[Abducens nerve palsy due to postraumatic retroclival and spinal subdural hematoma: case report and literature review]. / Paresia VI par craneal por hematoma subdural retroclival y espinal postraumatico: presentacin de un caso y revision de la literatura.

INTRODUCTION: Retroclival posttraumatic hematomas are extremely rare and almost exclusive to childhood. Only one case of retroclival subdural hematoma has been reported in the literature to date. CASE REPORT: An 8-year-old boy suffered a severe head injury with cervical hyperextension as the result of a bicycle accident. On admission his initial Glasgow Coma Score was 13 and he had diplopia due to right palsy of the VI nerve. A retroclival subdural hematoma was observed by CT and MRI of the craneovertebral junction. Management was conservative and a rigid collar was placed. Palsy of VI nerve recovered spontaneously at 6 days and at discharge the patient had only cervical pain. Follow up at 3 months after the accident showed clinical and radiological resolution. CONCLUSION: Traumatic retroclival hematomas are mainly a pediatric entity due to immaturity of the cranio-cervical junction. Treatment consists of placement of a rigid collar although clinical progression may require surgical evacuation.

Paresia VI par craneal por hematoma subdural retroclival y espinal postraumático: presentación de un caso y revisión de la literatura / Abducens nerve palsy due to postraumatic retroclival and spinal subdural hematoma: case report and litera­ture review

Introducción. Los hematomas retroclivales postrau-máticos son extremadamente infrecuentes y casi exclu­sivos de la edad pediátrica. Únicamente se ha documen­tado en la literatura un caso de hematoma subdural retroclival postraumático. Caso clínico. Varón de 8 años de edad que tras accidente de bicicleta sufre traumatismo cráneo-ence­fálico con hiperextensión cervical. A su ingreso presentó Glasgow inicial de 13 y diplopia por paresia del VI par derecho. En la TAC y RM cráneo-cervical se objetivó un hematoma subdural retroclival. Se realizó manejo conservador con colocación de collarín rígido. Se observó recuperación espontánea del VI par a los 6 días presentando únicamente cervicalgia al alta. Presentó resolución clínica y radiológica a los 3 meses del acci­dente. Conclusión. Las lesiones hemorrágicas retroclivales postraumáticas son típicas de la edad pediátrica por la inmadurez de la unión cráneo-cervical que presentan. El tratamiento de elección es la colocación de un colla­rín rígido aunque si existe progresión clínica puede ser necesaria la evacuación quirúrgica (AU)

Introduction. Retroclival posttraumatic hematomas are extremely rare and almost exclusive to child­hood. Only one case of retroclival subdural hema­toma has been reported in the literature to date. Case report. An 8-year-old boy suffered a severe head injury with cervical hyperextension as the result of a bicycle accident. On admission his initial Glasgow Coma Score was 13 and he had diplopia due to right palsy of the VI nerve. A retroclival subdural hematoma was observed by CT and MRI of the craneovertebral junction. Management was conservative and a rigid collar was placed. Palsy of VI nerve recovered sponta­neously at 6 days and at discharge the patient had only cervical pain. Follow up at 3 months after the accident showed clinical and radiological resolution. Conclusion. Traumatic retroclival hematomas are mainly a pediatric entity due to immaturity of the cranio-cervical junction. Treatment consists of place­ment of a rigid collar although clinical progression may require surgical evacuation (AU)

[Ureteral injury after posterior lumbar surgery. Case report]. / Lesión del uréter tras una cirugía lumbar posterior. Caso clínico.

INTRODUCTION: The percentage of complications in posterior lumbar spine surgery varies from 1,9 to 10,8%. Injury to retroperitoneal structures is a severe but unfrequent complication. Ureter injury is an extremely rare complication with only 24 documented cases up to date. CASE REPORT: 43 year old woman. A deep bleeding was observed while performing a L4-L5 microdiscectomy. It was controlled with firm pressure and hemostatic agents. 36 hours later the patient developed a distended and painful abdomen associated with anemia and an increase in white blood cell count. Abdominal CT and retrograde pyelography confirmed the diagnosis of ureter injury. An emergency laparotomy was perfomed and a total section of the left ureter was treated with a end to end anastomosis. DISCUSSION: Ureter injury in posterior lumbar spine surgery can happen due to its close anatomical relationship with the vertebral body and disc. L4-L5 is the level most often affected. Due to the fact the ureter is surrounded by retroperitoneal fat, injury is less likely to happen and thus the low number of documented cases. Although the initial symptomatology may be inespecific, an early diagnosis is essential in order to avoid further complications such as a sepsis or a kidney loss. There are several treatment options although the most often used is the end to end anastomosis specially if there is a complete ureter injury.

[Sinking skin flap syndrome]. / Sindrome del colgajo hundido.

INTRODUCTION: The sinking skin flap syndrome is a complication of decompressive craniectomies. It is of relevance not only due to its frequency, it is often underdiagnosed, but also because of the possibility of reversing the symptoms with the proper treatment. CASE REPORT: A 53-year-old female sustained a severe head injury. The initial Glasgow Coma Scale was 6T. The CT scan showed a severe traumatic injury in the left temporal lobe that required a decompressive craniectomy. After surgery the patient developed aphasia and right hemiparesis but progressively improved. Four months after surgery, however, she presented neurological worsening. An MRI showed skin retraction with a mass effect on the brain parenchyma at the craniectomy defect. A cranioplasty was performed and the patient progressively recovered neurologically. CONCLUSIONS: The symptoms of sinking skin flap are headache, dizziness, inappropriate behaviour, neurological functional impairment and/or seizures. The symptoms worsen with the Valsalva manoeuvres and with changes in position. Typically, symptoms 3 to 5 months to appear. Theories to explain these symptoms include a direct atmospheric pressure effect, brain blood flow changes, alteration in cerebrospinal fluid dynamics and metabolic disturbances. Diagnosis is performed through clinical observation but imaging studies are recommended to confirm the diagnosis. The treatment of choice is a cranioplasty. Prognosis is excellent and almost all patients recover completely.

Lesión del uréter tras una cirugía lumbar posterior. Caso clínico / Ureteral injury after posterior lumbar surgery. Case report

Introducción. La frecuencia de complicaciones enla cirugía lumbar por vía posterior oscila entre 1,9 y10,8%. Dentro de estas complicaciones la lesión deestructuras retroperitoneales es una complicación pococomún pero potencialmente grave. La lesión del uréteres una complicación extremadamente rara existiendoen la literatura únicamente 24 casos documentados.Caso clínico. Mujer de 43 años que durante la realizaciónde una microdiscectomía L4-L5 se observó unsangrado profundo que fue controlado con compresiónsin que existiera compromiso hemodinámico. A las 36horas la paciente presentó un abdomen distendido ydoloroso acompañado de anemia y leucocitosis. A travésde un TAC abdominal y una pielografía retrógrada sediagnostico de rotura del uréter izquierdo. Se le practicóuna laparotomía de urgencias y se observó unasección total del uréter izquierdo que se trató con unaanastomosis termino-terminal (..) (AU)

Introduction. The percentage of complications inposterior lumbar spine surgery varies from 1,9 to10,8%. Injury to retroperitoneal structures is a severebut unfrequent complication. Ureter injury is an extremelyrare complication with only 24 documented casesup to date.Case report. 43 year old woman. A deep bleeding wasobserved while performing a L4-L5 microdiscectomy.It was controlled with firm pressure and hemostaticagents. 36 hours later the patient developed a distendedand painful abdomen associated with anemia andan increase in white blood cell count. Abdominal CTand retrograde pyelography confirmed the diagnosis ofureter injury. An emergency laparotomy was perfomedand a total section of the left ureter was treated with aend to end anastomosis (..) (AU)

[The effectiveness of gravitational valves in the prevention of over-drainage in adult patients with hydrocephalus]. / Efectividad de las válvulas gravitacionales en la prevención del hiperdrenaje en pacientes adultos con hidrocefalia.

AIM: To evaluate the effect of gravitational valves on over-drainage in hydrocephalus in adults. PATIENTS AND METHODS: We performed a retrospective study of the shunt systems placed in patients over the age of 18 years between 1998 and 2006. Patients were divided into two groups: non-GV group (without gravitational valve) and GV group (with a gravitational valve, Aesculap-Miethke 5/35). The complications that occurred during the first year following the placement of the shunt system were recorded. RESULTS: Of a total of 137 patients, 91 were from the non-GV group and 46 belonged to the GV group. Mean age: non-GV group, 62.1 years; and GV group, 64.2 years, without any significant differences. In 80 patients the aetiology was chronic adult hydrocephalus, 19 were due to expansive processes, 15 due to vascular causes, eight pseudo tumours, six post-traumatic injuries and nine were due to other causes. In the non-GV group, 9.89% presented over-drainage, whereas there were no cases in the GV group; the difference was statistically significant (p = 0.029). In the rest of the complications there were no significant differences between the two groups. The total complications in the non-GV group were 25.27% and in the GV group, 6.52%, and there were significant differences (p = 0.01), although, above all, at the expense of over-drainage, because if this complication was excluded, then the differences were no longer significant (p = 0.175). CONCLUSIONS: In our series, the use of gravitational valves in the prevention of over-drainage in adult hydrocephalus proved to be more effective than employing valves without the gravitational device.

Efectividad de las válvulas gravitacionales en la prevención del hiperdrenaje en pacientes adultos con hidrocefalia / The effectiveness of gravitational valves in the prevention of over drainage in adult patients with hydrocephalus

Resumen. Objetivo. Evaluar el efecto de las válvulas gravitacionales sobre el hiperdrenaje en la hidrocefalia en el adulto. Pacientes y métodos. Estudio retrospectivo de los sistemas de derivación colocados en pacientes mayores de 18 años entre 1998 y 2006. Se dividió a los pacientes en dos grupos: grupo no VG (sin válvula gravitacional) y grupo VG (con válvula gravitacional, Aesculap-Miethke 5/35). Se contabilizaron las complicaciones producidas dentro del primer año tras la colocación del sistema de derivación. Resultados. Sobre un total de 137 pacientes, 91 fueron del grupo no VG y 46 del grupo VG. Edad media: grupo no VG, 62,1 años, y grupo VG, 64,2 años, sin que las diferencias fueran significativas. La etiología en 80 pacientes fue hidrocefalia crónica del adulto, 19 por procesos expansivos, 15 por causas vasculares, ocho pseudotumores, seis postraumáticos y nueve por otras causas. En el grupo no VG, un 9,89% presentó hiperdrenaje, mientras que en el grupo VG no hubo ningún caso; la diferencia fue estadísticamente significativa (p = 0,029). En el resto de las complicaciones no se obtuvieron diferencias significativas entre ambos grupos. Las complicaciones totales en el grupo no VG fueron del 25,27% y en el grupo VG del 6,52%, y hubo diferencias significativas (p = 0,01), aunque, sobre todo, a expensas del hiperdrenaje, ya que si se excluía esta complicación las diferencias no eran significativas (p = 0,175). Conclusión. En nuestra serie queda probada la eficacia de las válvulas gravitacionales en la prevención del hiperdrenaje en la hidrocefalia en el adulto comparado con las válvulas sin dispositivo gravitacional (AU)

Summary. Aim. To evaluate the effect of gravitational valves on over-drainage in hydrocephalus in adults. Patients and methods. We performed a retrospective study of the shunt systems placed in patients over the age of 18 years between 1998 and 2006. Patients were divided into two groups: non-GV group (without gravitational valve) and GV group (with a gravitational valve, Aesculap-Miethke 5/35). The complications that occurred during the first year following the placement of the shunt system were recorded. Results. Of a total of 137 patients, 91 were from the non-GV group and 46 belonged to the GV group. Mean age: non- GV group, 62.1 years; and GV group, 64.2 years, without any significant differences. In 80 patients the aetiology was chronic adult hydrocephalus, 19 were due to expansive processes, 15 due to vascular causes, eight pseudo tumours, six post-traumatic injuries and nine were due to other causes. In the non-GV group, 9.89% presented over-drainage, whereas there were no cases in the GV group; the difference was statistically significant (p = 0.029). In the rest of the complications there were no significant differences between the two groups. The total complications in the non-GV group were 25.27% and in the GV group, 6.52%, and there were significant differences (p = 0.01), although, above all, at the expense of over-drainage, because if this complication was excluded, then the differences were no longer significant (p = 0.175). Conclusions. In our series, the use of gravitational valves in the prevention of over-drainage in adult hydrocephalus proved to be more effective than employing valves without the gravitational device (AU)

Early Experience Studying Cerebral Aneurysms with Rotational and Threedimensional Angiography and Review of CT and MR Angiography Literature.

SUMMARY: From september 2000 to september 2001, 32 consecutive patients with ruptured intracranial aneurysms were examined with rotational and 3D reconstruction angiography using an Integris V5000 Philips Medical System: 39 aneurysms were detected. After a selective cerebral artery was catheterized with a 5F or 4F-catheter, 35 ml of contrast medium was intra-arterially administered at a rate of 4 ml/s and a 180 degrees rotational angiography was performed in eight seconds. This information was transferred to a computer (Silicon Graphics Octane) with software (Integris 3DRA, Philips Integris Systems) and a three-dimensional reconstruction was made. The information provided by Angio-3D was useful for evaluating the parent artery, aneurysmal sac, aneurysmal neck and arterial branches. It was also very useful in selecting the therapeutic method. For open surgery, this technique provides preoperative images that are useful for planning microsurgical approaches, especially in cases of large aneurysm showing complex surrounding arteries. For endovascular embolization, various anatomic characteristics of the aneurysm such as neck and sac size, shape, lobularity, parent artery and arterial branches adjacent to the aneurysmal neck must be demonstrated. This is very important to determine the best projection for embolization and to avoid multiple series. This is also essential in the choice of the first coil to create a good basket producing total occlusion. Microaneurysms are demonstrated well with this technique whereas this is difficult to do with conventional arteriography. The Angio-RM and Angio-CT literature show a lower sensitivity and specificity in comparasion with our experience with 3D IA-ROT-DSA. For this reason, we believe that 3D IA-ROTDSA is now the gold standard for patients presenting intracranial aneurysms.

[Frontal bone aneurysmal cyst. Case report]. / Quiste óseo aneurismático del hueso frontal. Caso clínico.

Aneurysmal bone cysts are very rare in the calvaria. We are reporting a 23 year old white male with a very large right frontal aneurysmal bone cyst and a large follow-up period. The MRI findings--a multiloculated expansive tumor with fluid levels inside--are almost pathognomonic for this lesion. Radical surgery was curative for this patient.

Fusion intersomatica lumbar posterior / Posterior lumbar interbody fusion

Desde finales de 1992 hemos venido realizando artrodesis intersomática lumbar, inicialmente añadiendo fusión posterolateral instrumentada con tornillos pediculares y, posteriormente artrodesis intersomática sola con cilindros de titanio y hueso autólogo. Queremos presentar nuestros resultados en un grupo de 52 pacientes con seguimiento que oscila desde los 4 años y medio hasta los seis meses. Para valorar los resultados hemos usado la, escala de Prolo (Prolo Functional Economic Outcome Rating Scale) obteniendo un alto porcentaje ( 92 por ciento ) de resultados satisfactorios. El porcentaje de fusión, aun considerando la dificultad de su valoración por el artefacto radiológico provocado por los cilindros, es igualmente muy elevada cercana al 100 por ciento ).Concluimos que la artrodesis intersomática con cilindros-es una-intervención- quirúrgica con la que se obtienen resultados muy favorables si se siguen unos criterios clínicos estrictos en su aplicación y una correcta técnica quirúrgica (AU)

[Posterior lumbar intersomatic fusion]. / Fusion intersomática lumbar posterior.

Since late 1992 we started performing posterior lumbar interbody fusions together with pedicular screws and intertransverse fusion. Later on we decided to use posterior lumbar interbody fusions with titanium cages and autologous bone. We are presenting our results with a group of 52 patients with 6 months to 4 and a half years of follow-up. We have used the Prolo Functional Economic Outcome Rating Scale to evaluate our results, obtaining a high percentage (92%) of satisfactory results. The fusion's percentage was also very high, although we express the difficulty to evaluate the fusion grade considering the X-ray artifact produced by the cages. We conclude that PLIF with cages it is a surgical procedure with a high rate of success if we establish clearly the clinical criteria for its application and perform correctly the surgical technique.

[Sphenoid ridge hyperostosis meningiomas "en plaque"]. / Meningiomas hiperostósicos esfenoidales "en placa".

We report the cases of two women who underwent surgery for radical resection of sphenoidal hyperostosing meningiomas "en plaque". Outcome was excellent seven and eight years after surgery. The removal of such osseous sphenoidal lesions has always been accompanied by high rates of morbidity, mortality and recurrence. With new surgical approaches and greater exposure of the skull base, interest is again being directed toward complete resection of these rare tumors, which involve scarce intradural but extensive bone invasion.