 30-day readmissions following ventricular shunt procedures were preventable when considering all shunt failures as preventable. When classifying shunts with excellent/good proximal catheter position as not preventable, 21% of ventricular shunt readmissions were deemed preventable. Interrater agreement on readmission preventability was high (kappa 0.88). Deficiencies in care existed in 29 readmissions (20%), the largest category being physician related, but not all deficiencies contributed to a readmission. CONCLUSIONS: Significant discrepancy exists in the preventability adjudication of ventricular shunt readmissions between administrative and chart review. Although using administrative data has determined that a majority of readmissions following pediatric ventricular shunt procedures are preventable, our review suggests a significantly lower degree of preventability.

Procedimientos neuroquirúrgicoscerebrales guiados por estereotaxiarealizados en el Hospital Universitario de San Ignacio (HUSI): evolución a corto y mediano plazo / Neurosurgical Brain Estereotactic- Guided Procedures Performed at Hospital Universitario San Ignacio (HUSI): Development in the Short and Medium Term

Objetivo: Describir los resultados postoperatorios de los pacientes a los que se lesrealizaron procedimientos neuroquirúrgicos cerebrales guiados por estereotaxia enel Hospital Universitario de San Ignacio durante el periodo julio del 2009-julio del2011. Materiales y métodos: Se revisaron las historias clínicas de 78 pacientes,sus características clínicas, la localización de las lesiones en las neuroimágenes,el tipo de procedimiento, los resultados funcionales y los desenlaces a corto ymediano plazo. Resultados: 78 pacientes tuvieron procedimientos neuroquirúrgicosguiados por estereotaxia entre julio del 2009 y julio del 2011. El 64,1 % (n = 50)eran hombres. La localización de las lesiones fue en orden de frecuencia: gangliossubtalámicos, lóbulo frontal, lóbulo temporal, tálamo, unión córtico-subcortical, tallocerebral, ubicación frontotemporal, lóbulo occipital, ubicación parieto-occipital ybase del cráneo. Discusión: La implementación de procedimientos neuroquirúrgicosguiados por estereotaxia sigue siendo una de las mejores opciones en el abordaje depatologías cerebrales profundas o de difícil acceso. Tanto en Colombia como en elresto del mundo son procedimientos con una baja tasa de morbilidad y mortalidad.Conclusiones: Independientemente del tipo de procedimiento guiado por estereotaxiala tasa de complicaciones no excede el 5 %, tasas similares a las obtenidas en laliteratura mundial...

Objective: Retrospective description of postoperativeoutcomes of patients who underwentneurosurgical brain stereotactic guided proceduresat the Hospital Universitario San Ignacioduring the period July 2009-July 2011. Materialsand Methods: A review of medical recordsof 78 patients who were taken to neurosurgicalstereotactic guided procedures at the HospitalUniversitario San Ignaci. We reviewed the clinicalcharacteristics of patients, the location of thelesions on neuroimaging, management, type ofprocedure of each patient, functional results andoutcomes in the short and medium term. Results:78 patients who underwent neurosurgical brainstereotactic guided procedures between July2009 to July 2011 at the Hospital UniversitarioSan Ignacio. The 64.1 % (n = 50) were men. Thelocation of the lesions were in order of frequencysub-thalamic ganglia, frontal lobe, temporallobe, thalamus, cortico-subcortical junction, brainstem,fronto-temporal location, occipital lobe,parieto-occipital location, and at the skull’s base.Discussion: Implementing guided stereotacticneurosurgical procedures remains one of the bestoptions in dealing with deep brain pathologies ordifficult access. In both Colombia and the rest ofthe world, these are procedures with low morbidityand mortality. It must, however, developmulticenter studies that allow us to observe thedevelopment of stereotactic neurosurgery in ourcountry, also develop studies with a larger continuityto assess the long-term outcomes. Conclusions:Whatever type of stereotactic guidedprocedure the rate of complications does not exceed5 %, similar rates to those obtained from theglobal literature...

Epilepsy surgery in Argentina: long-term results in a comprehensive epilepsy centre.

RATIONALE: Epilepsy surgery procedures started in Argentina more than 50 years ago. This is the first comprehensive and systematic survey of epilepsy surgery long-term outcome from our country. METHODS: A descriptive cohort study was conducted between 1998 and 2008 for drug-resistant epilepsy surgery with a minimum of 12 months follow-up (n=110). In 84 cases (76.36%) resective surgery was performed, and outcome periodically assessed using the Engel score. Patients were stratified into groups: 12, 13-36, 37-60 and over than 60 months of follow-up. Video-EEG with and without intracranial electrode implants, intraoperative electrocorticograms, Wada tests, pathology reports, use of antiepileptic drugs (AEDs), and surgical complication rates were evaluated. RESULTS: Surgical techniques included: 69 lobectomies (62.7%), 15 lesionectomies (13.6%), 6 callosotomies (5.4%), 6 multiple subpial transection (5.4%), 11 vagus nerve stimulations (10%), 3 hemispherectomies (2.7%). Male: female ratio: 1/1.44. Mean age at time of surgery: 26.2 years. Mean duration of epilepsy: 14 years. Age at seizure onset: 11.5 years. Mean follow-up: 46 months. Pathology findings: mesial temporal sclerosis 32 (35.1%); dual pathology 17 (18.7%); cortical dysplasia 15 (16.4%); non-specific inflammatory changes 11 (12.1%); tumors 7 (7.7%); other 6 (6.8%). Engel scores at 12 months follow-up: 72.6% (61) class I, 16.6% (14) class II and 15.5% (13) class III-IV; 13-36 months after surgery: 68.1% of cases were class I, 15.9% class II and 15.5% class III-IV. After 37-60 months, 74% class I, 14% class II, 14% class III-IV. Over 60 months (n=45) 78% class I, 13.5% class II and 8.1% class III-IV. CONCLUSION: Conducting a successful epilepsy surgery program in a developing country is challenging. These results should encourage specialists in these countries. Long-term outcome results comparable to centres in developed countries can be achieved.

Perioperative factors associated with prolonged intensive care unit and hospital length of stay after pediatric neurosurgery.

OBJECTIVES: This study aims to describe the association between different postoperative complications and the length of hospital stay among children undergoing neurosurgical procedures. METHODS: A retrospective cohort study was carried out between May 2004 and May 2009 in a tertiary community hospital. All postoperative complications following neurosurgical procedures and their association with the main outcomes [length of intensive care unit (ICU) and hospital stay] were investigated in a univariate and multivariate analysis. RESULTS: The medical records of 198 patients treated during the study period were reviewed. The most frequently performed surgeries were ventriculoperitoneal shunting (16.7%), correction of craniosynostosis (30%) and brain tumor resections (28.3%). Of the 198 patients eligible for this analysis, 79 (39.9%) suffered from at least one complication. The most frequent complications were fever (30.3%), hypothermia (16%), postextubation laryngitis (15.1%) and postoperative bleeding (7%). Factors independently associated with a longer pediatric ICU stay were fever (odds ratio 1.39, 95% confidence interval 1.1-3.2; p = 0.001), laryngitis (odds ratio 2.24, 95% confidence interval 1.8-5.2; p = 0.001), postoperative bleeding requiring reoperation (odds ratio 1.8, 95% confidence interval 1.4-3.9; p < 0.001) and infection (odds ratio 3.71, 95% confidence interval 1.8-12.4; p = 0.033). Fever (odds ratio 2.54, 95% confidence interval 2-7.4; p = 0.001) and infection (odds ratio 11.23, 95% confidence interval 4-22.4; p = 0.003) were related to the total length of the patient's hospital stay. CONCLUSIONS: In this study population, most elective neurosurgical procedures were not associated with significant complications, and morbidity and mortality were low. Some complications significantly influenced patients' outcomes and should be monitored for early diagnosis. This study may improve our understanding and identification of postoperative outcomes in pediatric neurosurgery.

Neurophysiological monitoring in spinal cord surgery.

BACKGROUND: Intraoperative neurophysiological monitoring (IOM) during spine surgery consists of several functional tests including somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), dermatomal potentials (DPs) and EMG (electromyography). Permanent neurological damage after spine surgery performed without intraoperative neurophysiological monitoring is frequent and often very costly. The main goal of IOM is the immediate detection, prevention and correction of neurological damage during surgery, which may go unnoticed without using these tests. METHODS: A total of 351 clinical files of patients with spinal surgery and continuous neurophysiological monitoring were transversally and descriptively reviewed from 2007 to 2008. RESULTS: There were 135 male patients (38.46%) and 216 female patients (61.54%); 82% of the cases were osteodiscal pathology with or without medullar involvement, 12% were patients with traumatic injuries, 4% with scoliosis and 2% had medullary tumors. Regarding localization, 62.1% were lumbar, 33% cervical, 4.3% thoracic and 0.5% sacral involvement; 12.4% of our cases showed significant improvement of the basal responses on SSEPs, and 56.8% showed no significant change during the procedure. In 28.4% of the cases, the surgical team had to be advised of potential neurological damage and in 2.4% there was absence of neurophysiological responses. No patient showed complete loss of any neurophysiological response. All patients reported clinical improvement after hospital discharge. CONCLUSIONS: Intraoperative neurophysiological monitoring may help avoid certain neurological risks during spine surgery, which may go unnoticed without the use of this technique.

Vigilancia neurofisiológica transoperatoria multimodal en cirugía de columna / Neurophysiological monitoring in spinal cord surgery

Introducción: La vigilancia neurofisiológica durante la cirugía de columna vertebral y de la médula espinal consiste en pruebas de potenciales evocados somatosensoriales, potenciales motores musculares, potenciales dermatomales y electromiografía. El riesgo de daño neurológico permanente después de una cirugía medular sin monitorización es significativo y el costo alto. El objetivo de la vigilancia neurofisiológica es identificar, prevenir y corregir de forma inmediata el daño neurológico que puede pasar inadvertido durante la cirugía de columna vertebral y médula espinal. Material y métodos: Estudio transversal, observacional y descriptivo de los pacientes sometidos a cirugía de columna entre 2007 y 2008 con vigilancia neurofisiológica transoperatoria. Resultados: La muestra estuvo integrada por 351 pacientes, 135 del sexo masculino (38.46 %) y 216 del femenino (61.54 %); 82 % correspondió a patología osteodiscal con o sin afectación medular, 12 % a etiología traumática, 4 % a corrección de escoliosis y 2 % a tumores medulares; por localización, 62.1 % a patología lumbar, 33 % a cervical, 4.3 % a nivel dorsal y 0.5 % a nivel sacro. El 12.4 % de los pacientes presentó mejoría de la respuesta basal de sus potenciales evocados somatosensoriales; 56.8 % los mantuvo similares a sus controles prequirúrgicos, 28.4 % requirió llamada de alerta al cirujano por riesgo de daño y 2.4 % caída severa de respuesta. En ningún caso hubo pérdida permanente. Conclusiones: La vigilancia neurofisiológica constituye una herramienta de gran valor que evita daños que pueden producirse durante esta cirugía.

BACKGROUND: Intraoperative neurophysiological monitoring (IOM) during spine surgery consists of several functional tests including somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), dermatomal potentials (DPs) and EMG (electromyography). Permanent neurological damage after spine surgery performed without intraoperative neurophysiological monitoring is frequent and often very costly. The main goal of IOM is the immediate detection, prevention and correction of neurological damage during surgery, which may go unnoticed without using these tests. METHODS: A total of 351 clinical files of patients with spinal surgery and continuous neurophysiological monitoring were transversally and descriptively reviewed from 2007 to 2008. RESULTS: There were 135 male patients (38.46%) and 216 female patients (61.54%); 82% of the cases were osteodiscal pathology with or without medullar involvement, 12% were patients with traumatic injuries, 4% with scoliosis and 2% had medullary tumors. Regarding localization, 62.1% were lumbar, 33% cervical, 4.3% thoracic and 0.5% sacral involvement; 12.4% of our cases showed significant improvement of the basal responses on SSEPs, and 56.8% showed no significant change during the procedure. In 28.4% of the cases, the surgical team had to be advised of potential neurological damage and in 2.4% there was absence of neurophysiological responses. No patient showed complete loss of any neurophysiological response. All patients reported clinical improvement after hospital discharge. CONCLUSIONS: Intraoperative neurophysiological monitoring may help avoid certain neurological risks during spine surgery, which may go unnoticed without the use of this technique.

A model for neurosurgical humanitarian aid based on 12 years of medical trips to South and Central America.

The pediatric neurosurgical mission trips led by physicians at Virginia Commonwealth University (VCU) Health Systems began in 1996 with the formation of Medical Outreach to Children, founded by 1 of the authors (J.D.W.) after a visit to Guatemala. Since then, 19 surgical trips to 4 different countries in Central and South America have been coordinated from 1996 to 2008. This humanitarian work serves a number of purposes. First and foremost, it provides children with access to surgical care that they would otherwise not receive, thereby significantly improving their quality of life. Second, the visiting surgical team participates in the education of local physicians, parents, and caregivers to help improve the healthcare provided to the children. Last, the team works to promote sustainable global health solutions in the countries it travels to by generating a forum for clinical and public health research discourse. Thus far, a total of 414 children have undergone 463 operations, including 154 initial shunt surgeries, 110 myelomeningocele repairs, 39 lipoma resections, 33 tethered cord releases, 18 shunt revisions, 16 encephalocele repairs, 9 lipomyelomeningocele repairs, and 7 diastematomyelia repairs. The complication rate has been 5-8%, and the team has obtained reliable follow-up in approximately 77% of patients. A correlation was found between an increase in the number of trained neurosurgeons in the host countries and a decrease in the average age of patients treated by the visiting surgical team over time. It is also hypothesized that a decrease in the percentage of myelomeningocele repairs performed by the surgical team (as a fraction of total cases between 1996 and 2006) correlates to an increase in the number of local neurosurgeons able to treat common neural tube defects in patients of younger ages. Such analysis can be used by visiting surgical teams to assess the changing healthcare needs in a particular host country.

Cirugía de los meningiomas intracraneales en el Servicio de Neurocirugía del Hospital Provincial Docente "Manuel Ascunce Domenech" / Intracraneal meningiona surgery at the Neurosurgery Service of Provincial Academic Hospital Manuel Ascunce Domenech

Se realizó un estudio descriptivo observacional de todos los pacientes diagnosticados de meningiomas Intracraneales en el Servicio de Neurocirugía del Hospital provincial Docente "Manuel Ascunce Domenech". Se determinó que los meningiomas Intracraneales resultaron más frecuentes en mujeres de la cuarta y quinta décadas de la vida, la cefalea, el déficit motor y las alteraciones mentales fueron los signos y síntomas neurológicos de mayor incidencia. La localización más frecuente de la lesión fue la de la convexidad frontal y resultó ser la de mejor grado de resección quirúrgica. El meningioma meningotelial, seguido del psamomatoso fueron los tipos histológicos predominante y las complicaciones respiratorias, la fístula de LCR y la sepsis quirúrgica ocuparon el primer lugar en cuanto a complicaciones. Se discuten y comparan estos resultados con la literatura nacional e internacional.

A descriptive observational study was run on all patients with intracranial meningiomas diagnosis at the Neurosurgery Department of the Academic Hospital "Manuel Ascunce Domenech". The result was that intracranial meningiomas are more frequent in women in their forties and fifties, migraine, motor deficit and mental disturbances were the neurological signs and symptoms of main incidence. The most frequent location of the lesion was the frontal convexity and proved to be of the best level of surgical resection. The meningiothelial meningioma followed by the psammomatous were the predominant histological types as well as the respiratory complications. As for complications the CSV fistula and surgical sepsis were on the first place. These results are discussed and compared with national and international literature.

Outcome of surgical intrasellar growth hormone tumor performed by a pituitary specialist surgeon in a developing country.

BACKGROUND: Acromegaly is an excessive GH secretion, which in most cases, is caused by a pituitary GH-secreting adenoma. Traditional treatment of acromegaly consists of surgery, drug therapy, and eventually radiotherapy. The aim of this retrospective study is to evaluate the results of transsphenoidal endoscopic surgery in a group of patients with intrasellar GH adenoma who were operated by a pituitary specialist surgeon. We shall then argue about the economical advantages, for the NHS of a developing country, between surgical and medical treatment. METHODS: We have analyzed data from 33 patients with intrasellar GH tumor who had been referred to the neuroendocrine department of the HGF, Brazil. The patients underwent a transsphenoidal endoscopic adenomectomy for acromegaly between 2000 and 2005. Their ages were between 20 and 67 years (mean, 44 years) at the moment of surgery. No cavernous sinus invasion was present. Follow-up was a median of 2 years (range, 12 months-6 years). RESULTS: All 33 patients had intrasellar adenoma, 84.84% of patients achieved remission by surgery. One patient was operated twice and reached hormonal normalization. Five patients still had the disease and refused a second surgery. A treatment with octreotide was started for these 5 patients and resulted in an adequate control of GH and IGF-1 levels. No patients had radiotherapy. CONCLUSION: Our patients, with intrasellar GH tumor, operated by a pituitary specialist neurosurgeon had remission rates approaching those obtained by most specialized neurosurgical centers worldwide. For equal results, our study shows that the surgical treatment is the best issue for the patient and for the NHS.

Assessment of risk and incidence of falls in neurosurgical inpatients.

Neurosurgical patients may present motor, sensitive and balance impairment and increased risk of falling. The aim of this study was to evaluate the fall-related risk factors and the incidence of falls in the pre and post-operative period of neurosurgical patients. A prospective cohort study with a research population of patients undergoing elective neurosurgical procedures. Ninety-seven patients took part in the study. Eight (8.2%) have presented falls with a total of 12 falls (12.4%). In two falls (16.7%), bed side rails were down, whereas in six falls (50%), beds had no rails at all. There was no difference among fall-related risk factors during pre and the post-operative periods. We have concluded that most falls could have been prevented through an improvement in the hospital internal structure and with the introduction of a falls prevention program.

Examination of the management of traumatic brain injury in the developing and developed world: focus on resource utilization, protocols, and practices that alter outcome.

OBJECT: We evaluated management and outcome of traumatic brain injury (TBI) in a developed country (US) and a developing country (Jamaica). METHODS: Data were collected prospectively at Grady Memorial Hospital (GMH) in the US and at University Hospital of the West Indies (UHWI) and Kingston Public Hospital (KPH) in Jamaica between September 1, 2003, and September 30, 2004. RESULTS: Complete data were available for 1607 patients. Grady Memorial Hospital had a higher proportion of females (p = 0.003), and patients were older at GMH (p = 0.0009) compared with patients at KPH and UHWI. The most common mode of injury was a motor vehicle accident at KPH and GMH (42 and 66%, respectively) and assaults at UHWI (37%). Grady Memorial Hospital admitted more patients with severe head injuries (25.5%) than KPH (18.5%) and UHWI (14.4%). More CT scans were performed (p < 0.0001) and a higher proportion of patients were admitted to the intensive care unit (p < 0.0001) at GMH. There were no statistically significant differences in median days in the intensive care unit among the 3 hospitals. Patients experienced statistically significant differences in days undergoing ventilation between GMH, KPH, and UHWI (p = 0.004). Intracranial pressure monitoring was performed in 1 patient at KPH, in 6 at UHWI, and in 91 at GMH. There were 174 total deaths, but no statistically significant differences in mortality rates between the 3 sites (p = 0.3). Hospital location and TBI severity were associated with a decreased risk of mortality; patients with severe TBI at GMH had a 53% decrease in the risk of mortality (odds ratio = 0.47, p = 0.04). Patients at GMH had lower mean Glasgow Outcome Scale scores (p < 0.0001) and lower Functional Independence Measure self-feed (p = 0.0003), locomotion (p = 0.04), and verbal scores (p < 0.0001). CONCLUSIONS: Despite the availability of advanced technology and more aggressive neurological support at GMH, the overall mortality rate for TBI was similar at all locations. Patients identified with severe TBI had a significantly decreased risk of mortality if they were treated at GMH compared with those patients treated at hospitals in the developing world.