Técnica de "slalom" quirúrgico en estenosis de canal lumbar multinivel. Serie de casos tratados de manera simultánea con descompresión endoscópica y tubular con asistencia microscópica bilateral / Slalom Technique as a treatment in multilevel lumbar spinal stenosis. Series of cases treated simultaneously with endoscopic and tubular decompression with microscopic assistance

Introducción: La laminectomía unilateral para descompresión bilateral por abordaje único ha tomado relevancia en pacientes con estenosis multinivel. Cuando se realiza en más de un nivel por un abordaje único, de manera alterna y de forma cruzada, al abordaje anterior es conocida como técnica de "slalom". Elobjetivode este artículo es presentar una serie de casos tratados con la técnica de "slalom" con asistencia endoscópica y microscópica bilateral, simultánea, en pacientes con estenosis de canal lumbar multinivel.materiales y métodos: Análisis retrospectivo de pacientes tratados de forma simultánea, entre enero de 2017 y enero de 2018, todos operados por el mismo equipo quirúrgico con separadores tubulares, y asistencia endoscópica y micros-cópica simultánea.Resultados: Se incluyó a 4 hombres, con una edad promedio de 73.5 años y patología lumbar multinivel. Se descomprimieron 10 segmentos (2,5 media de niveles por paciente), con un tiempo quirúrgico promedio de 107 minutos. No hubo complicaciones asociadas y los pacientes recibieron el alta hospitalaria el día de la cirugía.Conclusiones:La técnica de "slalom" mínimamente invasiva resulta ser un procedimiento muy eficaz para resolver síntomas de estenosis multinivel asociada a una técnica combinada bilateral con dos equipos quirúrgicos para el tratamiento de este tipo de pacientes. Nivel de Evidencia: IV

Introduction: Unilateral laminectomy for bilateral decompression (ULBD) by single approach has become relevant in patients with multilevel stenosis, when it is performed at more than one level with single approach, alternately and crosswise to the previous approach is known as a slalom technique.The objective of the following work is to present a series of cases treated with the slalom technique with bilateral endoscopic and microscopic assistance, simultaneous in patients with multilevel lumbar canal stenosis. Materials and Methods: Retrospective analysis of patients treated simultaneously between the months of January 2017 to January 2018, all operated by the same surgical team with tubular separators and simultaneous endoscopic and microscopic assistance. Results: Four patients, all male, with an average age of 73.5 years with multilevel lumbar pathology, were included. In total 10 segments were decompressed (2.5 average level for patients), with an average surgery of 107 minutes. No associated complications, with hospital discharge within the day of surgery. Conclusions: The minimally invasive Slalom technique turns out to be a very effective procedure to resolve symptoms of multilevel stenosis associated with a bilateral combined technique with two surgical teams, resulting in a viable option for the treatment of this type of patient. Level of Evidence: IV

Descompresión lumbar en pacientes con enfermedad de Parkinson: serie de casos tratados con cirugía mínimamente invasiva / Lumbar decompression in patients with Parkinson's disease: series of cases treated with minimally invasive surgery

Introducción: La enfermedad de Parkinson afecta principalmente a personas >65 años. El cuadro degenerativo lumbar en el contexto de un canal estrecho sumado a la alteración neuromuscular y la mala calidad ósea, favorece al desequilibrio sagital y coronal. Los pacientes que necesitan cirugía tienen altas tasas de revisión y reoperación con técnicas instrumentadas y no ins-trumentadas. El objetivo de este estudio fue evaluar la técnica quirúrgica de descompresión mínimamente invasiva en pacientes con enfermedad de Parkinson y dolor radicular o claudicación neurogénica en los miembros inferiores. materiales y métodos: Se evaluó a pacientes con diagnóstico de canal lumbar estrecho y enfermedad de Parkinson tratados quirúrgicamente. El procedimiento se indicó por síntomas de canal estrecho o estenosis foraminal de causa degenerativa. Todos fueron tratados con una cirugía descompresiva a través de una hemilaminectomía mínimamente invasiva mediante retracción tubular y asistencia con microscopia. Resultados: De enero de 2015 a diciembre de 2017, se trató a 6 pacientes con enfermedad de Parkinson y canal lumbar estrecho. Se descomprimieron 12 niveles en total, todos estuvieron internados <24 h. No se necesitaron transfusiones, no hubo complicaciones asociadas, el tiempo promedio de cirugía fue de 120 minutos. El seguimiento mínimo fue de 12 meses, los síntomas no reaparecieron. Conclusiones: La elevada tasa de complicaciones en pacientes operados con enfermedad de Parkinson y la disminución de las complicaciones en este estudio sugieren que la cirugía mínimamente invasiva de columna lumbar debería ser una alternativa quirúrgica en estos pacientes. Nivel de Evidencia: IV

Introduction: Parkinson's disease mainly affects patients aged 65 and older. The degenerative condition at the lumbar spine in the context of a narrow canal added to the neuromuscular disorder and poor bone quality favors sagittal and coronal imbalance. Patients who need surgery have high rates of revision and reoperation with instrumented and non-instrumented techniques. The objective of this study was to evaluate the minimally invasive surgical decompression technique in patients with Parkinson's disease and radicular pain or neurogenic claudication in the lower limbs. Materials and Methods: Surgically treated patients with a diagnosis of lumbar spinal stenosis and Parkinson's disease were evaluated. The indication for the procedure was due to symptoms of the lumbar or foraminal stenosis of degenerative cause. All the patients were treated with decompressive surgery through a minimally invasive hemilaminectomy using tubular retraction and assistance with microscopy. Results: From January 2015 to December 2017, 6 patients with Parkinson's disease and lumbar spinal stenosis were treated. A total of 12 segments were decompressed, all patients were hospitalized for less than 24 hours. They did not require a transfusion nor suffered associated complications, with an average surgery time of 120 minutes. All with a minimum follow-up of 12 months and no relapse of the symptoms. Conclusion: The high rate of surgical complications in patients with Parkinson's disease, in contrast to the low rate of complications in the present study, suggests that minimally invasive surgery of the lumbar spine should be a surgical alternative in these patients. Level of Evidence: IV

Hemorragia subaracnoidea posterior a descompresión Lumbar mínimamente invasiva. Presentación de un caso y revisión de la literatura / Subarachnoid hemorrhage after minimally invasive lumbar decompression. Case report and literature review

Introducción: Las lesiones durales son complicaciones frecuentes en la cirugía de columna. La fuga de liquidocefalorraquideo (LCR) puede originar hemorragia en todos los compartimientos del cerebro. La mayoría ocurre en venas ubicadas en región cerebelosa.Material y método: Se presenta un caso de hemorragia subaracnoidea posterior a una descompresión lumbar mínimamente invasiva asociada a desgarro dural. Resultados: Evoluciona en el postoperatorio con síntomas neurológicos de cefaleas y trastornos del sensorio por lo que se decide evaluarlo con estudios por imágenes vasculares cerebrales identificándose sangrado subaracnoideo.Discusión: El sitio más frecuente de hemorragia intracraneal posterior a una cirugía de columna es el cerebelo. El mecanismo de acción de este tipo de sangrados es desconocido y controversial, hay algunos reportes que sugieren que se trataría de un sangrado venoso. El síntoma más característico de este síndrome es la cefalea. Aunque se desconoce la etiología exacta, se postula que la pérdida de volumen de LCR causa una caída en la presión intracraneal, lo que lleva a un agrandamiento de los senos venosos durales que predisponen al paciente a un hematoma subdural espontáneoConclusión: La fuga de LCR, las alteraciones asociadas al edema cerebral en la hipotensión cerebral podría ser llave del mecanismo que desencadena una hemorragia subaracnoidea.

compartments of the brain. Most occur in veins located in the cerebellar region.Material and method: A case of subarachnoid hemorrhage after a minimally invasive lumbar decompression associated with dural tear is presented.Results: It evolves in the postoperative period with neurological symptoms of headaches and sensory disorders, so it is decided to evaluate it with studies by cerebral vascular images identifying subarachnoid bleeding.Discussion: The most frequent site of intracranial hemorrhage after spinal surgery is the cerebellum. The mechanism of action of this type of bleeding is unknown and controversial, there are some reports that suggest that it would be a venous bleeding. The most characteristic symptom of this syndrome is headache. Although the exact etiology is unknown, it is postulated that the loss of CSF volume causes a drop in intracranial pressure, which leads to an enlargement of the dural venous sinuses that predispose the patient to a spontaneous subdural hematomaConclusion: CSF leakage, alterations associated with cerebral edema in cerebral hypotension could be key to the mechanism that triggers a subarachnoid hemorrhage.

Tasa de infección en 212 pacientes consecutivos tratados mediante descompresión tubular mininvasiva de la columna lumbar / Infection rate in 212 consecutive patients treated by minimally invasive lumbar tubular decompression

Introducción: Las infecciones del sitio quirúrgico pueden requerir tratamientos prolongados con antibióticos, una estancia hospitalaria más prolongada y operaciones repetidas. Las incisiones pequeñas y la posibilidad de evitar la disección subperióstica en la cirugía mininvasiva pueden reducir, al mínimo, el riesgo de infecciones posoperatorias. Sin embargo, los estudios publicados sobre infecciones después de procedimientos mininvasivos son escasos. El objetivo de este estudio fue evaluar retrospectivamente una serie de pacientes operados, de manera consecutiva, con una técnica mininvasiva y la incidencia de infección posoperatoria. Materiales y Métodos: Se incluyó a los pacientes sometidos a cirugía lumbar posterior con retractores tubulares y microscopio, en nuestro Servicio, entre enero de 2015 y enero de 2018. Los procedimientos realizados fueron discectomías tubulares, descompresiones para la estenosis de canal y resecciones de quistes sinoviales. La incidencia de infección del sitio quirúrgico se calculó y comparó con el rango de tasas de infección del sitio quirúrgico publicado. Resultados: Se realizaron cirugías no instrumentadas (discectomías, descompresiones) en 212 pacientes. La media de la edad era de 62.4 años y la relación hombre:mujer, de 1,27:1. Solo un paciente sufrió una infección del sitio quirúrgico, diagnosticada el día 9 poscirugía, que fue tratada mediante lavado y limpieza de la herida. Conclusión: La tasa de infección fue del 0,47%. La cirugía mininvasiva puede disminuir notablemente la tasa de infección del sitio quirúrgico y puede ser una herramienta eficaz para reducir, al mínimo, los costos hospitalarios. Nivel de Evidencia: IV

Introduction: Surgical site infections (SSI) can lead to prolonged antibiotic treatments, increased hospital stays, and repeated operations. Small incisions and the possibility of avoiding subperiosteal dissection in minimally invasive surgery can minimize the risk of postoperative infections. However, there is a shortage of literature on infections after mini-invasive procedures. Objective: To evaluate retrospectively a series of patients consecutively operated on with minimally invasive technique and the incidence of postoperative infection. Materials and Methods: All patients undergoing posterior lumbar surgery with tubular retractors and microscope in our department from January 2015 to January 2018 were included. The procedures performed included tubular discectomies, lumbar stenosis decompressions, and synovial cyst resections. The incidence of postoperative SSIs was calculated and compared with the literature range for SSI rates. Results: A total of 212 patients underwent non-instrumented surgeries (discectomies, decompressions). The mean age was 62.4 years with a male:female ratio of 1.27:1. Only one patient had SSI, which was diagnosed on day 9 and treated by reoperation, surgical toilet of the wound, and antibiotic therapy. Conclusion: The infection rate was 0.47%. Minimally invasive surgery can significantly reduce the SSI rate and can be an effective tool in minimizing hospital costs. Level of Evidence: IV

Diseminación meníngea atípica en meningiomas anaplásicos / Atypical meningeal dissemination in anaplastic meningioma

Objective. To present two cases of aplastic meningiomas refractory to surgical and radiotherapeutic tretement, with torpide evolution and clinical deterioration. Descpription. Case 1. 61, female. Left extraaxial temporo-occipital formation enhancing with gadolinium, tentorial implantation. Simpson II resection. PA: atypical metaplasic meningioma, EMA, VIM and PGR positive, Ki-67; 13%. Without parenchimal infiltration. Local 3D radiotherapy. Visual deterioration, walk disturbance. Relapse with compromise of rectus and transverse sinuses. Simpson II resection. In 12 months, progression of the disease along the convexity. Paliative treatement with hidroxiurea. Case 2: 69, female. Rt. Occipito-parietal meningioma 1995 subtotal resection in other center. Radiotherapy of remnant tumor. 2001 reoperated. Simpson II resection. PA: meningtheliomatous meningioma Ki-67: 5%. Dec. 2006 total resection of relapsing anaplastic meningioma. June 2007, extensive FPT dural dissemination. Medical treatement. Discussion. Anaplasic meningiomas present an exponential growing pattern that differenciates them from better grade lesions, possibly mediated by genetic factors (10q, 14q, 9p deletions). However, the only independent predictor seems to be the cellular kinetic index Ki-67. 5yr. 95% and 10yr. 79% survival rates are reported for anaplastic meningiomas with shorter relapse delays. Conclusion. High aggressive recurrent dissemination of anaplastic meningiomas is uncommon. Simpson´s I or II total resection is the initial tratement complemented as second line treatement by radiotherapy. Chemotherapy is of scant utility.

Quistes dermoides y epidermoides intracraneales / Dermoid and epidermoid itracranial cysts

Objective. To present the clinical and radiologic features and surgical results in the management of dermal and epidermal cysts treated in our institution between 1997 and 2006. Material a method. Age, sex, way of presentation, location, radiologic features, surgical technique and compications of 15 epidermal and 1 dermal tumors diagnosed between may 1997 and October 2006, were retrospectively assessed. Results. Mean age: 43 yrs. Most frequent clinical manifestation: headache. Most tumors were at CPA. All resections were done with microsurgical technique. There were 3 cases of chemical meningitis that resolve without sequel. Discussion. Dermal and epidermal cysts are originated by inclusion of ectodermic material at the moment of occlusion of the neural tube. They represent the 0.3-1.5 of intracranial tumors beeng dermal 5-9 times less frequent. The most frequent location of epidermal cysts is at the CPA while dermal are more frequent in the midline. Clinical fatures depend on location. MRI is the gold standard for diagnosis, epecially the DWI sequence. CT is important for the detection of bone invasion. Treatement is so extensive as possible surgical resection, difficult, sometimes because of strong adhesions to eloquent structures. Conclusion. Dermal and epidermal cysts are high fat content lesions, that produce edherence to neural structures. Surgical excision is the election tratement.

Angiomas cavernosos de tronco cerebral / Brain stem cavernous angiomas

Introduction: The incidence of intracranial aneurysm ranges from 0,5 to 0,6 por ciento and the diagnosis of incidental aneurysms has increased due to the development of non invasive neuroimaging techniques. Minimally invasive treatment modality in incidental cases. Methods: A series of 119 incidental aneurysms in 77 patients were treated by embolization with GDC coils. Results: One hundred and seven aneurysms were succesfully embolized with total or almost total occlusion rate of 86,8 por ciento. Thirteen procedural complications occurred causing definite morbidity in 5 patients and one death. None of the embolized aneurysms bled during the follow up. Conclusion: Embolization of incidental aneurysms is associated to a low morbidity and mortality rates

Neuronavegacion en cirugias intracraneales / Neuronavigation in intracranial surgeries

Objectives: to present our experience with Neuronavigation system in intracranial surgery. Material and Methods: The use of neuronavigation system was evaluated in 104 consecutive patients operated on during the period September 1999 - April 2003 (Range of age: 5 months - 75 years). Surgical procedures included the remotion of brain tumor, arteriovenous malformation, cavernous angiomas and epilepsy surgeries. The neuronavigation system is the Elekta Insight View Scope (Elekta Instrumental). Results: The additional time required for preoperative organization of the Neuronavigation system was 30 minutes. There were no differences during the registration process related to the surgical position (prone, supine and park-bench). The reference system planning of the surgical approach, to guide endoscopical procedures, perform smaller craniotomies, localize deep-seated subcortical lesions, identify the boundaries of low grade tumors and evaluate the extent of resection in epilepsy surgeries. Conclusion: Neuronavigation system improves the surgical approach of intracranial surgeries allowing to short the operating time, define the less invasive trajector, and identify the margins of low grade lesions

Angiomas cavernosos de tronco cerebral / Brain stem cavernous angiomas

Introduction: The incidence of intracranial aneurysm ranges from 0,5 to 0,6 por ciento and the diagnosis of incidental aneurysms has increased due to the development of non invasive neuroimaging techniques. Minimally invasive treatment modality in incidental cases. Methods: A series of 119 incidental aneurysms in 77 patients were treated by embolization with GDC coils. Results: One hundred and seven aneurysms were succesfully embolized with total or almost total occlusion rate of 86,8 por ciento. Thirteen procedural complications occurred causing definite morbidity in 5 patients and one death. None of the embolized aneurysms bled during the follow up. Conclusion: Embolization of incidental aneurysms is associated to a low morbidity and mortality rates (AU)

Neuronavegacion en cirugias intracraneales / Neuronavigation in intracranial surgeries

Objectives: to present our experience with Neuronavigation system in intracranial surgery. Material and Methods: The use of neuronavigation system was evaluated in 104 consecutive patients operated on during the period September 1999 - April 2003 (Range of age: 5 months - 75 years). Surgical procedures included the remotion of brain tumor, arteriovenous malformation, cavernous angiomas and epilepsy surgeries. The neuronavigation system is the Elekta Insight View Scope (Elekta Instrumental). Results: The additional time required for preoperative organization of the Neuronavigation system was 30 minutes. There were no differences during the registration process related to the surgical position (prone, supine and park-bench). The reference system planning of the surgical approach, to guide endoscopical procedures, perform smaller craniotomies, localize deep-seated subcortical lesions, identify the boundaries of low grade tumors and evaluate the extent of resection in epilepsy surgeries. Conclusion: Neuronavigation system improves the surgical approach of intracranial surgeries allowing to short the operating time, define the less invasive trajector, and identify the margins of low grade lesions (AU)