Ecografía clínica abdominal y educación médica / Abdominal ultrasound and medical education

Introducción. La ecografía es una técnica muy versátil, que permite en tiempo real visualizar múltiples órganos internos y es de inestimable ayuda para la exploración física de los pacientes. Objetivo. Evaluar si la ecografía puede incorporarse en la enseñanza de la medicina y si los alumnos pueden realizar una exploración ecográfica abdominal básica sin un largo periodo de formación. Metodología. Doce estudiantes de medicina recibieron formación en ecografía abdominal básica durante un programa formativo de 15h de duración, que incluía un curso teórico-práctico de 5h y prácticas supervisadas en 20 pacientes seleccionados. Posteriormente realizamos una prueba de evaluación objetiva en la que valoramos la capacidad de los alumnos para obtener los planos ecográficos y detectar diversas enfermedades en 5 pacientes distintos. Resultados. Los estudiantes fueron capaces de identificar correctamente los planos abdominales en más del 90% de las ocasiones. Solo en el corte subcostal derecho para localizar la vesícula este porcentaje fue inferior (80%). La precisión o eficiencia global de la ecografía para el diagnóstico de los hallazgos patológicos relevantes de los enfermos fue superior al 90% (colelitiasis 91,1%; aneurisma de aorta abdominal 100%; esplenomegalia 98,3%; ascitis 100%; vena cava inferior dilatada 100%, y retención aguda de orina 100%). Conclusión. La ecografía puede ser una herramienta formativa en la enseñanza de la medicina y puede ayudar a los alumnos a mejorar la exploración física (AU)

Introduction. Ultrasound is a very versatile diagnostic modality that permits real-time visualization of multiple internal organs. It is of invaluable help for the physical examination of the patients. Aim. To assess if ultrasound can be incorporated into medical education and if the students can perform a basic abdominal ultrasound examination without the necessity of a long period of training. Methodology. Twelve medical students were trained in basic abdominal ultrasound during a 15-hour training program including a 5-hour theoretical and practical course and supervised practice in 20 selected patients. Subsequently, we conducted an evaluation test that assessed the ability of students to obtain the ultrasound views and to detect various pathologies in five different patients. Results. The students were able to correctly identify the abdominal views more than 90% of the times. This percentage was only lower (80%) in the right subcostal view to locate the gallbladder. The accuracy or global efficiency of the ultrasound for the diagnosis of relevant pathological findings of the patients was greater than 90% (91.1% gallstones, abdominal aortic aneurysm 100%; splenomegaly 98.3%, ascites 100%; dilated inferior vena cava 100%; acute urinary retention 100%). Conclusion. The ultrasound may be a feasible learning tool in medical education. Ultrasound can help students to the improve the physical examination (AU)

Frontal sinus obliteration after trauma: analysis of bone regeneration for two selected methods.

We present a prospective randomized experimental study comparing bone regeneration obtained in 60 post-traumatic frontal sinuses obliterated with either calvarial bone dust (n=30, group I) or calvarial bone and demineralized bone matrix (DBM; n=30, group II). Radiological follow-up included high-resolution computed tomography with quantitative micro-density analysis in Hounsfield units (HU), together with a volumetric evaluation of the ossification at 6 and 24 months after surgical treatment. Epidemiological information and potential drawbacks were analysed. Bone volume and density data (HU) for the regenerated areas were subjected to statistical analysis at 6 and 24 months for both groups. Results were compared with reference values obtained from frontal and temporal bone in every patient. Complications developed for 10% of operated sinuses. The resulting bone formation (HU) in group I patients was significantly better than that obtained in group II. Ossification progressed in a statistically significant manner in both groups when compared at 6 and 24 months postoperatively. The use of DBM as a biomaterial associated with calvarial bone dust for sinus obliteration shows long-term safe results, similar to autogenous bone, but with a lower final bone density.

Abdominal ultrasound and medical education.

INTRODUCTION: Ultrasound is a very versatile diagnostic modality that permits real-time visualization of multiple internal organs. It is of invaluable help for the physical examination of the patients. AIM: To assess if ultrasound can be incorporated into medical education and if the students can perform a basic abdominal ultrasound examination without the necessity of a long period of training. METHODOLOGY: Twelve medical students were trained in basic abdominal ultrasound during a 15-h training program including a 5-h theoretical and practical course and supervised practice in 20 selected patients. Subsequently, we conducted an evaluation test that assessed the ability of students to obtain the ultrasound views and to detect various pathologies in five different patients. RESULTS: The students were able to correctly identify the abdominal views more than 90% of the times. This percentage was only lower (80%) in the right subcostal view to locate the gallbladder. The accuracy or global efficiency of the ultrasound for the diagnosis of relevant pathological findings of the patients was greater than 90% (91.1% gallstones, abdominal aortic aneurysm 100%; splenomegaly 98.3%, ascites 100%; dilated inferior vena cava 100%; acute urinary retention 100%). CONCLUSION: The ultrasound may be a feasible learning tool in medical education. Ultrasound can help students to improve the physical examination.

Severe traumatic head injury: prognostic value of brain stem injuries detected at MRI.

BACKGROUND AND PURPOSE: Traumatic brain injuries represent an important cause of death for young people. The main objectives of this work are to correlate brain stem injuries detected at MR imaging with outcome at 6 months in patients with severe TBI, and to determine which MR imaging findings could be related to a worse prognosis. MATERIALS AND METHODS: One hundred and eight patients with severe TBI were studied by MR imaging in the first 30 days after trauma. Brain stem injury was categorized as anterior or posterior, hemorrhagic or nonhemorrhagic, and unilateral or bilateral. Outcome measures were GOSE and Barthel Index 6 months postinjury. The relationship between MR imaging findings of brain stem injuries, outcome, and disability was explored by univariate analysis. Prognostic capability of MR imaging findings was also explored by calculation of sensitivity, specificity, and area under the ROC curve for poor and good outcome. RESULTS: Brain stem lesions were detected in 51 patients, of whom 66% showed a poor outcome, as expressed by the GOSE scale. Bilateral involvement was strongly associated with poor outcome (P < .05). Posterior location showed the best discriminatory capability in terms of outcome (OR 6.8, P < .05) and disability (OR 4.8, P < .01). The addition of nonhemorrhagic and anterior lesions or unilateral injuries showed the highest odds and best discriminatory capacity for good outcome. CONCLUSIONS: The prognosis worsens in direct relationship to the extent of traumatic injury. Posterior and bilateral brain stem injuries detected at MR imaging are poor prognostic signs. Nonhemorrhagic injuries showed the highest positive predictive value for good outcome.

[Subcranial approach. Technical aspects and application in craneofacial traumatic pathology]. / Abordaje subcraneal. Consideraciones técnicas y aplicaciones en patología traumática craneofacial.

UNLABELLED: INTRODUCTION. Suitable approach to anterior cranial base is mandatory to get global satisfactory surgical outcomes. In the beginning it depends on the exactly anatomical position into the cranial fossa and tridimensional spread. Surgical approach implies the evaluation of the patient status, reconstructive options and surgical team experience. Subcranial approach is a safe surgical option in the treatment of frontal traumatic pathology. It allows adequate management of frontal sinus and its obliteration with easy radiologic follow-up. OBJECTIVES. To analyse subcranial approach as a treatment option in traumatic pathology of the anterior cranial base and to present our review of subcranial approach. Valuation of surgical technical aspects. and related complications. MATERIAL AND METHODS. Retrospective analysis of 50 patients operated (subcranial approach) from January 2004 to December 2009 by Maxillofacial and Neurosurgery Department, University Hospital 12 de Octubre, Madrid. 34 patients presented craniofacial trauma or postraumatic sequela and 16 patients presented craniofacial tumours. Oncological cases offers experience to discuss surgical aspects. Results are related to traumatic pathology and sequela. Main items review were surgical technique including materials used for frontal sinus obliteration, associated traumatic pathology, hospital stay and complication rates. RESULTS. No perioperatory mortality was found. Patients´ age ranged 15-76 years. 22 were male and 12 female. Description of frontal fractures involved. Frontal sinus obliteration was made with calvarian bone dust. Morbidity rates was 29% in posttraumatic patients. Mean hospital stay was 13 days. CONCLUSIONS: Subcranial approach to anterior cranial base is a safe and reliable treatment option to the pathology of this area. It allows outstanding exposure of the nasal cavity, orbits, ethmoidal cells-sphenoid sinus and great access to anterior fossa without frontal lobe retraction.

Abordaje subcraneal. Consideraciones técnicas y aplicaciones en patología traumática craneofacial / Subcranial approach. Technical aspects and application in craneofacial traumatic pathology

Introducción. La elección del abordaje más adecuado a la base craneal en cada caso es esencial para la obtención de resultados quirúrgicos globales satisfactorios. Inicialmente dependerá de la localización anatómica exacta de la lesión dentro de la base craneal y de su extensión tridimensional, así como de la naturaleza de la misma. Las opciones posibles deben ser depuradas finalmente en función del status global del paciente, planificación reconstructiva y experiencia del equipo quirúrgico. El abordaje subcraneal es una opción terapéutica segura en el tratamiento de la patología traumática frontal. Permite el manejo adecuado del seno frontal y su obliteración si es precisa, favoreciendo el seguimiento radiológico del mismo. Objetivos. Validar el abordaje subcraneal como vía adecuada de acceso en patología traumática de la base craneal anterior. Revisión de nuestra serie clínica. Valoración de aspectos técnicos quirúrgicos. Análisis de complicaciones. Material y métodos. Estudio retrospectivo de 50 pacientes intervenidos desde Enero de 2004 hasta Diciembre 2009 por el Servicio de Cirugía Maxilofacialy Servicio de Neurocirugía del Hospital Universitario 12 de Octubre (Madrid) mediante abordaje subcraneal. 34 pacientes presentaban traumatismos cráneo faciales o secuelas postraumáticas y 16 pacientes presentaban patología oncológica. Se enumeran los casos oncológicos como base de experiencia para la descripción de los aspectos técnicos. La casuística descrita se refiere a la patología traumática y sus secuelas. Los principales parámetros analizados fueron la técnica quirúrgica incluyendo el material de relleno para la obliteración del seno frontal, patología traumática asociada, estancia hospitalaria y tasa de complicaciones. Resultados. No existió mortalidad intra-postoperatoria inmediata. La edad varía entre los 15-76 años siendo 22 varones y 12 mujeres. Se describe el tipo de fracturas frontales (..) (AU)

Introduction. Suitable approach to anterior cranial base is mandatory to get global satisfactory surgical outcomes. In the beginning it depends on the exactly anatomical position into the cranial fossa and tridimensional spread. Surgical approach implies the evaluation of the patient status, reconstructive options and surgicalteam experience. Subcranial approach is a safe surgicaloption in the treatment of frontal traumatic pathology. It allows adequate management of frontal sinus and its obliteration with easy radiologic follow-up. Objectives. To analyse subcranial approach as atreatment option in traumatic pathology of the anteriorcranial base and to present our review of subcranial approach. Valuation of surgical technical aspects. andrelated complications. Material and methods. Retrospective analysis of 50 patients operated (subcranial approach) from January 2004 to December 2009 by Maxillofacial and (..) (AU)

Classification of oligodendroglial tumors based on histopathology criteria is a significant predictor of survival--clinical, radiological and pathologic long-term follow-up analysis.

BACKGROUND: The clinical course of oligodendroglial tumors is variable and there is a lack of consensus with regard to precisely diagnose which minimal criteria are required to make a diagnosis of a high-grade oligodendrial tumor. The aims of the present study are to assess pathologic factors with prognostic significance, in addiction to clinical and neuroradiologic variables, in an attempt to identify reproducible histological parameters that are useful for classification of oligodendroglial tumors. METHODS: 80 oligodendroglial tumors diagnosed between 1977 and 2004 were analyzed. To make a diagnosis of anaplastic tumor we used reproducible parameters: endothelial proliferation, high cellularity, increased mitotic activity and necrosis. Oligoastrocytomas (mixed gliomas) were diagnosed when the astrocytic component was clearly identified as part of the neoplastic cell population. Survival univariate analysis was made constructing survival curves using Kaplan-Meier method and comparing subgroups by log-rank probability test. A Cox regression model was made for multivariable analysis. RESULTS: The histologic diagnosis was low-grade oligodendroglioma in 35 patients (43.75%), anaplastic oligodendroglioma in 23 patients (28.75%), low-grade oligoastrocytoma in 11 patients (13.75%) and anaplastic oligoastrocytoma in 11 patients (13.75%). Median overall survival of the whole series was 80 months. The median overall survival of oligodendroglioma, anaplastic oligodendroglioma, oligoastrocytoma and anaplastic oligoastrocytoma was 148, 105, 47 and 7 months, respectively (p < 0.0001). Multivariate analysis revealed that age, Karnofsky performance status, histological grade and histological diagnosis (oligodendroglioma vs. oligoastrocytoma) were independently associated with survival. CONCLUSIONS: Clear cut histopathological criteria (endothelial proliferation, high cellularity, mitotic activity and necrosis) allow to establish different oligodendroglial tumor entities with distinct survival outcome.

Relaciones de la facultad de medicina con el hospital universitario. La enseñanza de la medicina clínica / Relationships between the medical school and the university hospital. The teaching of clinical medicine

Las nuevas necesidades en la formación de los futuros médicos, particularmente aquellas relacionadas con la definición, adquisición y evaluación de competencias, necesitan una potente estructura hospitalaria que soporte la docencia práctica en habilidades clínicas. El trascendente papel reservado a los hospitales universitarios significa que la institución sanitaria debe adaptarse para facilitar la implantación de una enseñanza de calidad, en aspectos estructurales y en el proceso de definición de objetivos y de evaluación de resultados a través de pruebas objetivas. Ellos implica cambios en la estructura, en la organización y en la gestión (AU)

The training of future doctors entails a series of new needs, especially in relation to the definition, acquisition and evaluation of abilities, and this requires the backing of a powerful hospital structure that ist capable of offering the practical teaching and learning of clinical skills. The fundamental role played by university hospitals means that the health care institution must adapt itself to facilitate the implementation of high quality teaching, both as regards structural aspects and in the process of defining aims and evaluationg results by means of objective testing. This involves changes in the structure, the organisation and management (AU)

[Neurochemical treatment of Parkinson's disease and essential tremor]. / Tratamiento neuroquirúrgico en la enfermedad de Parkinson y el temblor esencial.

INTRODUCTION: Recent technological advances along with new neuroimaging techniques and progress in neuro-monitoring have provided us with new therapeutical options from the neurosurgical point of view in the management of movement disorders. Deep brain stimulators become more and more frequently used in the last few years since they have reversible effects, are easily implantable and have shown good initial results. However, only now we start knowing the clinical effects in the middle run. AIM: To review the main neurosurgical options in Parkinson's disease and tremor. DEVELOPMENT: We reviewed the articles considering ablative or stimulating neurosurgical treatments in these diseases, and we grouped the results according to the technique performed and the time of follow-up. CONCLUSION: Clinical results are often similar despite the use of different techniques. However, the side-effects are critical in deciding which technique should be used once medical therapy has been considered insufficient.

Tratamiento neuroquirúrgico en la enfermedad de Parkinson y el temblor esencial / Neurochemical treatment of parkinson's disease and essential tremor

Introducción. Los recientes avances tecnológicos, la revolución de la neuroimagen y el progreso de la neuromonitorización han abierto nuevas opciones terapéuticas en el tratamiento neuroquirúrgico de los trastornos del movimiento. El uso de los sistemas de estimulación profunda programables se ha multiplicado en los últimos años debido a la sencillez de su implantación, a la reversibilidad de su acción y a los buenos resultados iniciales obtenidos. Sin embargo, sólo ahora comenzamos a conocer cuál es el resultado clínico a medio plazo que brindan estas nuevas tecnologías. Objetivo. Revisar las principales opciones terapéuticas neuroquirúrgicas en la enfermedad de Parkinson y el temblor, a la luz de los últimos resultados conocidos. Desarrollo. Revisamos los artículos de la literatura que consideran el tratamiento de la enfermedad de Parkinson y del temblor, bien con métodos ablativos, bien con sistemas de neuroestimulación, separando los resultados disponibles tanto por la técnica empleada como por la diana anatómica escogida y el tiempo de seguimiento. Conclusión. Aunque los beneficios a medio plazo son, en general, similares independientemente de la técnica empleada, a menudo el patrón de efectos secundarios va a definir qué opción neuroquirúrgica es la más adecuada, una vez que se considera insuficiente el tratamiento médico (AU)

[Treatment in spontaneous intracerebral haemorrhage. Analysis of Spanish clinical series]. / Tratamiento de la hemorragia intracerebral espontánea. Análisis de las series clínicas españolas.

OBJECTIVE: In the spontaneous intracerebral hemorrhage (SICH) there are a small number of unequivocally indicators of surgical or conservative treatment. DEVELOPMENT: An extensive bibliographic revision of studies of patients with spontaneous ICH admitted to Spanish Hospitals has been completed. Later on, studies related to analyses and results of mortality and functional state of surgical and conservative treatments of ICH were gathered. Using the Cochrane Collaboration Manual the methodological quality of the studies has been evaluated. CONCLUSIONS: The chosen studies were 25 clinical series. Only two studies comparing the surgical against the conservative treatment of supratentorial ICH has been found. The intrinsic methodological quality associated to this type of studies does not allow to establish valid conclusions on the efficacy of one treatment over another. Nonetheless it has utility considering that it reveals the chosen treatment and the outcomes in the published studies. We did not found studies evaluating the efficacy of both treatments in Spain with a prospective randomised design, with an adequate size, analysing mortality, dependency and quality of life of the affected patients. Therefore, our final conclusion is that given the importance of the information that could be extracted from these studies in order to design the more efficient treatment of ICH no delay to complete them can be admitted.

Análisis y evaluación de la calidad en la cirugía de la hernia discal lumbar I. Metodología / Quality analysis and evaluation of lumbar discectomy procedure. I. Methodology

Para el análisis de la calidad en la cirugía de la hernia discal lumbar se ha desarrollado un método orientado a la valoración de las dimensiones de la calidad más relevantes: calidad científico-técnica (CCT), efectividad clínica (EC), calidad de vida (CV), satisfacción del paciente (SP) y costes económicos.La CCT, referida a valoración de la asistencia prestada según los conocimientos médicos y tecnológicos disponibles, se realizó según el cumplimiento de criterios y estándares explícitos en la documentación clínica (método PEP: Performance Evaluation Procedure). La EC, o beneficio de salud, se midió según la puntuación lograda en el cuestionario específico de Spangfort. La CV fue analizada, utilizando el cuestionario SF-12 modificado (Short-Form-12), que recoge aspectos de dolor, actividad familiar, social y laboral y estado psicológico. La SP fue medida utilizando un cuestionario diseñado definiendo previamente los pacientes y profesionales los atributos del consumo. Asimismo, se contempló la ponderación que los pacientes y profesionales realizaron en cada uno de los bloques de estudio (asistencia, información, trato y hostelería). Para el cálculo de costes se ha propuesto tres sistemas diferentes: 1. Sistema de Contabilidad analítica (ABC-ABM); 2. Costes por pesos de GRDs (Grupos Relacionados con el Diagnóstico) y 3. Costes definidos a partir de las tarifas para consultas y hospitalización establecidas por el INSALUD (AU)

Evaluación del proceso quirúrgico de la hernia discal lumbar II. Una aproximación a la calidad científico técnica / Evaluation of lumbar discectomy procedure. An approach to the scientific and technical quality

Introducción. El proceso quirúrgico de la hernia discal lumbar se encuentra entre el grupo de patologías y procedimientos de la práctica clínica de enorme repercusión sanitaria, social y económica. Su elevada prevalencia, variabilidad en el manejo y posibilidad de mejora, hacen que la evaluación de la calidad, tanto de los resultados como del proceso, tenga un gran interés. Objetivos. Determinación y análisis descriptivo de la calidad científico técnica (CCT) del proceso quirúrgico de la hernia discal lumbar y su posible relación con algunos aspectos del resultado (efectividad clínica y calidad de vida).Pacientes y métodos. Estudio retrospectivo y prospectivo de una serie de 172 pacientes intervenidos de hernia discal lumbar en el periodo 1996-1999. Para el análisis de la CCT se ha empleado el método Performance Evaluation Procedure (PEP). Los parámetros utilizados para la medida del resultado han sido el estado funcional, a través de los criterios de Spangfort y la calidad de vida, siguiendo el cuestionario SF12 (Short Form 12). Los resultados han sido registrados a los 12, 24 y 36 meses de la intervención. Resultados. La puntuación media de la CCT del proceso ha sido de 0,83 (0-1). El bloque en el que se registraron peor los datos fue el de anamnesis. No siempre los criterios de anamnesis y exploración física considerados como más importantes por los neurocirujanos son los que se han registrado mejor en la historia clínica (esto ha sucedido también en sentido inverso).Se apreció una correlación significativa entre la puntuación de la CCT y la situación laboral, así como con ciertos parámetros de calidad de vida. Las puntuaciones lilas altas de la CC T la presentaron aquellos pacientes que a los 12 y 24 meses de la intervención no trabajaban a causa del dolor (p < 0,02 y p < 0,04 respectivamente), así como en pacientes que a los 12 meses de la intervención presentaban una menor actividad social y mucho dolor (p < 0,02). Al analizar la calidad en la cumplimentación de los datos de la historia clínica se observaron diferencias significativas con respecto al tipo de trabajo y al esfuerzo requerido; fueron aquellos pacientes que realizaban trabajos poco cualificados (p < 0,002) y de gran esfuerzo (p < 0,05) los que tienen mejor cumplimentados sus datos. En general, los pacientes que tenían mejor registro de la información parecían presentar corno característica común el que la decisión quirúrgica no estaba clara. (p. ej.: test de Lasègue preoperatorio negativo (n.s), duración de episodio previo a la cirugía de más de seis meses y pacientes asintomáticos (p< 0,01), que tardan más de un año en operarse (p < 0,01), etc.).Conclusiones. Se han obtenido correlaciones significativas entre CCT y aspectos clínicos y laborales preoperatorios, así corno entre CCT y dolor y actividad postquirúrgica (AU)

[Quality analysis and evaluation of surgery for herniated lumbar disk. I. Methodology]. / Análisis y evaluación de la calidad en la cirugía de la hernia discal lumbar I. Metodología.

A method for the analysis of the quality of the lumbar disc surgery was developed. The method assesses the important quality parameters such as scientific and technical quality (STQ), functional grades, quality of life, patients satisfaction and economic costs. The STQ related to the measurement of the care according to the available medical and technological knowledge was determined according to the performance of explicit criteria and standards in the clinic documentation (PEP method: Performance Evaluation Procedure). To measure the functional grade, a modification of Spanfort's criteria was used. To assess the quality of life a modification of 12-item Short Form health survey was applied. This form includes aspects like pain, social interaction, family characteristics, employment and psychological status. A questionnaire was used to measure satisfaction. The form was previously designed taking into account the patients and professionals criteria. In every stage care given, information issued, management and hosting, the patients and professionals opinions was considered and weighted. To calculate the cost three different systems were proposed i.e., Analytic economic management system (ABC-ABM), Weight related costs of DRGs (Diagnostic Related Groups) and Costs computed from price listing for consulting and hospitalization established by INSALUD.

[Evaluation of the surgical process for herniated lumbar disk. II. Approximation to scientific-technical quality]. / Evaluación del proceso quirúrgico de la hernia discal lumbar II. Una aproximación a la calidad científico técnica.

INTRODUCTION: The procedure of surgical treatment of lumbar disc herniation belongs to the group of clinical practice procedures that have a great repercussion on health care systems. The high prevalence of this disease, the management variability and the possibility of improvement, explain the great interest in the evaluation of the quality of both treatment procedure and outcomes. OBJECTIVE: To determine and analyze the scientific and technical quality (STQ) of lumbar disc disease surgery and its correlation with some outcome measurements (clinical efficacy-functional grade and quality of life). METHODS: 172 patients who underwent a hemilaminectomy for lumbar herniated disc between 1996 and 1999 were studied. To analyze the STQ, we used the PEP (Performance Evaluation Procedure) method. A modification of Spangfort's criteria: to measure the functional grade- and the 12-item Short-form health survey (SF-12) to measure the quality of life- were the methods used to quantify outcomes, assessed after 12, 24 and 36 months after surgery. RESULTS: The mean overall STQ score was 0.83 (0-1). The anamnesis was the stage with worse information quality. Though neurosurgeons usually consider the anamnesis and physical examination data as the most important factors for decision making, these were no the best collected in the clinical reports. Surprisingly, data considered not relevant by neurosurgeons were registered with higher fidelity. An statistically significant correlation was found between STQ score and employment status among other parameters associated to the quality of life. The highest STQ scores were found in patients who did not return to work because of persistent pain 12 or 24 months after surgery (p < 0.02 and p < 0.04) and in patients showing poor social interaction and severe pain 12 months after surgery. When analyzing the completeness of clinical history data, statistically significant differences were observed in relation to the type of employment and the degree of physical effort needed at work. Patients working in positions without high skill requirements (p < 0.002) and involving a great physical effort (p < 0.05) had better registered data. Patients with better registered information tended to show a lesser clear surgical indication as a common characteristic, i.e., negative straight leg raising test, length of the current episode lasting more than 6 months and absence of symptoms (p < 0.01) for more than one year since the initial visit to the physician from the beginning of symptoms (p < 0.01), etc. CONCLUSIONS: This method established a significant correlation between STQ and clinical and presurgical variables, as well as between STQ and pain and activity after surgery.

Bilateral dural arteriovenous fistula in the region of the cavernous sinus.

The case of a patient with a fistula between the left internal carotid artery and the cavernous sinus, and another fistula between the right external carotid artery and the cavernous sinus, is reported. The clinical symptomatology, which was of spontaneous onset, was unilateral and consisted of exophthalmos and injection of the conjunctiva on the left side. Almost complete remission occurred after angiography.

Neurocutaneous melanosis. Report of a case and review of the literature.

A case of neurocutaneous melanosis in a 15 year old male is described. A primary malignant meningeal melanoma caused the death of the patient in six months. The skin lesions were benign. The literature is reviewed, and the nature of the disease and its relationship with other phakomatoses is discussed.

Intracranial pressure in adult non-tumoral hydrocephalus.

Intracranial pressure (ICP) was monitored continuously for 48 hours in four patients with different types of non-tumoral adult hydrocephalus and classificated according to ICP recordings. It is emphasized that ICP monitoring is essential in the diagnosis of normal pressure hydrocephalus (NPH), since its possible to observe abnormal pressure recordings with morphological alterations which can be accompanied or not by periods of raised ICP. It is suggested that this method may help identify cases suitable for surgery.