Olivary body exposure through far lateral and lower retrosigmoid approaches. Comparative analysis of the exposed surface and angle of attack.

OBJECTIVES: Throughout neurosurgical history, the treatment of intrinsic lesions located in the brainstem has been subject of much controversy. The brainstem is the anatomical structure of the central nervous system (CNS) that presents the highest concentration of nuclei and fibers, and its simple manipulation can lead to significant morbidity and mortality. Once one of the safe entry points at the medulla oblongata has been established, we wanted to evaluate the safest approach to the olivary body (the most used safe entry zone on the anterolateral surface of the medulla oblongata). The proposed objective was to evaluate the working channel from the surface of each of the far lateral and retrosigmoid approaches to the olivary body: distances, angles of attack and channel content. MATERIAL AND METHODS: To complete this work, a total of 10 heads injected with red/blue silicone were used. A total of 40 approaches were made in the 10 heads used (20 retrosigmoid and 20 far lateral). After completing the anatomical study and obtaining the data referring to all the approaches performed, it was decided to expand the sample of this research study by using 30 high-definition magnetic resonance imaging of anonymous patients without cranial or cerebral pathology. The reference points used were the same ones defined in the anatomical study. After defining the working channels in each of the approaches, the working distances, angle of attack, exposed surface, and the number of neurovascular structures present in the central trajectory were analyzed. RESULTS: The distances to the cranial and medial region of the olivary body were 52.71 mm (SD 3.59) from the retrosigmoid approach and 27.94 mm (SD 3.99) from the far lateral; to the most basal region of the olivary body, the distances were 49.93 (SD 3.72) from the retrosigmoid approach and 18.1 mm (SD 2.5) from the far lateral. The angle of attack to the caudal region was 19.44° (SD 1.3) for the retrosigmoid approach and 50.97° (SD 8.01) for the far lateral approach; the angle of attack to the cranial region was 20.3° (SD 1.22) for the retrosigmoid and 39.9° (SD 5.12) for the far lateral. Regarding neurovascular structures, the probability of finding an arterial structure is higher for the lateral far, whereas a neural structure will be more likely from a retrosigmoid approach. CONCLUSIONS: As conclusions of this work, we can say that far lateral approach presents more favorable conditions for the microsurgical treatment of intrinsic bulbar and bulbomedullary lesions approached through the caudal half of the olivary body. In those cases of bulbar and pontine-bulbar lesions approached through the cranial half of the olivary body, the retrosigmoid approach can be considered for selected cases.

The temporary resection of the cranial vault by Wilhelm Wagner (1848-1900) instead of trepanation: the cornerstone of the modern craniotomy.

In this paper, the authors trace the history of cranial temporary resection, described by Wilhelm Wagner (1848-1900) in 1889, which changed the paradigm of the cranial opening from trephining to the craniotomy. The objective of the temporary resection was to obtain wide openings in the skull, keeping the cranial flap attached to the soft tissues to maintain bone vitality. The cranial temporary resection was reproduced by the authors in an anatomical study faithfully following the original technique, demonstrating the feasibility of the surgical procedure as described by Wagner. Surgical steps include a large omega-shaped skin incision and a beveled cut of the bone with the chisel and mallet until reaching the dura mater, lifting the bone flap en bloc along with all superficial soft tissues. A literature review shows that the temporary cranial resection became a great success at that time because it allowed physicians to improve a number of constraints of the cranial opening using the crown trephine: bone vitality; a wide cranial window; easy, safe, and quick surgery; and economy of surgical instruments. The crude, primitive proposal of the temporary resection was ameliorated to quickly build the successful model of the modern craniotomy.

The Smith-Robinson Approach to the Subaxial Cervical Spine: A Stepwise Microsurgical Technique Using Volumetric Models From Anatomic Dissections.

BACKGROUND: The Smith-Robinson1 approach (SRA) is the most widely used route to access the anterior cervical spine. Although several authors have described this approach, there is a lack of the stepwise anatomic description of this operative technique. With the advent of new technologies in neuroanatomy education, such as volumetric models (VMs), the understanding of the spatial relation of the different neurovascular structures can be simplified. OBJECTIVE: To describe the anatomy of the SRA through the creation of VMs of anatomic dissections. METHODS: A total of 4 postmortem heads and a cervical replica were used to perform and record the SRA approach to the C4-C5 level. The most relevant steps and anatomy of the SRA were recorded using photogrammetry to construct VM. RESULTS: The SRA was divided into 6 major steps: positioning, incision of the skin, platysma, and muscle dissection with and without submandibular gland eversion and after microdiscectomy with cage positioning. Anatomic model of the cervical spine and anterior neck multilayer dissection was also integrated to improve the spatial relation of the different structures. CONCLUSION: In this study, we review the different steps of the classic SRA and its variations to different cervical levels. The VMs presented allow clear visualization of the 360-degree anatomy of this approach. This new way of representing surgical anatomy can be valuable resources for education and surgical planning.

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions.

Objectives The main objective of this article is to describe a simple and safe protocol for the microsurgical management of ventrally located intrinsic pontomedullary lesions based on the retrosigmoid approach, cortectomy performed utilizing safe entry zones of the pons and medulla, and a delicate microsurgical resection. The intraoperative protocol includes redundant procedures that provide security in decision-making during surgery. Design A prospective series of 11 cases is presented. All patients were studied following the same clinical and imaging workup. A regular retrosigmoid craniotomy surgical approach was utilized. The peritrigeminal area in the pons and the olivary area in the medulla were considered as the safe entry zones. Neuronavigation of the white fiber tracts and electrophysiological monitoring were used as intraoperative aids to locate the lesions, the safe entry zones, and the placement of the cortectomy. Results Six lesions were pontine, two medullary, and the remaining six pontomedullary. Eight lesions were cavernomas, while the remaining three tumors. Overall, we obtained a postoperative functional improvement in the affected cranial nerves in 90.1% of the patients and a total or partial recovery of long ascending or descending pathway symptoms in 72.3% of the patients. All the patients were satisfied with the procedure and the results. Conclusions Radical resection of ventral intrinsic pontomedullary lesions displays a high degree of intraoperative reliability, and a good clinical result is possible using simple surgical procedures. The anatomical references are the first element in the decision-making process during surgery.

Magnetic Resonance Imaging Surveillance for Vestibular Schwannoma After Microsurgical Resection Using a Retrosigmoid Transmeatal Approach.

BACKGROUND: Vestibular schwannoma (VS) is a benign, usually slow-growing tumor. The drawback of radical microsurgical VS resection is the increased likelihood of neurologic injury, forcing surgeons to leave a tumor remnant in some cases. We evaluated the prognostic value of magnetic resonance imaging (MRI) enhancement patterns to determine the risk of tumor regrowth. METHODS: This clinical study included 30 patients (20 women and 10 men) with VS who underwent surgery via a retrosigmoid transmeatal approach. The extent of resection was assessed by MRI 6 months after surgery. Two subtypes of intracanalicular linear enhancement were defined: linear enhancement of the walls of the internal auditory canal (IAC) or in the cerebellopontine angle (CPA) and linear enhancement covering the end of the IAC. All patients included in the study underwent follow-up MRI every year for at least 6 years. RESULTS: Intracanalicular nodular enhancement suggestive of a tumor remnant was seen in the IAC in 11 patients (36.7%). Volume of nodular enhancements was <0.5 cm3 when measurable. The enhancement remained stable throughout follow-up except in 2 cases that showed a slight decrease in size and in 1 case with an initial tumor remnant of 0.5 cm3 showing a slight increase over the years. Eighteen patients (60%) had linear enhancement in the IAC or in the CPA. No patients with linear enhancement showed nodular enhancement. CONCLUSIONS: Although specific monitoring protocols can be designed based on MRI findings 6 months after microsurgical VS resection, follow-up should be maintained indefinitely given the slight possibility of very late regrowth.

Side-to-End Hypoglossal-Facial Neurorrhaphy for Treatment of Complete and Irreversible Facial Paralysis after Vestibular Schwannoma Removal by Means of a Retrosigmoid Approach: A Clinical and Anatomic Study.

BACKGROUND: Facial paralysis secondary to a complete and irreversible anatomic or functional lesion of the facial nerve (FN) causes severe functional and psychological disorders for the patient. A large number of surgical techniques have therefore been developed for FN repair. Our objective was to propose a surgical FN reanimation protocol for patients with irreversible anatomic or functional postsurgical injury of the FN in the cerebellopontine angle after vestibular schwannoma resection. METHODS: The clinical study included a total of 16 patients undergoing side-to-end hypoglossal-facial neurorrhaphy (SEHFN) since 2010, in which the FN injury was always secondary to vestibular schwannoma surgery in the cerebellopontine angle using a retrosigmoid approach. All patients had complete clinical facial paralysis at the time of the SEHFN. The anatomic study was conducted using 3 heads and necks (6 SEHFN). RESULTS: Twelve months after surgery, FN function assessment with the House and Brackmann scale showed 2 patients with grade II, 13 patients with grade III, and only 1 patient with grade IV, and after 2 years, 4 patients had grade II, 11 patients had grade III, and 1 patient had grade IV. The average length of the anastomotic translocation portion of the FN in the anatomic study was 34.76 mm. CONCLUSIONS: Side-to-end epineural suture of the FN, mobilizing its mastoid segment on the hypoglossal nerve with partial section of the dorsal aspect of the hypoglossal nerve, is a safe anatomic surgical technique for FN reanimation with outstanding clinical results.

White Matter Relationships Examined by Transillumination Technique Using a Lateral Transcortical Parietal Approach to the Atrium: Three-Dimensional Images and Surgical Considerations.

BACKGROUND: Numerous lesions are found in the ventricular atrium (VA). Access is gained through many white matter tracts with great relevance and specific neurologic functions. It is important to understand the configuration of the most relevant structures surrounding this zone and, thus, select the safest entry zone on the lateral cerebral surface. OBJECTIVE: We studied the white matter layers traversed in the lateral transcortical parietal approach through the intraparietal sulcus (IPS), adding a transillumination technique. With this knowledge, we selected the safest highway to improve this particular approach. METHODS: An in-depth study of the white matter tracts was performed on 24 cerebral hemispheres (12 human whole brains). The Klingler technique and microsurgical dissection techniques were used under ×6 to ×40 magnification. The transillumination technique (torch illuminating the ventricular cavity) was used to expose the layers surrounding the VA and, thus, guide the dissection. RESULTS: Taking the IPS on the cerebral surface as a reference, we identified the following white matter layers ordered from the surface to the ependyma: U fibers, superior longitudinal fascicle, arcuate fascicle, vertical occipital fascicle, sagittal stratum with the optic radiations, and tapetum fibers. The transillumination technique allowed for the easier identification of the white matter deep periventricular layers. CONCLUSIONS: Knowledge of the main fascicles in the path and neighborhood of the VA allowed us to understand how certain neurologic functions can be affected by lesions at this level and to select the most appropriate way to avoid damaging relevant fascicles.

Combined Extradural and Intradural Pterional Transzygomatic Approach to Large Sphenoid Wing Meningiomas. Operative Technique and Surgical Results.

Objectives Describe a unique and safe surgical procedure for the microsurgical management of large sphenoid wing meningiomas (SWMs) aimed to a radical resection of these tumors. Design A prospective series of 26 cases with SWMs larger than 3 cm in one of its main diameter is presented. All patients were studied following the same clinical and imaging procedures. The surgical approach was through a pterional transzygomatic craniotomy. The surgical procedure has the following steps: 1. Extradural tumor devascularization and resection of the hyperostotic and/or infiltrated bone and then intradurally; 2. Intradural tumor debunking; 3. Microdissection of vascular branches and perforators from the capsule; 4. Identification of the optic and oculomotor nerves and internal carotid artery; 5. Tumor capsule dissection and resection; 6. Dural resection or cauterization; 7. Dural and bone reconstruction and closing. Results All lesions were completely removed. Most complications were transient. The most relevant complication was a large middle cerebral artery infarct with permanent hemiplegia despite a decompressive craniotomy. Conclusion Large SWMs can be considered as a single pathology regarding the surgical approach and intraoperative microsurgical procedure strategies. The pterional transzygomatic approach allows an extradural devascularization of the tumor and an extensive bone resection that facilitates the intradural stage of tumor resection. The proposed approach allows a wide and radical resection of the duramater and bone that increases the Simpson grade. However, surgery does not control other biological or molecular prognostic factors involved in tumor recurrence.

Microsurgical Anatomy of the Insular Region and Operculoinsular Association Fibers and its Neurosurgical Application.

OBJECTIVE: To analyze the three-dimensional relationships of the operculoinsular compartments, using standard hemispheric and white matter fiber dissection and review the anatomy of association fibers related to the operculoinsular compartments of the Sylvian fissure and the main white matter tracts located deep into the insula. The secondary aim of this study was to improve the knowledge on this complex region to safely address tumor, vascular, and epilepsy lesions with an integrated perspective of the topographic and white matter fiber anatomy using 2D and 3D photographs. METHODS: Six cadaveric hemispheres were dissected. Two were fixed with formalin and the arteries were injected with red latex dye; the remaining four were prepared using the Kingler method and white fiber dissections were performed. RESULTS: The insula is located entirely inside the Sylvian fissure. The topographic hemispheric anatomy, Sylvian fissure, opercula, surrounding sulci and gyri, as well as the M2, M3, and M4 segments were identified. The anatomy of the insula, with the sulci and gyri and the limiting sulci, were also identified and described. The main white matter fiber tracts of the operculoinsular compartments of the Sylvian fissure as well as the main association and commissural fibers located deep in the insula were dissected and demonstrated. CONCLUSIONS: Complementing topographic anatomy with detailed study of white matter fibers and their integration can help the neurosurgeon to safely approach lesions in the insular region, improving postoperative results in the microsurgical treatment of aneurysmal lesions, insular tumors, or epilepsy surgery.

Using NMR in saliva to identify possible biomarkers of glioblastoma and chronic periodontitis.

Nowadays there is increasing interest in identifying-and using-metabolites that can be employed as biomarkers for diagnosing, treating and monitoring diseases. Saliva and NMR have been widely used for this purpose as they are fast and inexpensive methods. This case-control study aimed to find biomarkers that could be related to glioblastoma (GBL) and periodontal disease (PD) and studied a possible association between GBL and periodontal status. The participants numbered 130, of whom 10 were diagnosed with GBL and were assigned to the cases group, while the remaining 120 did not present any pathology and were assigned to the control group. On one hand, significantly increased (p < 0.05) metabolites were found in GBL group: leucine, valine, isoleucine, propionate, alanine, acetate, ethanolamine and sucrose. Moreover, a good tendency to separation between the two groups was observed on the scatterplot of the NMR. On the other hand, the distribution of the groups attending to the periodontal status was very similar and we didn´t find any association between GBL and periodontal status (Chi-Square 0.1968, p = 0.91). Subsequently, the sample as a whole (130 individuals) was divided into three groups by periodontal status in order to identify biomarkers for PD. Group 1 was composed of periodontally healthy individuals, group 2 had gingivitis or early periodontitis and group 3 had moderate to advanced periodontitis. On comparing periodontal status, a significant increase (p < 0.05) in certain metabolites was observed. These findings along with previous reports suggest that these could be used as biomarkers of a PD: caproate, isocaproate+butyrate, isovalerate, isopropanol+methanol, 4 aminobutyrate, choline, sucrose, sucrose-glucose-lysine, lactate-proline, lactate and proline. The scatter plot showed a good tendency to wards separation between group 1 and 3.

La trepanación craneal en las culturas primitivas / Cranial trepanation in primitive cultures

En el presente trabajo se revisan las trepanaciones craneales realizadas en el seno de las civilizaciones primitivas. El interés científico por este tema se inicia con el estudio de un cráneo precolombino trepanado encontrado en 1865 por Ephraim G. Squier en Perú y estudiado en París por Paul Broca. Se revisan las seudotrepanaciones y otras formas de manipulación craneal. Las técnicas, la tecnología y los instrumentos para los diferentes procedimientos de trepanación están bien establecidos. Hay un sorprendentemente alto porcentaje de casos con criterios de supervivencia. Más especulativas son las indicaciones, probablemente mágicas. Aunque la trepanación en culturas primitivas se extiende en el tiempo y por todo el mundo, hay 3 focos de mayor relevancia: Neolítico europeo, Sudamérica andina antes de la colonización española y algunas tribus oceánicas o africanas contemporáneas. Esta forma de apertura craneal no tiene ninguna relación con la neurocirugía moderna ni con las trepanaciones con finalidad médica iniciadas en la época grecorromana en Europa

A review is presented on cranial trepanations performed by primitive cultures. The scientific interest in this topic began after the discovery in 1965 by Ephraim G. Squier of a pre-Columbian trepanated skull, and studied by Paul Broca in Paris. Pseudotrepanation and other types of cranial manipulation are reviewed. The techniques, technology, and instruments for every type of trepanation are well known. There are a surprisingly high percentage of cases showing signs of post-trepanation survival. Indications for trepanation are speculative, perhaps magic. Although trepanation in primitive cultures is widespread around the world, and throughout time, the main fields of interest are the Neolithic Period in Europe, the pre-Columbian Period in Andean South America, and some contemporaneous Pacific and African tribes. This particular trepanation procedure has no relationship with modern Neurosurgery, or with trepanations with therapeutic purposes performed since the Greco-Roman period in Europe, and afterwards around the world

[Cranial trepanation in primitive cultures]. / La trepanación craneal en las culturas primitivas.

A review is presented on cranial trepanations performed by primitive cultures. The scientific interest in this topic began after the discovery in 1965 by Ephraim G. Squier of a pre-Columbian trepanated skull, and studied by Paul Broca in Paris. Pseudotrepanation and other types of cranial manipulation are reviewed. The techniques, technology, and instruments for every type of trepanation are well known. There are a surprisingly high percentage of cases showing signs of post-trepanation survival. Indications for trepanation are speculative, perhaps magic. Although trepanation in primitive cultures is widespread around the world, and throughout time, the main fields of interest are the Neolithic Period in Europe, the pre-Columbian Period in Andean South America, and some contemporaneous Pacific and African tribes. This particular trepanation procedure has no relationship with modern Neurosurgery, or with trepanations with therapeutic purposes performed since the Greco-Roman period in Europe, and afterwards around the world.

Historia de la craneotomía / History of the craniotomy

La craneotomía es el procedimiento neuroquirúrgico de apertura craneal amplia con el fin de realizar una actuación terapéutica quirúrgica en el espacio intracraneal. La técnica actual de la craneotomía es el resultado de la evolución de la misma desde su introducción a finales del siglo XIX. El primer abordaje craneal amplio fue descrito por Wagner en 1889 como una «resección craneal temporal», que podría denominarse ahora «craneotomía osteoplástica con colgajo óseo pediculado». Para abrir el cráneo se han usado desde entonces múltiples sistemas manuales, mecánicos y motorizados que son revisados. El resultado final de este largo proceso de mejora es la «craneotomía osteoplástica de colgajo óseo libre» que se realiza en la actualidad de forma universal. En el presente trabajo revisamos la evolución histórica de la craneotomía desde el punto de vista de la técnica quirúrgica utilizada

Craniotomy can be defined as the neurosurgical procedure aimed at achieving a wide cranial opening with the final purpose of performing a surgical therapeutic manoeuvre within the intracranial space. The current surgical technique for craniotomy is the final result of the development of the procedure since its introduction at the end of the 19th century. The very first wide cranial approach was introduced in 1889 by Wagner, and described as a 'temporary cranial resection'. This procedure could be named today as 'osteoplastic craniotomy with pedicle bone flap'. The final result of the procedural development of the craniotomy is the 'osteoplastic craniotomy with free bone flap’, used widely around the world. In this paper, we review the historic evolution of craniotomy from a technical perspective

[History of the craniotomy]. / Historia de la craneotomía.

Craniotomy can be defined as the neurosurgical procedure aimed at achieving a wide cranial opening with the final purpose of performing a surgical therapeutic manoeuvre within the intracranial space. The current surgical technique for craniotomy is the final result of the development of the procedure since its introduction at the end of the 19th century. The very first wide cranial approach was introduced in 1889 by Wagner, and described as a 'temporary cranial resection'. This procedure could be named today as 'osteoplastic craniotomy with pedicle bone flap'. The final result of the procedural development of the craniotomy is the 'osteoplastic craniotomy with free bone flap', used widely around the world. In this paper, we review the historic evolution of craniotomy from a technical perspective.

Variabilidad pronóstica del meningioma atípico con resección completa. Propuesta de algoritmo de tratamiento / Prognostic variability in atypical meningioma with complete resection. Proposed treatment algorithm

Objetivo: Los autores pretenden evidenciar que los factores pronósticos actuales que intentan evaluar el riesgo de recidiva de los meningiomas atípicos se muestran insuficientes para predecir el devenir de dicha patología. Material y método: Mediante los datos obtenidos de las bases de datos hospitalarias se adquiere una muestra de 27 pacientes con un diagnóstico anatomopatológico de meningioma atípico, con un tiempo mínimo de seguimiento de 6meses tras el diagnóstico. Posteriormente se evalúan los factores pronóstico (edad < 50años, sexo masculino, afectación ósea, edema perilesional, volumen tumoral, localización, Ki67/MIB-1) tras la estratificación de los pacientes sometidos a resección completa en recidivantes y no recidivantes. El análisis univariante se realiza mediante test de Mann-Whitney, test χ2 de homogeneidad/test exacto de Fisher. Finalmente se realiza el análisis multivariante mediante regresión logística binaria, obteniéndose los valores correspondientes a la R2 de Nagelkerke y el test de Hosmer-Lemeshow para evaluar la bondad del ajuste. Resultados: Los análisis uni y multivariante no muestran diferencias estadísticamente significativas entre los subgrupos recidivante y no recidivante de los pacientes sometidos a resección completa. Como resultado destacable se objetiva que por cada año de edad por encima de los 50años se disminuye el riesgo de recidiva un 5,8%. Conclusiones: Aunque los factores pronósticos actuales puedan mostrar un incremento del riesgo de recidiva una vez se estratifica a los pacientes por los 2 factores más importantes (anatomía patológica y grado de resección), dichos factores se muestran insuficientes para predecir el pronóstico final de los pacientes afectos por dicha patología

Objective: The authors attempt to show how the current prognostic factors that try to assess the risk of recurrence of atypical meningiomas are insufficient to predict the future of this disease. Materials and method: Using data obtained from hospital databases, a sample of 27 patients was obtained with pathological diagnosis of atypical meningioma, and who had a minimum follow-up time of 6months after diagnosis. Later prognostic factors (age <50years, male gender, bone involvement, peri-lesional swelling, tumour volume, location, Ki67/MIB-1) were evaluated after the stratification of patients undergoing complete resection in recurrencies and non-recurrencies. Univariate analysis was performed using Mann-Whitney test, χ2 homogeneity test/Fisher exact test. Finally, multivariate analysis was performed using binary logistic regression to obtain the values for R2 Nagelkerke and the Hosmer-Lemeshow to evaluate the goodness of fit. Results: The uni- and multivariate analysis showed no statistically significant differences between recurrent and non-recurrent subgroups of patients undergoing complete resection. It is noted in the results that for each year of age above 50years, the risk of recurrence is decreased by 5.8%. Conclusions: Although current prognostic factors may show an increased risk of recurrence once patients are stratified by the two most important factors (pathology and extent of resection), those factors are insufficient to predict the ultimate outcome of patients affected by this pathology

[Prognostic variability in atypical meningioma with complete resection. Proposed treatment algorithm]. / Variabilidad pronóstica del meningioma atípico con resección completa. Propuesta de algoritmo de tratamiento.

OBJECTIVE: The authors attempt to show how the current prognostic factors that try to assess the risk of recurrence of atypical meningiomas are insufficient to predict the future of this disease. MATERIALS AND METHOD: Using data obtained from hospital databases, a sample of 27 patients was obtained with pathological diagnosis of atypical meningioma, and who had a minimum follow-up time of 6months after diagnosis. Later prognostic factors (age <50years, male gender, bone involvement, peri-lesional swelling, tumour volume, location, Ki67/MIB-1) were evaluated after the stratification of patients undergoing complete resection in recurrencies and non-recurrencies. Univariate analysis was performed using Mann-Whitney test, χ(2) homogeneity test/Fisher exact test. Finally, multivariate analysis was performed using binary logistic regression to obtain the values for R(2) Nagelkerke and the Hosmer-Lemeshow to evaluate the goodness of fit. RESULTS: The uni- and multivariate analysis showed no statistically significant differences between recurrent and non-recurrent subgroups of patients undergoing complete resection. It is noted in the results that for each year of age above 50 years, the risk of recurrence is decreased by 5.8%. CONCLUSIONS: Although current prognostic factors may show an increased risk of recurrence once patients are stratified by the two most important factors (pathology and extent of resection), those factors are insufficient to predict the ultimate outcome of patients affected by this pathology.

Estimulación medular crónica y síndrome de cirugía de espalda fallida. Resultados clínicos con la utilización de electrodos planos quirúrgicos / Spinal cord stimulation and failed back surgery syndrome. Clinical results with laminectomy electrodes

Introducción: La estimulación medular crónica es una técnica ampliamente aceptada en el tratamiento del dolor lumbar resultante de una cirugía de espalda fallida. Clásicamente la estimulación se ha venido realizando con electrodos percutáneos implantados bajo anestesia local y sedación, sin embargo, la facilidad de migración, así como la dificultad de reproducción de parestesias eléctricas en zonas amplias recogidas con los mismos, han hecho que cada vez más se recurra a la utilización de electrodos planos quirúrgicos, que presentaban como inconveniente la necesidad de una laminectomía y anestesia general para su implantación. Objetivos Presentar los resultados clínicos, los detalles técnicos, las ventajas y los beneficios de la implantación de electrodos planos de estimulación medular bajo anestesia espinal, en síndromes de cirugía de espalda fallida. Material y métodos La estimulación medular se realizó en un total de 119 pacientes (52 hombres y 67 mujeres), con edades comprendidas entre los 31 y los 73 años (47,3 de media). La anestesia epidural fue inducida con ropivacaína. En todos los casos, a través de una laminectomía mínima, se implantó en el espacio epidural un electrodo plano de 8 contactos o un electrodo plano de moderna generación de 16 polos. La situación definitiva de los electrodos se dispuso en función de la reproducción de parestesias eléctricas en la zona dolorosa de los enfermos. Los electrodos se conectaron con posterioridad a generadores de impulsos eléctricos de doble canal o recargables. Resultados Después de un seguimiento medio de 4,7 años, el resultado en cuanto a la mejoría de la situación dolorosa previa es satisfactorio, constatando una disminución del dolor del 58% en el axial y del 60% en el radicular, en más del 70% de los casos. Ninguno de los pacientes ha manifestado que el tiempo quirúrgico fuera doloroso o desagradable. No se han recogido complicaciones serias en el grupo, y en 6 de los casos se ha tenido que explantar el sistema por ineficacia o intolerancia de la neuroestimulación a largo plazo. Conclusiones: En este estudio, realizado en un número importante de pacientes, se ha utilizado la anestesia epidural para la colocación de electrodos planos de estimulación medular en síndromes de cirugía fallida de espalda o poslaminectomía. La técnica se ha mostrado segura, eficaz y satisfactoria

Introduction: Spinal cord stimulation is a widely-accepted technique in the treatment of back pain resulting from failed back surgery. Classically, stimulation has been carried out with percutaneous electrodes implanted under local anaesthesia and sedation. However, the ease of migration and the difficulty of reproducing electrical paraesthesia’s in large areas with such electrodes has led to increasing use of surgical plate leads, which have the disadvantage of the need for general anaesthesia and a laminectomy for implantation. Objectives: Our objective was to report the clinical results, technical details, advantages and benefits of laminectomy lead placement under epidural anaesthesia in failed back surgery syndrome cases. Material and methods: Spinal cord stimulation was performed in a total of 119 patients (52 men and 67 women), aged between 31 and 73 years (average, 47.3). Epidural anaesthesia was induced with ropivacaine. In all cases we inserted the octapolar or 16-polar lead in the epidural space through a small laminectomy. The final position of the leads was the vertebral level that provided coverage of the patient’s pain. The electrodes were connected at dual-channel or rechargeable pulse generators. Results: After a mean follow-up of 4.7 years, the results in terms of improvement of the previous painful situation was satisfactory, with an analgesia level of 58% of axial pain and 60% of radicular pain in more than 70% of cases. None of the patients said that the surgery stage was painful or unpleasant. No serious complications were included in the group, but in 6 cases the system had to be explanted because of ineffectiveness or intolerance of longterm neurostimulation. Conclusions: This study, with a significant number of patients, used epidural anaesthesia for spinal cord stimulation of lead implants by laminectomy in failed back surgery syndromes. The technique seems to be safe and effective

[Spinal cord stimulation and failed back surgery syndrome. Clinical results with laminectomy electrodes]. / Estimulación medular crónica y síndrome de cirugía de espalda fallida. Resultados clínicos con la utilización de electrodos planos quirúrgicos.

INTRODUCTION: Spinal cord stimulation is a widely-accepted technique in the treatment of back pain resulting from failed back surgery. Classically, stimulation has been carried out with percutaneous electrodes implanted under local anaesthesia and sedation. However, the ease of migration and the difficulty of reproducing electrical paresthesias in large areas with such electrodes has led to increasing use of surgical plate leads, which have the disadvantage of the need for general anaesthesia and a laminectomy for implantation. OBJECTIVES: Our objective was to report the clinical results, technical details, advantages and benefits of laminectomy lead placement under epidural anaesthesia in failed back surgery syndrome cases. MATERIAL AND METHODS: Spinal cord stimulation was performed in a total of 119 patients (52 men and 67 women), aged between 31 and 73 years (average, 47.3). Epidural anaesthesia was induced with ropivacaine. In all cases we inserted the octapolar or 16-polar lead in the epidural space through a small laminectomy. The final position of the leads was the vertebral level that provided coverage of the patient's pain. The electrodes were connected at dual-channel or rechargeable pulse generators. RESULTS: After a mean follow-up of 4.7 years, the results in terms of improvement of the previous painful situation was satisfactory, with an analgesia level of 58% of axial pain and 60% of radicular pain in more than 70% of cases. None of the patients said that the surgery stage was painful or unpleasant. No serious complications were included in the group, but in 6 cases the system had to be explanted because of ineffectiveness or intolerance of long-term neurostimulation. CONCLUSIONS: This study, with a significant number of patients, used epidural anaesthesia for spinal cord stimulation of lead implants by laminectomy in failed back surgery syndromes. The technique seems to be safe and effective.

Demasiada fusión en la artrodesis posfacetectomía cervical / Excessive fusion in cervical post-facetectomy arthrodesis

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