Litigabilidad y defendibilidad en neurología y neurocirugía. Un modelo «terapéutico» para el manejo de reclamaciones por mala praxis asistencial / Litigability and defensibility in neurology and neurosurgery. A “therapeutic” model for handling claims for malpractice care

Pese a su indiscutible importancia, no abundan los datos oficiales sobre reclamaciones por mala praxis asistencial a nivel nacional en España, debido principalmente a las transferencias de Sanidad a las comunidades autónomas. Esta falta de información unificada, junto a otras variables relacionadas con la moderna medicina asistencial (tipo de sistema sanitario, aspectos éticos, consentimiento, derechos de los pacientes, nuevas tecnologías, etc.), complica la respuesta del profesional sanitario ante las reclamaciones y podría no garantizar una adecuada protección de este ante posibles denuncias. Este artículo analiza la situación actual en España y enfatiza aspectos como la defendibilidad y la litigabilidad en las reclamaciones por mala praxis, tomando como modelo la especialidad de neurocirugía, una de las más proclives a este tipo de situaciones. Se ofrecen líneas guía de prevención y actuación mediante un modelo encaminado a reforzar la defendibilidad y reducir la litigabilidad. Dicho enfoque, al que llamamos «modelo terapéutico», considera el problema análogamente a una enfermedad, proporcionando bases para su prevención y manejo. Creemos que este enfoque puede ser útil tanto al Neurocirujano como a cualquier sanitario en un momento, como el actual, en que existe cierta confusión sobre estos temas y también alguna reticencia de las Compañías aseguradoras a proporcionar cobertura en algunos casos (AU)

Despite its indisputable importance, there are not many official data on claims for malpractice at the national level in Spain, mainly due to transfers from Health to the Autonomous Communities. This lack of unified information, together with other variables related to modern Healthcare Medicine (type of healthcare system, ethical aspects, consent, patients’ rights, new technologies, etc.), complicates the healthcare professional's response to claims, and could not guarantee adequate protection of this against possible liability. This article analyzes the current situation in Spain and emphasizes aspects such as defensibility and liability in malpractice claims, taking as a model the Neurosurgery Specialty, one of the most prone to this type of situation. Prevention and action guidelines are offered, through a model aimed at reinforcing defensibility and reducing liability. This approach, which we call a «therapeutic model», considers the problem analogously to a disease, providing the basis for its prevention and management.We believe that this approach can be useful both to the neurosurgeon and to any healthcare provider at a time, such as today, when there is some confusion on these issues and some reluctance of insurance companies to provide coverage in some cases (AU)

Guía para la valoración multiaxial del "esguince cervical" y la patología discal asociada / Multiaxial guideline for evaluation of whiplash and associated disk disorders

Se aporta un enfoque de la valoración del esguince cervical basado en un modelo multidimensional. A modo de checklist se consideran aspectos relativos al accidente, las lesiones cervicales, el estado anterior, las lesiones extracervicales y aspectos psicológicos, incluyendo la simulación. Ya que el esguince cervical es no sólo, ni a veces principalmente, un cuadro médico, sino derivado de factores no médicos, se considera este modelo multiaxial como la mejor manera de abordar su valoración y tratamiento. Se insiste en la necesidad de valorar pericialmente las pruebas complementarias, en la importancia de algunas patologías asociadas y en la utilidad de un lenguaje común al hablar de la simulación o la exageración (AU)

A multiaxial approach to whiplash assessment is proposed. Following a checklist-like model, the accident, cervical and extra-cervical injuries, premorbid spine status, and psychological-malingering factors are, consecutively, considered. Provided that whiplash is not only a medical condition, but derived also from non-biological elements, the multiaxial model is presented as the best way to approach the forensic and therapeutic problems of whiplash. Remarks are made on the assessment of complementary tests under an expertise point of view, the importance of several whiplash-associated conditions, and the usefulness of using a unified terminology when facing malingering or simulation (AU)

[Biological cement extravasation into the spinal canal following kyphoplasty. Long-term follow-up. Report of one case and review of the literature]. / Fuga intrarraquídea de cemento biológico tras cifoplastia. Evolución a largo plazo.Presentación de un caso y revisión de la literatura.

BACKGROUND: Vertebroplasty and kyphoplasty are minimally invasive percutaneous techniques indicated in the treatment of some somatic vertebral fractures. Both are based on the introduction of a substance, called cement, inside the vertebral body. We can choose acrylic or biological cement. These techniques are not risk-free, cement extravasation being the main complication. Due to the short experience in the use of the biological cements, nowadays there are a lot of unresolved doubts about the long-term behaviour of these materials, especially in the case of leakage. PURPOSE: We report a case of biologic cement extravasation into the spinal canal during a kyphoplasty in a 23 year old man and its long-term follow-up (3 years), performing a review of the scientific literature related to the topic. CONCLUSIONS: Most of the papers in the literature discuss the behaviour of the reinforcement material inside a bony environment, but they do not refer to the evolution of the cement outside the vertebral space. We have appreciated in our case that the leaked cement is not being substituted for bone but it suffers a process of progressive resorption. The extravasation of the vertebral reinforcement material is an important and potentially serious complication of the vertebral augmentation techniques. To avoid this, a very precise chirurgical technique is necessary, under radiological guidance. Biocompatibility, biodegradability and osteoconductivity are the main advantages of biological cements. We base the choice of the cement on the balloon/trabeculae interaction.

Líneas guía en autopsias por sospecha de mala praxis asistencial / Guidelines of autopsy in cases of suspected clinical malpractice

El presente trabajo revisa las líneas seguidas en casos de autopsia por sospecha de mala praxis. Se revisan las indicaciones, propósitos generales, técnicas de disección, exámenes complementarios, junto con los problemas éticos, de acuerdo con la experiencia del autor y la literatura. Un grado significativo de entrenamiento y experiencia tanto clínica como patológica es requerido en estos casos. Esta necesidad puede contrastar con la relativa falta de expertizatión de los médicos forenses en España, y con las limitaciones de la autopsia médico-legal. Algunas guías para solucionar este problema, como consulta con especialistas independientes, o con los comités de las especialidades médicas, son consideradas. Existen importantes problemas éticos en estos fallecimientos. En consecuencia, hay una necesidad de enfoque correcto de estos problemas. Se consideran algunas orientaciones en este sentido (AU)

The present paper reviews the guidelines for autopsy in cases of suspected clinical malpractice. Indications, general purposes, dissection techniques, laboratory and complementary examinations, as well as ethical problems are revised, according to the author's experience and literature review. A significant degree of training and skill, both clinical and pathologically, are required. This needing can contrast with the relative lack of specialization of Forensic Pathologists in Spain, and limitations of the judicial autopsy in these cases. Some guidelines to solve this problem, like independent expert consultation or advise by the Specialties Boards, are considered. Important ethical issues can arise from these deaths, therefore, a needing of correct address of these issues is perceived. Some orientations in this subject are considered (AU)

Fuga intrarraquídea de cemento biológico tras cifoplastia. Evolución a largo plazo. Presentación de un caso y revisión de la literatura / Biological cement extravasation into the spinal canal following kyphoplasty. Long-term follow-up. Report of one case and review of the literature

Introducción. La vertebroplastia y la cifoplastia son técnicas percutáneas mínimamente invasivas indicadas en el tratamiento de ciertas fracturas somáticas vertebrales. Ambas se basan en la introducción dentro del cuerpo vertebral de una sustancia llamada genéricamente cemento, el cual puede ser acrílico o biológico. Son técnicas no exentas de riesgos, destacando como principal complicación la extravasación del cemento. Dada la corta experiencia en el uso de cementos biológicos, existen hoy en día muchas dudas sin resolver acerca de su comportamiento a largo plazo, especialmente en caso de que se produzca una fuga del material de refuerzo vertebral.Objetivo. Presentamos un caso de extravasación intrarraquídea de cemento biológico durante una cifoplastia en un varón de 23 años y su evolución a largo plazo (3 años), realizando una revisión de la literatura publicada al respecto.Conclusiones. La mayoría de los estudios publicados tratan sobre la evolución del material de refuerzo dentro de un ambiente óseo, pero no hacen referencia a cómo evolucionaría el mismo fuera del espacio vertebral. Hemos apreciado, en nuestro caso, que el cemento extravasado no está siendo sustituido por hueso, sino que está sufriendo un proceso de reabsorción. La extravasación del material de refuerzo vertebral es una complicación importante y potencialmente grave de las técnicas de refuerzo vertebral percutáneo. Para evitarla se requiere una rigurosa técnica quirúrgica bajo control radioscópico. Los cementos biológicos tienen la ventaja de ser biocompatibles, biodegradables y osteoconductivos. La elección del cemento dependerá de las características de la interacción balón-trabécula (AU)

Background. Vertebroplasty and kyphoplasty are minimally invasive percutaneous techniques indicated in the treatment of some somatic vertebral fractures. Both are based on the introduction of a substance, called cement, inside the vertebral body. We can choose acrylic or biological cement. These techniques are not risk-free, cement extravasation being the main complication. Due to the short experience in the use of the biological cements, nowadays there are a lot of unresolved doubts about the long-term behaviour of these materials, especially in the case of leakage.Purpose. We report a case of biologic cement extravasation into the spinal canal during a kyphoplasty in a 23 year old man and its long-term follow-up (3 years), performing a review of the scientific literature related to the topic.Conclusions. Most of the papers in the literature discuss the behaviour of the reinforcement material inside a bony environment, but they do not refer to the evolution of the cement outside the vertebral space. We have appreciated in our case that the leaked cement is not being substituted for bone but it suffers a process of progressive resorption. The extravasation of the vertebral reinforcement material is an important and potentially serious complication of the vertebral augmentation techniques. To avoid this, a very precise chirurgical technique is necessary, under radiological guidance. Biocompatibility, biodegradability and osteoconductivity are the main advantages of biological cemnets. We base the choice of the cement on the balloom/trabeculae interaction (AU)

[Ganglioneuroma coinciding with a lumbar disk herniation]. / Ganglioneuroma coincidente con una extrusión discal lumbar.

INTRODUCTION. Ganglioneuromas or gangliomas are tumours of the sympathetic ganglia that contain cells of the neural crest, so they can appear in all body localizations. They are generally benign, more frequent between 10 and 40 years, may secrete hormones and, sometimes, Neurofibromatosis type I and other genetic disorders can be associated. OBJECTIVE. To review the scientific literature related to the topic and to present a case treated in our service. DISCUSSION. The symptoms depend on location and vasoactive secreted hormones. In spite of that, they are generally benign tumours, although sometimes they can spread out. Since laboratory and image test are of limited usefulness, the conclusive diagnosis is anatomopathologic. In symptomatic patients the best procedure is surgical removing. CONCLUSION. Ganglioneuroma and disk herniation association constitute an exceptional disorder. Its treatment implies surgery resection.

Ganglioneuroma coincidente con una extrusión discal lumbar / Ganglioneuroma coinciding with a lumbar disk herniation

Introducción. Los ganglioneuromas o gangliomas son tumores de los ganglios simpáticos que contienen células de la cresta neural, pudiendo aparecer en cualquier parte del organismo. Son generalmente benignos, más frecuente entre los 10 y los 40 años, pueden secretar hormonas y, en ocasiones, asociarse a trastornos genéticos, como la neurofibromatosis tipo I.Objetivo. Revisar la literatura científica relacionada con el tema y presentar un caso tratado en nuestro servicio.Discusión. La sintomatología de estas lesiones depende de su ubicación y de las sustancias vasoactivas que puedan secretar. A pesar de que son tumores benignos en su mayoría, en ocasiones pueden metastatizar. Las pruebas de imagen y de laboratorio son inespecíficas, por lo que el diagnóstico definitivo es anatomopatológico. En los casos sintomáticos el tratamiento de elección es la resección quirúrgica.Conclusión. La asociación de un ganglioneuroma y de una hernia discal lumbar es algo excepcional. El tratamiento requiere su resección quirúrgica (AU)

Introduction. Ganglioneuromas or gangliomas are tumours of the sympathetic ganglia that contain cells of the neural crest, so they can appear in all body localizations. They are generally benign, more frequent between 10 and 40 years, may secrete hormones and, sometimes, Neurofibromatosis type I and other genetic disorders can be associated. Objective. To review the scientific literature related to the topic and to present a case treated in our service.Discussion. The symptoms depend on location and vasoactive secreted hormones. In spite of that, they are generally benign tumours, although sometimes they can spread out. Since laboratory and image test are of limited usefulness, the conclusive diagnosis is anatomopathologic. In symptomatic patients the best procedure is surgical revoming.Conclusión. Ganglioneuroma and disk herniation association constitute an excepcional disorder. Its treatment implies surgery resection (AU)

[Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases]. / Regresión espontánea de hernias discales intervertebrales. A propósito de una serie de 37 casos.

INTRODUCTION: The intervertebral disc disease (IDD) is one of the most common muscle-skeletal disorders, causing both high work disability and elevated healthcare costs. There are two specific origins of disk disease that should be kept in mind: degenerative (DDD) and traumatic (TDD). Concerning the TDD, nowadays it has not been determined which patients could gradually improve and which ones will require surgery. Some studies indicate that about 85% of lumbar and 90% cervical acute disc herniation will get better in an average of 6 weeks. MATERIALS AND METHODS: We conducted an observational, prospective study, over a group of 858 patients, with the following inclusion criteria: 1. MRI imaging indicating TDD, 2. No signs or symptoms requiring urgent surgical treatment (cauda equina syndrome, progressive or serious motor deficit or unbearable pain) and 3. Development of progressively spontaneous symptoms remission. All of the patients included in our study were treated in our Department of Neurosurgery from 2006 to 2007. Patients were tested for disc herniation regression with a second MRI study. RESULTS: A spontaneous regression of their hernia was appreciated as follow: 33 cases of lumbar hernia (29 male, 4 female), 3 cervical hernia (1 male, 2 female) and 1 dorsal hernia (male). DISCUSSION: Research about other reported series was done, and the different factors that could take place in disc spontaneous regression were analyzed: a) lodgement of the herniated disc back into the intervertebral space; b) disappearance of the herniated fragment due to dehydration and retraction mechanisms; c) gradual resorption of the herniated tissue by phagocytosis and enzymatic degradation induced by an inflammatory reaction that appeared as the disc (acting the extrusion itself as an foreign body) and, d) pulsion of cephaloarchidian liquid against the herniated portion. CONCLUSIONS: Disc herniation can regress, or even disappear, in a number of patients, rendering the radiological findings not to be taken as the only surgical indication criterium. We consider that the best treatment is the one relying on a good doctor-patient relationship, suspended in a balance between conservative and surgical treatment. According to clinical data, the first one (conservative) should not exceed the estimated time beyond which the surgical result would be unsatisfactory. The second one (operative), excepting "need-to operate" situations (such as cauda equina compression, progressive or serious motor déficit, or unbearable pain), should be prudently supedited to MRI regresión control, in particular in patients in which a clinical improvement is observed. Thus, the disc herniation conservative healing, both clinical as radiological, do exist, being a concept to widespread among clinicians and patients also.

Regresión espontánea de hernias discales intervertebrales. A propósito de una serie de 37 casos / Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases

Introducción. La enfermedad discal intervertebral(EDI) es uno de los trastornos musculoesqueléticos máscomunes, que induce tanto una elevada proporción dediscapacidad laboral como un gran coste sanitario.Dentro de la EDI cabría considerar dos modalidades,la enfermedad discal de origen degenerativo (EDD) yla de origen traumático (hernias discales traumáticas- HDT). Con respecto a las HDT no se ha podido determinar,a día de hoy, qué pacientes son susceptiblesde mejorar espontáneamente y cuales lo harán si sesometen a tratamiento quirúrgico. Algunos estudioshan determinado, que hasta el 85% de los pacientescon una hernia discal lumbar aguda y hasta el 90% conuna hernia discal cervical aguda, mejorarán en el plazomedio de 6 semanas.Material y método. Durante el bienio 2006-2007,realizamos un estudio observacional, prospectivo en858 pacientes diagnosticados clínica y radiológicamentede HDT, que no cumplimentaban los criterios de unacirugía urgente -síndrome de la cola de caballo, déficitmotor progresivo/grave, o dolor incoercible-. Un grupode pacientes evolucionaron de forma progresiva a laremisión espontánea de la clínica que motivara su asistenciamédica. Se solicitó, en aquellos pacientes que asílo aceptaron, un nuevo estudio de neuroimagen.Resultados. Se ha apreciado una regresión espontáneade la herniación en 33 casos a nivel lumbar (29varones y 4 mujeres), en 3 casos a nivel cervical (1 varóny 2 mujeres) y en 1 caso a nivel dorsal (1 varón).Discusión. Se lleva acabo una revisión de otrasseries publicadas y se analizan los distintos factoresque pueden intervenir en la regresión espontánea delas mismas: a) el realojo del disco herniado en el espaciointervertebral; b) la desaparición del fragmento(..) (AU)

Introduction. The intervertebral disc disease (IDD)is one of the most common muscle-skeletic disorders,causing both high work disability and elevated healthcarecosts. There are two specific origins of disk diseasethat should be kept in mind: degenerative (DDD) andtraumatic (TDD). Concerning the TDD, nowadays ithas not been determined which patients could graduallyimprove and which ones will requiere surgery.Some studies indicate that about 85% of lumbar and90% cervical acute disc herniation will get better in anaverage of 6 weeks.Materials and methods. We conducted an observational,prospective study, over a group of 858 patients,with the following inclusion criteria: 1. MRI imaging (..) (AU)

Bioética de la actividad pericial médica / Bioethics of Medical Expert-Witness Activity

La Bioética implica hoy en día a toda la actividad médica, habiéndose convertido en un factor crucial a la hora de orientar la acción en muchas situaciones clínicas y evaluar materias médicas tales como publicaciones, artículos y conferencias. Sin embargo, hasta el momento, la Bioética ha prestado poca atención a la actividad pericial médica. Ello a pesar de los importantes problemas que surgen en los peritajes ante los Tribunales. Factores como la cualificación del perito, sesgo, error, confidencialidad, conflictos entre actividad asistencial y pericial, están entre las principales materias potenciales de discusión ética. En España, en particular, hay una falta de regulación de estos aspectos, causando importantes consecuencias sobre todo en casos de litigación por cuestiones de responsabilidad médica. El presente trabajo intenta revisar la situación en España, comparada con las posiciones en el extranjero, y enfatizar la necesidad de una regulación legal, profesional pero sobre todo ética de la actividad pericial médica ante los Tribunales (AU)

Bioethics involves the entire medical activity, becoming, in recent years, a crucial factor in evaluating medical matters such as publications, conferences, articles, and clinical cases analysis. Nevertheless, expert-witness testimony is sheldomly included in Bioethic discussions, despite the important problems that arise from medical testimonies in tribunals. Factors as expert qualification, bias, error, confidentiality, conflict between clinical and expert activities, are among the main potential subjects of Ethical discussion. In Spain in particular, there is a lack of regulation in these matters, determining important consequences mainly in professional responsability judgement cases. The present paper tries to review the Spanish situation, compared to abroad positions, and enphasize the need of a more extensive legal, professional but mainly ethical regulation of medical expert testimony in court in Spain (AU)

[Vertebral reinforcement by means of kyphoplasty in the treatment of non-osteoporotic thoraco-lumbar fractures. Study of 40 cases and review of the literature]. / Papel del refuerzo vertebral mediante cifoplastia en el tratamiento de las fracturas dorsolumbares de índole no osteoporótico. Revisión del tema y análisis de 40 casos.

OBJECT: We present a series of patients with acute thoraco-lumbar fractures in whom we performed balloon vertebroplasty (kyphoplasty), either alone (percutaneous) or combined to posterior transpedicular fusion (open kyphoplasty). We emphasize the possibility of extending the use of kyphoplasty to non-osteoporotic vertebral fractures, and combining this method with traditional posterior fusion procedures. METHODS: Between 2003 and 2005, 138 patients suffering from thoraco-lumbar acute fractures, were treated in our Department. 87 corresponded to one vertebral level fractures; 34 to two levels, and the remaining 17 patients had more than two vertebrae affected. 65 patients (47%) received conservative therapy (rest in bed, physiotherapy, and subsequent progressive mobilization with cast). The remaining ones (73 cases; 43%) were treated invasively, performing balloon vertebroplasty alone (n=25), or kyphoplasty associated to posterior fusion in 15 cases (11%). Different kinds of screw posterior fusions were performed in the remaining patients (n=33; 24%). The latter group was not included in the present study. In the conservatively treated group (CTG), seven patients (11%) had a bad outcome, showing a persistency of hyperintensity in MRI-T2 sequences of the vertebral body, suggesting local edema. Mean hospitalization rate was 29 days in CTG. None of the 40 patients treated with kyphoplasty alone or combined with fusion showed abnormalities in neurological examination. They were classified in two groups: "Group a": Kyphoplasty alone (n=25). Mean of sagittal index in this group was 11 degrees (range: 6 degrees -15 degrees). In 9 patients, vertebral body collapse exceeded 25%. Mean hospitalization rate was 14 days. "Group b": Kyphoplasty and posterior fusion techniques (n=15): Mean sagittal index was 23 degrees (range: 13 degrees - 40 degrees). All the patients presented with a vertebral body collapse superior to 25%. All of them had posterior body wall involvement. This group was treated by surgery (decompression and fusion) and open vertebral body kyphoplasty. Mean hospitalization rate was 35 days. Clinical results of these 40 patients were measured by means of work status, restriction of physical activities and analgesic drug intake. Except for four patients of "Group b", 36 returned to their work. In 11 cases a slight reduction of physical activity was registered. Average "Group a" follow-up was 47 months (range: 10-72 months). A mean kyphosis correction of 5,3 degrees (sagittal index) was reached in this group. Average "Group b" follow-up was 26 months (range: 9-54). Mean kyphosis correction was 10,3 degrees . As for complications, we registered three balloon disruptions and five leakages into the disc. CONCLUSIONS: Kyphoplasty could constitute an alternative and/or complementary treatment of traditional spinal stabilization-fusion procedures in non osteoporotic vertebral fractures. Therefore, it should be offered, when indicated, as a substantial possible part of the treatment, to the patients suffering from vertebral fractures. Additional advantages of combining kyphoplasty and posterior fusion are the possibility of reducing the number of fused levels (shorter instrumentations), and to perform a 360 degree stabilization-remodeling through a single posterior approach.

Papel del refuerzo vertebral mediante cifoplastia en el tratamiento de las fracturasdorsolumbares de índole no osteoporótico. Revisión del tema y análisis de 40 casos / Vertebral reinforcement by means of kyphoplasty in the treatment of non-osteoporotic thoraco-lumbar fractures. Study of 40 cases and review of the literature

Objetivo. Presentamos una serie de pacientes confracturas toraco-lumbares agudas en los que se hapracticado un refuerzo vertebral mediante cifoplastia,bien de forma aislada (cifoplastia percutánea) biencombinada con una fijación transpedicular posterior(cifoplastia abierta). Analizamos la posibilidad deampliar el uso de la cifoplastia a las fracturas vertebralesde causa no osteoporótica, así como combinarla a losmétodos tradicionales de fusión posterior.Método. En nuestro servicio, entre los años 2003 y2005, se trataron 138 pacientes afectos de una fracturaaguda toraco-lumbar. En 87 casos se apreció una fracturaa un nivel; en 34 a 2 niveles y, en los 17 restantesen más de dos. Un tratamiento conservador (reposo encama, fisioterapia y movilización progresiva con corsé),fue realizado en 65 pacientes (47%). Los 73 pacientesrestantes fueron tratados quirúrgicamente, realizándoseun refuerzo mediante cifoplastia percutánea en25 casos (18%), ó una cifoplastia asociada a fusiónvertebral posterior en otros 15 (11%). Diferentes modalidadesde fijaciones atornilladas se realizaron en los 33pacientes restantes (24%). Este último grupo no ha sidoobjeto del presente estudio.La estancia media hospitalaria de los pacientes tratadosconservadoramente fue de 29 días. Siete de ellos(11%) experimentaron una mala evolución, mostrandoen las secuencias T2 del control de resonancia magnéticauna persistencia de hiperintensidad en el somavertebral, sugerente de edema local.Todos los pacientes que fueron tratados mediantecifoplastia aislada (percutánea) o combinada (abierta)mantenían una integridad neurológica; fueron clasificadosen dos grupos:• "Grupo a": Tratados mediante cifoplastia percutánea(n=25). El índice medio sagital de este grupo fue de11° (6°-15°). En 9 pacientes, el acuñamiento vertebralsuperaba el 25%. La estancia media hospitalaria(..) (AU)

Object. We present a series of patients with acutethoraco-lumbar fractures in whom we performedballoon vertebroplasty (kyphoplasty), either alone(percutaneous) or combined to posterior transpedicularfusion (open kyphoplasty). We emphasize the possibilityof extending the use of kyphoplasty to non-osteoporoticvertebral fractures, and combining this method withtraditional posterior fusion procedures.Methods. Between 2003 and 2005, 138 patients sufferingfrom thoraco-lumbar acute fractures, were treatedin our Department. 87 corresponded to one vertebrallevel fractures; 34 to two levels, and the remaining17 patients had more than two vertebrae affected. 65patients (47%) received conservative therapy (restin bed, physiotherapy, and subsequent progressivemobilization with cast). The remaining ones (73 cases;43%) were treated invasively, performing balloon vertebroplastyalone (n=25), or kyphoplasty associated toposterior fusion in 15 cases (11%). Different kinds ofscrew posterior fusions were performed in the remaninigpacients (n=33; 24%). The latter group was notincluded in the present study.In the conservatively treated group (CTG), sevenpatients (11%) had a bad outcome, showing a persistencyof hyperintensity in MRI-T2 sequences of thevertebral body, suggesting local edema. Mean hospitalizationrate was 29 days in CTG.None of the 40 patients treated with kyphoplasty aloneor combined with fusion showed abnormalities inneurological examination. They were classified in twogroups:• "Group a": Kyphoplasty alone (n=25). Mean ofsagital index in this group was 11° (range: 6°-15°).In 9 patients, vertebral body collapse exceeded25%. Mean hospitalization rate was 14 days.• "Group b": Kyphoplasty and posterior fusiontechniques (n=15): Mean sagital index was 23°(range: 13°- 40° ). All the patients presented witha vertebral body collapse superior to 25%. (..) (AU)

[Percutaneous vertebral augmentation: vertebroplasty and kyphoplasty: operative technique]. / Refuerzo vertebral percutáneo: vertebroplastia y cifoplastia: pocedimiento técnico.

The intravertebral injection of acrylic resin cement -usually polymethylmethacrylate (PMMA)- into a fractured vertebral body, constitutes the basis of the so called "vertebral augmentation techniques", "vertebroplasty" and "kyphoplasty", to manage pain and to strengthen and stabilize the compromised vertebra. In some ocassion, prior to the PMMA injection, an inflatable bone tamp was inserted into both pedicles of the fractured vertebra with the aim of restoring vertebral height to correct the kyphosis deformation. This procedure is called kyphoplasty (balloon-assisted vertebroplasty). The indications for vertebroplasty and kyphoplasty are evolving, from stabilization of painful osteoporotic vertebral fractures to vertebral collapse secondary to spinal metastases. In this paper we review the technical basis of both procedures, according to our experience in the treatment of vertebral fractures. Further studies are required to define the role for each technique in the spinal surgery's armamentarium.

Refuerzo vertebral percutáneo: vertebroplastia y cifoplastia. Procedimiento técnico / Percutaneous vertebral augmentation: vertebroplasty and kyphoplasty. Operative technique

Las técnicas de refuerzo vertebral, vertebroplastia y cifoplastia, consisten básicamente en la introducción de un cemento óseo -polimetilmetacrilato (PMMA)- en un cuerpo vertebral fracturado, para aliviar el dolor mediante la estabilización de la fractura vertebral. En ocasiones, previamente a la administración del cemento, a nivel de la vértebra colapsada, se inserta un balón que se insufla con la finalidad de restaurar la altura del cuerpo vertebral y reducir la deformidad cifótica; en estos casos hablamos de cifoplastia o de vertebroplastia mediante balón. Las indicaciones de la vertebroplastia y cifoplastia han ido evolucionando, pasando de la estabilización de una fractura vertebral osteoporótica dolorosa, al refuerzo de un colapso vertebral secundario a metástasis.En el presente trabajo se revisan los principales aspectos técnicos de la vertebroplastia y de la cifoplastia,a la luz de nuestra experiencia en el tratamiento de las fracturas vertebrales. Se necesitan más estudios que permitan definir el papel de cada procedimiento dentro del arsenal terapéuticode la cirugía de columna

The intravertebral injection of acrylic resin cement -usually polymethylmethacrylate (PMMA)- into a fractured vertebral body, constitutes the basis of the so called “vertebral augmentation techniques”, “vertebroplasty”and “kyphoplasty”, to manage pain and to strengthen and stabilize the compromised vertebra. In some ocassion, prior to the PMMA injection, an inflatable bone tamp was inserted into both pedicles of the fractured vertebra with the aim of restoring vertebralheight to correct the kyphosis deformation. This procedure is called kyphoplasty (balloon-assisted vertebroplasty).The indications for vertebroplasty and kyphoplasty are evolving, from stabilization of painful osteoporotic vertebral fractures to vertebral collapse secondary to spinal metastases. In this paper we review the technical basis of both procedures, according to our experience in the treatmentof vertebral fractures. Further studies are requiredto define the role for each techniques in the spinal surgery’s armamentarium

Protocolo de toma de muestras en la autopsia forense mínimamente invasiva / Protocol for postmortem sampling technique in minimally invasive medico-legal autopsy

Partiendo de la especificidad de la autopsia forense, es posible definir un muestreo de referencia a través de técnicas mínimamente invasivas que cumplan de forma simultánea tanto su máxima utilidad eventual en la investigación forense, como un mínimo de dificultad en su obtención y necesidad de medios de conservación y almacenamiento. Se describen los métodos autópsicos mínimamente invasivos para la obtención de distintas muestras orgánicas. Se aborda la conveniencia de formularios normalizados de almacenamiento de muestras con valor forense que aseguren su valor probatorio dentro de un eventual procedimiento judicial. Se aporta un anexo con un formulario simple susceptible de ser tratado a través de un procesador de texto convencional y su inclusión en una eventual base de datos (AU)

Elección del tipo de autopsia forense I. Autopsia mínimamente invasiva (AMI) / Choosing the type of Medicolegal Autopsy in Practice I. Minimally Invasive Necropsy (MIN)

La autopsia en la investigación forense sigue una línea de decisión diferente a la de la autopsia clínica en algunos aspectos que le son específicos, encontrándose regida por una normativa propia que se recoge en nuestra Ley de Enjuiciamiento Criminal.En base a esta especificidad, en Medicina Forense es posible establecer un árbol de decisión autópsica basado en el estudio de las siguientes categorías: grado de contenido forense, nivel de conocimiento previo del sujeto, interés clínico o social de la autopsia, riesgo de aquella para los médicos y técnicos forenses e impacto emocional para la familia, que permitan diferentes opciones respecto al abordaje necrópsico. Estas opciones incluyen, desde la decisión de llevar a cabo una autopsia reglada y completa, hasta la de no practicar aquella (aspecto éste que se encuentra regulado en España por el art. 785,8° f de la Ley E. Cr.), pasando por la aplicación de una autopsia parcial, utilizando técnicas necrópsicas mínimamente invasivas como una alternativa a la aplicación de otras técnicas destructivas cadavéricas (AU)

[Suicides in Zaragoza (1988-1991). Epidemiology and outline of suicides]. / El suicidio consumado en Zaragoza (1988-1991). Aspectos epidemiológicos y perfiles suicidas.

We review 312 suicide cases autopsied in the Forensic Institute of Zaragoza (Spain) during 1988-1991. Suicide rate was notabily higher than official statistics (15.01/100,000 habs. in Zaragoza vs. 4.3/100,000 Habs. from the National Statistic Institute). Reasons for this discrepancy are discussed emphasizing the role of suicide underrecording in the official statistics. Forensic Institute data are considered as a precise source for suicide epidemiologic study in Spain. Profiles for each different suicide type are described according to the results of our study concerning to age, sex, seasonal and month distribution, and other epidemiological data. A National Forensic Suicide Data Bank is proposed to approach properly the problematic of suicide epidemiology, based in the desirable informatic support to the Forensic Institutes. A modification in the Death Certificates is essential to include medico-legal etiology (suicide, accidental or criminal) which is essential in Forensic Reports but is not included, at the present, in the usual Death Certificates.

Effects of CDP-choline on the recovery of patients with head injury.

A single blind randomized study has been conducted in 216 patients with severe or moderate head injury, with the aim of comparing the evolution of those that received only conventional treatment with the evolution of those treated with CDP-choline. Our results indicate that CDP-choline improves the global outcome of patients. We have found a trend towards a greater improvement in motor, cognitive and psychic alterations in the patients treated with CDP-choline, as well as a shortening of the stay in the hospital ward in the patients receiving this drug that initially presented with severe head injuries.