Daño medular intraoperatorio en cirugía de escoliosis idiopática: reinstrumentar y cuándo / Spinal cord injury as a complication of idiopathic scoliosis surgery: when to plan a new surgical procedure

La lesión medular es una complicación temida y devastadora del tratamiento quirúrgico de la escoliosis idiopática. Su prevención requiere una técnica quirúrgica y anestésica depurada y potenciales evocados somatosensoriales (PESS) y motores (PEM) intraoperatorios para poder instaurar rápidamente medidas neuroprotectoras, entre ellas la desinstrumentación vertebral. Es esperable que la escoliosis continúe progresando posteriormente. Presentamos el caso de una niña de 12 años, con una escoliosis juvenil grave y progresiva, que en la cirugía correctora sufre una lesión medular espinal. A pesar de la buena evolución neurológica, la deformidad vertebral sigue progresando y se replantea la reinstrumentación vertebral, con su inherente riesgo de relesión medular y secuelas finales más graves. En conclusión, el manejo de las escoliosis progresivas graves que coexisten con daño medular debe individualizarse. La gravedad de las secuelas neurológicas parece aumentar la progresión de la deformidad ortopédica y hacer más incierta la respuesta a cualquier tratamiento posterior (AU)

Spinal cord injury (SCI) is a dreaded and devastating complication of the surgical treatment of idiopathic scoliosis. Its prevention requires meticulous surgical and anaesthetic procedures and combined monitoring of somatosensory (SEPs) and motor (PEM) evoked potentials to quickly establish neuroprotective measures such as pedicle screw removal. It is expected that the scoliosis keeps progressing afterwards. We report the case of a 12-year-old girl who had a spinal cord injury during scoliosis corrective surgery. Despite the good neurological outcome, the spinal deformity continues to progress and a new surgical procedure might be considered, with its inherent risk of a second SCI and more serious neural damage. In conclusion, the management of progressive scoliosis that coexists with an SCI must be individualized. The severity of neurologic sequelae seems to worsen the progression of spinal deformity and make the response to any subsequent treatment more uncertain (AU)

Intervenciones que mejoran el pronóstico en la neurofibromatosis tipo 2: a propósito de un caso / Interventions that improve the prognosis in neurofibromatosis type 2: a case report

La neurofibromatosis tipo 2 (NF2) es una enfermedad autosómica dominante (AD) que predispone a múltiples lesiones neoplásicas; el neurinoma del acústico bilateral es patognomónico. Es frecuente la presencia en el mismo paciente de varios tipos de tumores con estirpe patológica y localización diferentes, lo que hace más difícil las decisiones terapéuticas, especialmente en niños y adolescentes. El trastorno se localiza en el cromosoma 22q12. Las distintas modalidades de cirugía y radioterapia son armas fundamentales en el tratamiento de la NF2. El tratamiento rehabilitador individualizado influye en el pronóstico funcional final. El seguimiento clínico y de neuroimagen debe tener como objetivo el control evolutivo de los tumores y la decisión terapéutica(AU)

Neurofibromatosis type 2 (NF2) is an autosomal dominant (AD) disease that predisposes to multiple neoplasms; the bilateral acoustic neuroma is pathognomonic. The presence of several types of tumors having different pathological lineage and localization is frequent in the same patient. This hinds treatment decisions, especially in children and adolescents. The disorder is located on chromosome 22q12. The different types of surgery and radiotherapy are essential tools for the treatment of NF2. Therefore, individualized rehabilitation treatment influences the final functional prognosis. The purpose of the clinical and neuroimaging follow-up should be that of controlling the progression of tumors and therapeutic decision(AU)

Mielitis transversa aguda: revisión clínica y algoritmo de actuación diagnóstica / Acute transverse myelitis: a clinical review and algorithm for diagnostic intervention

Introducción. Bajo el término de mielitis transversa aguda (MTA) se engloba un grupo heterogéneo de enfermedades, con el nexo común de producir una lesión focal inflamatoria de la médula espinal, de forma aguda. Para intentar agrupar todas las etiologías que pueden cursar con dicha afectación, se intenta hoy en día definir varios grupos de patologías con un nexo común: aquellas MTA asociadas a algún proceso causante, o al menos predisponente de la MTA, como son ciertas infecciones, procesos sistémicos y/o multifocales inmunológicos, e incluso tumorales, y aquéllas en las que no llegamos a conocer dicho desencadenante, a las que llamamos entonces MTA idiopáticas. Objetivo. Conocer las distintas clases de MTA existentes, creando un algoritmo diagnóstico que ayude a dicha clasificación de forma ordenada, simplificando el trabajo al clínico que se enfrente a una MTA, y exponiendo su diagnóstico diferencial, pronóstico y posible tratamiento. Desarrollo. Se consultan las últimas guías y trabajos publicados relacionados con la MTA, sobre todo desde el punto de vista diagnóstico y terapéutico. Conclusiones. Nuestro conocimiento de la MTA se está viendo modificado constantemente con el advenimiento de nuevas técnicas diagnósticas y teorías que intentan explicar su origen, probablemente inmunológico. Desgraciadamente, el tratamiento y, por tanto, el pronóstico no han variado en la misma proporción al conocimiento que vamos adquiriendo en las otras áreas. Sin duda, queda un camino importante por recorrer, pero el futuro próximo nos puede enseñar más sobre esta enfermedad (AU)

Introduction. Under the term of acute transverse myelitis (ATM), there are included a heterogeneous group of diseases, with the nexus common to produce an inflammatory focal injury of the spinal cord, of acute form. In order to try to group all the etiologies that can provoke this affectation, it is nowadays tried to define several groups of pathologies with a common nexus: those ATM associated to some process, or at least predisposed of the ATM, like are certain infections, immunological systemic and/or multifocal processes, and inclusive tumors, but when we did not get to know this triggering factor, then calling them idiopathic ATM. Aim. To know the different classes from existing ATM, creating an algorithm diagnosis that helps to this classification of ordinate form, simplifying the work to the clinicians that faces a ATM, exposing its differential diagnosis, prognosis and possible treatment. Development. For it we consulted the last guides and works published related to the ATM, mainly from the diagnostic and therapeutic point of view. Conclusions. Our knowledge of the ATM is being constantly modified with the coming of new diagnostic techniques and theories that try to explain their origin, probably immunological. Unfortunately, the treatment, and therefore the prognosis, has not varied in the same proportion to the knowledge that we are acquiring in the other areas. Without a doubt, it is a way important to walk, but the next future can teach to us more on this disease (AU)

[Acute transverse myelitis: a clinical review and algorithm for diagnostic intervention]. / Mielitis transversa aguda: revisión clínica y algoritmo de actuación diagnóstica.

INTRODUCTION: Under the term of acute transverse myelitis (ATM), there are included a heterogeneous group of diseases, with the nexus common to produce an inflammatory focal injury of the spinal cord, of acute form. In order to try to group all the etiologies that can provoke this affectation, it is nowadays tried to define several groups of pathologies with a common nexus: those ATM associated to some process, or at least predisposed of the ATM, like are certain infections, immunological systemic and/or multifocal processes, and inclusive tumors, but when we did not get to know this triggering factor, then calling them idiopathic ATM. AIM: To know the different classes from existing ATM, creating an algorithm diagnosis that helps to this classification of ordinate form, simplifying the work to the clinicians that faces a ATM, exposing its differential diagnosis, prognosis and possible treatment. DEVELOPMENT: For it we consulted the last guides and works published related to the ATM, mainly from the diagnostic and therapeutic point of view. CONCLUSIONS: Our knowledge of the ATM is being constantly modified with the coming of new diagnostic techniques and theories that try to explain their origin, probably immunological. Unfortunately, the treatment, and therefore the prognosis, has not varied in the same proportion to the knowledge that we are acquiring in the other areas. Without a doubt, it is a way important to walk, but the next future can teach to us more on this disease.

Tratamiento de la tendinopatía calcificante de hombro: ¿iontoforesis con ácido acético u onda corta? / Treatment of calcifying tendinitis of the shoulder: iontophoresis with acetic acid or shortwave?

Introducción. La tendinopatía calcificante de hombro (TCH) es una patología invalidante, dolorosa, frecuente y con alto impacto socioeconómico. El objetivo de este estudio es comparar la eficacia de la iontoforesis con ácido acético (IAA) con la onda corta (OC), asociadas ambas a ultrasonidos (US) y a un programa de cinesiterapia domiciliaria en dos grupos de pacientes con TCH. Material y método. Se estudia una muestra de 23 pacientes, aleatorizados en dos grupos de tratamiento: en el grupo I (GI) se emplea IAA al 2 % y en el grupo II (GII) OC. En ambos grupos se utilizaron los US y un programa estandarizado de ejercicios de hombro. Se aplicaron 15 sesiones de tratamiento y se valoraron las diferencias estadísticamente significativas en la escala visual analógica, índice de Constant (IC) y tamaño de la calcificación del hombro afecto. Resultados. Se encontró mejoría estadísticamente significativa en ambos grupos en el dolor (GI p = 0,002; GII p = 0,003) y en el apartado nivel de actividad del IC para el GII (p = 0,01). No se detectaron diferencias en la fuerza, movilidad y tamaño de la calcificación. Conclusiones. La asociación de IAA al 2 %, US y ejercicios no ha demostrado ser mejor en la TCH que la combinación de OC, US y ejercicios en lo referente a la mejoría del dolor, el IC y el tamaño de la calcificación. Son precisos más estudios con mayor número de pacientes y apoyados en técnicas de imagen que permitan mejores correlaciones clínico-patológicas para llegar a resultados más concluyentes

Introduction. Calcifying tendinitis of the shoulder (TCH) is a crippling, painful and common disease with high socio-economic impact. This study has aimed to compare iontophoresis with acetic acid (IAA) with shortwave (SW), both associated with ultrasound (US) and a physiotherapy home shoulder program in two groups of patients with TCH. Materials and methods. We studied a sample of 23 patients, randomized into two treatment groups. Group I uses IAA 2 % and the group II uses SW. US and an exercise shoulder program were used in both groups. Fifteen treatment sessions were applied and the statistically significant differences on the EVA, Constant index (CI) and size of the calcification were evaluated. Results. Statistically significant improvement for both groups regarding pain (GI, p = 0.002; GII, p = 0.003) and in the CI (p = 0.01) was found. No differences were detected in force, mobility and size of the calcification. Conclusions. It has not proven that the association of IAA at 2 %, US and exercises is better than the association of SW, US and exercises, in terms of improvement in pain, CI and size of calcification. Further studies with a larger sample population and complementary imaging techniques that can better define the clinical pathological correlations are needed

Effects of baclofen on temperature perception in humans.

The aim of this study was to evaluate the effect of chronic consumption of the GABAB agonist baclofen on temperature perception in humans. We investigated temperature perception thresholds to detect warm and cold stimuli in a group of 21 patients with spinal cord injury, who were chronically consuming oral baclofen at different daily doses to treat spasticity. Temperature perception thresholds were assessed above the level of the lesion, using a psychophysical approach based on the ability of the subjects to perceive precisely quantified sensory stimuli (quantitative sensory testing, QST). The data were compared with a control group of healthy subjects, not receiving baclofen. We found that chronic baclofen consumption increased temperature perception thresholds for both cold and warm stimuli in a dose-dependent manner. Temperature perception thresholds did not depend on the level of the lesion nor on the duration of baclofen treatment, suggesting that our finding represent normal GABAB-mediated modulation in spared nervous structures. We conclude that GABAB therefore plays a role in temperature perception in humans.

Cortical correlates of TMS-induced phantom hand movements revealed with concurrent TMS-fMRI.

We studied an amputee patient who experiences a conscious sense of movement (SoM) in her phantom hand, without significant activity in remaining muscles, when transcranial magnetic stimulation (TMS) is applied at appropriate intensity over the corresponding sector of contralateral motor cortex. We used the novel methodological combination of TMS during fMRI to reveal the neural correlates of her phantom SoM. A critical contrast concerned trials at intermediate TMS intensities: low enough not to produce overt activity in remaining muscles; but high enough to produce a phantom SoM on approximately half such trials. Comparing trials with versus without a phantom SoM reported phenomenally, for the same intermediate TMS intensities, factored out any non-specific TMS effects on brain activity to reveal neural correlates of the phantom SoM itself. Areas activated included primary motor cortex, dorsal premotor cortex, anterior intraparietal sulcus, and caudal supplementary motor area, regions that are also involved in some hand movement illusions and motor imagery in normals. This adds support to proposals that a conscious sense of movement for the hand can be conveyed by activity within corresponding motor-related cortical structures.

[Gait training in incomplete spinal cord injuries with body weight support]. / Entrenamiento de la marcha en lesiones medulares incompletas con soporte del peso corporal.

INTRODUCTION: A spinal cord injury implies the loss of or alteration to the gait pattern. Stimulating the pattern generating centres in the sublesional spinal cord determines the appearance of flexion and extension automatisms that are useful for gait training in patients with spinal cord injuries. These centres can be stimulated using a treadmill and supporting the body weight by means of a harness. AIMS: To be able to trigger spinal cord automatisms and to stimulate pattern generating centres. To determine the value of an electromechanical system for mobilising the lower limbs as a complement to the treadmill and body weight support. To study changes in muscle tone. PATIENTS AND METHODS: A short gait training programming was carried out with ten individuals with incomplete spinal cord injuries who satisfied eligibility-exclusion criteria using a treadmill in association with a body weight support system and an electromechanical system for mobilising the lower limbs. RESULTS AND CONCLUSIONS: Spinal cord flexion and extension automatisms were stimulated and an important improvement in spasticity was achieved. Longer programmes are needed in order to evidence changes in the gait pattern and in muscular balance.

Entrenamiento de la marcha en lesiones medulares incompletas con soporte del peso corporal / Gait training in incomplete spinal cord injuries with body weight support

Introducción. La lesión medular supone una pérdida o alteración del patrón de la marcha. La estimulación de los centros generadores de patrones de la médula sublesional determina la aparición de automatismos de flexión y extensión útiles para el entrenamiento de la marcha en lesionados medulares. Estos centros pueden estimularse empleando un tapiz rodante asociado a la descarga del peso corporal con un arnés. Objetivos. Conseguir desencadenar los automatismos medulares y estimular los centros generadores de patrones. Valorar la utilidad de un sistema electromecánico de mo vilización de los miembros inferiores como complemento al tapiz rodante y a la descarga del peso corporal. Estudiar cambios en el tono muscular. Pacientes y métodos. Se ha realizado un programa de entrenamiento de la marcha de corta duración a diez individuos con lesión medular incompleta que cumplían los criterios de inclusión-exclusión, utilizando un tapiz rodante asociado a un sistema de soporte del peso corporal y a un dispositivo electromecánico de movilización de los miembros inferiores. Resultados y conclusión. Se ha conseguido la estimulación de automatismos de flexión y extensión medulares y una importante mejoría de la espasticidad. Para objetivar cambios en el patrón de marcha y en el balance muscular es necesario llevar a cabo programas de mayor duración (AU)

Introduction. A spinal cord injury implies the loss of or alteration to the gait pattern. Stimulating the pattern generating centres in the sublesional spinal cord determines the appearance of flexion and extension automatisms that are useful for gait training in patients with spinal cord injuries. These centres can be stimulated using a treadmill and supporting the body weight by means of a harness. Aims. To be able to trigger spinal cord automatisms and to stimulate pattern generating centres. To determine the value of an electromechanical system for mobilising the lower limbs as a complement to the treadmill and body weight support. To study changes in muscle tone. Patients and methods. A short gait training programming was carried out with ten individuals with incomplete spinal cord injuries who satisfied eligibility-exclusion criteria using a treadmill in association with a body weight support system and an electromechanical system for mobilising the lower limbs. Results and conclusions. Spinal cord flexion and extension automatisms were stimulated and an important improvement in spasticity was achieved. Longer programmes are needed in order to evidence changes in the gait pattern and in muscular balance (AU)

[Devic's optic neuromyelitis: analysis of 7 cases]. / Neuromielitis óptica de Devic: análisis de siete casos.

INTRODUCTION: Devic's optic neuromyelitis is an unusual condition characterized by the association of unilateral or bilateral optic neuritis and myelitis, both of which are relapsing. Prognosis is usually poor, both for the optic nerve and for the spinal medulla which becomes cavitated. This leads to severe handicap and deterioration in quality of life, except in cases presenting as children. PATIENTS AND METHODS: We studied seven cases of this condition and describe their clinical and neuroimaging features, cerebrospinal fluid (CSF), evaluation, complications, prognosis and treatment. This data was compared with that in the literature. RESULTS AND CONCLUSIONS: 1. It is an unusual condition--only 7 cases have been seen at our centre--making up approximately 0.1% of the inflammatory pathology of the spinal cord seen. 2. During the first few hours or days the clinical and radiological findings may not correspond. There may be marked deterioration of CNS function but with normal neuroimaging findings. This may lead to serious problems in diagnosis, which can usually be resolved by repeating the investigation. 3. Differential diagnosis should be made with intramedullary tumors when on neuroimaging there is increased spinal cord diameter with uptake of contrast, and psychiatric disorders when this is normal. 4. The condition usually deteriorates leading to severe disability, since loss of visual acuity is added to the severe spinal cord lesion. 5. Diagnosis should be made by application of the criteria of clinical evolution, imaging and biochemistry defined in the literature, although firm diagnosis can only be made on anatomopathological studies, usually at autopsy.