Archivos de la categoría Articulos

New Lumbar Disc Nomenclature

Free Article

This article comprises a review of the literature pertaining to the normal and pathological lumbar disc and the compilation of a standardized nomenclature.

Objective. To provide a resource that promotes a clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers.

Summary of Background Data. The article “Nomenclature and Classification of Lumbar Disc Pathology. Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology and American Society of Neuroradiology” was published in 2001 in Spine © Lippincott, Williams and Wilkins1 and formally endorsed by the 3 boards. Its purpose, which it served for well over a decade, was to promote greater clarity and consistency of usage of spine terminology. Since 2001, there has been sufficient evolution in our understanding of the lumbar disc to suggest the need for revision and updating. The document represents the consensus recommendations of the current combined task forces and reflects changes consistent with current concepts in radiological and clinical care.

Methods. A PubMed search was performed for literature pertaining to the lumbar disc. The task force members individually and collectively reviewed the literature and revised the 2001 document. It was then reviewed by the governing boards of the American Society of Spine Radiology, the American Society of Neuroradiology, and the North American Spine Society. After further revision based on their feedback, the paper was approved for publication.

Results. The article provides a discussion of the recommended diagnostic categories and a glossary of terms pertaining to the lumbar disc, a detailed discussion of the terms and their recommended usage, as well as updated illustrations and literature references.

Conclusion. We have revised and updated a document that, since 2001, has provided a widely accepted nomenclature that helps maintain consistency and accuracy in the description of the properties of the normal and abnormal lumbar discs and that serves as a system for classification and reporting built upon that nomenclature.

Control cerebral a distancia

Investigadores estadounidenses han demostrado cómo se puede controlar el cerebro de otra persona a distancia. La conexión se realizó a través de internet.

El departamento de neurociencia de la Universidad de Washington, ideó un juego en el que había que defender la ciudad de los cohetes que le lanzaban unos piratas. Dos voluntarios contaban con un cañón para abatir los misiles. Mientras uno de los defensores podía ver el juego en la pantalla, el disparador del cañón se encontraba bajo la mano de otro defensor, situado en otro edificio del campus y sin poder ver la escena. Así que el primero debía concentrarse y pensar con todas sus fuerzas en disparar. En menos de un segundo, el dedo de su compañero debía salvar a la ciudad.

Se trata de uno de los primeros casos de comunicación cerebral entre humanos. Los investigadores diseñaron un interfaz cerebro a cerebro capaz de interpretar las órdenes de un emisor y que un receptor situado a 1.500 metros las ejecutara. El primero llevaba en su cabeza un sistema de electroencefalografía  que registraba las señales eléctricas de su cerebro. El segundo tenía un aparato de estimulación magnética transcraneal (TMS) sobre la zona cerebral que controla las señales motoras.

Entre medias, un software descodificaba las señales eléctricas del “quiero disparar” del emisor, las enviaba por internet y las volvía a codificar en pulsos magnéticos para que el cerebro del receptor diera la orden de pulsar el disparador. Toda la comunicación no superó los 650 milisegundos de media.

Además de la velocidad y la pericia, contaban los reflejos. Ocasionalmente, en el cielo aparecía un avión aliado con suministros al que no había que derribar. El sistema fue ensayado durante tres meses por tres parejas diferentes de emisor-receptor, alcanzando una eficacia de entre el 25% y el 83%.

“Estos números no reflejan la eficacia de la tecnología, que debe ser evaluada por separado de la exactitud de la que sean capaces los sujetos”, recalca el coautor del estudio, Andrea Stocco. “Para que funcione correctamente, tanto el emisor como el receptor deben hacer su trabajo: el remitente debe identificar los cohetes y la mano del receptor debe golpear el teclado. A veces, al remitente se le escapa un cohete y, en ocasiones, la mano del receptor se movía de manera errónea. Estos fallos ocurren cuando se juega a cualquier juego y reflejan la exactitud de los sujetos”, añade. Y lo compara con elTetris. “Si uno no pasa de nivel es problema del jugador, no del juego”, recuerda.

Esta serie de experimentos, cuyos resultados han sido publicados en la revista científica PLoS ONE, son continuación de una primera fase que tanto Stocco como su colega Rajesh Rao realizaron el año pasado.

En un artículo de la revista Scientific American, Stocco y su colega Rao dibujan las posibilidades de una ciencia cada vez menos ficción. Una persona paralizada, por ejemplo, podría compartir sus pensamientos y emociones con los que le rodean. Quizá, en el futuro, un virtuoso del violín pueda comunicar a su pupilo su destreza mentalmente. O, por qué no, un profesor podría colarse en el cerebro de sus alumnos para que entiendan esa ecuación diferencial tan difícil de explicar.

Journal of Neurosurgery: Spine November 2014

FEATURED ARTICLE

Adverse events in emergency oncological spine surgery: a prospective analysis

Cover ImageEmergency oncological spine surgery are generally palliative to reduce pain and improve patients neurology and health-related quality of life. In individuals with limited life expectancy, adverse events (AEs) can have catastrophic implications; therefore, an accurate AE incidence must be considered in the surgical decision-making process.

Dea et al., carried out a Prospective cohort study in a quaternary care referral center that included consecutive patients admitted between January 1, 2009, and December 31, 2012. Inclusion criteria were all patients undergoing emergency surgery for metastatic spine disease. AE data were reported and collected with the Spine AdVerse Events Severity System, version 2 [SAVES V2] forms) at weekly dedicated morbidity and mortality rounds attended by attending surgeons, residents, fellows, and nursing staff.

A total of 101 patients (50 males, 51 females) met the inclusion criteria and had complete data. Seventysix patients (76.2%) had at least 1 AE, and 11 patients (10.9%) died during their admission. Intraoperative surgical AEs were observed in 32% of patients (9.9% incidental durotomy, 16.8% blood loss > 2 L). Transient neurological deterioration occurred in 6 patients (5.9%). Infectious complications in this patient population were significant (surgical site 6%, other 50.5%). Delirium complicated the postoperative period in 20.8% of cases.

When evaluated in a rigorous prospective manner, metastatic spine surgery is associated with a higher morbidity rate than previously reported. This AE incidence must be considered by the patient, oncologist, and surgeon to determine appropriate management and preventative strategies to reduce AEs in this fragile patient population.

Dea N, Versteeg A, Fisher C, Kelly A, Hartig D, Boyd M, Paquette S, Kwon BK, Dvorak M, Street J. Adverse events in emergency oncological spine surgery: a prospective analysis. J Neurosurg Spine. 2014 Aug 22:1-6. [Epub ahead of print] PubMed PMID: 25147976.

Neurosurgery – Noviembre 2014

To date, there is no standard treatment for recurrent glioblastoma.

Optimal management of recurrent high grade glioma continues to be a controversial topic. Current indications for reoperation include new focal neurological deficits, tumor mass effect resulting in signs and symptoms of increased intracranial pressure, increased seizure frequency, and radiographic evidence of tumor progression with or without accompanying changes in clinical status. Existing evidence indicates that age should not be an absolute contraindication to reoperation. A time interval of at least 6 months between operations and favorable performance status (KPS score >70) are predictors of improved survival after reoperation. Extent of resection (EOR) at reoperation appears to be an important determinant of improved survival, even in patients with subtotal resection (STR) at the time of initial operation. Although fraught with patient selection bias, mounting evidence suggests a survival benefit in patients receiving gross total resection (GTR) at recurrence compared with a lesser degree of resection. Additional reoperations beyond the first reoperation may add to overall survival and should be considered in patients with a favorable KPS score at the time of recurrence, regardless of symptomatology

Hervey-Jumper SL, Berger MS. Reoperation for recurrent high-grade glioma: a current perspective of the literature. Neurosurgery. 2014 Nov;75(5):491-9. doi: 10.1227/NEU.0000000000000486. PubMed PMID: 24991712.


Hospital case volume may be associated with improved outcomes after subarachnoid hemorrhage (SAH)

Using the Get With The Guidelines Stroke registry, Prabhakaran et al., analyzed patients with a discharge diagnosis of SAH between April 2003 and March 2012 and assessed the association of annual SAH case volume with in-hospital mortality by using multivariable logistic regressionadjusting for relevant patient, hospital, and geographic characteristics.

Among 31,973 patients with SAH from 685 hospitals, the median annual case volume per hospital was 8.5 (25th-75th percentile, 6.7-12.9) patients. Mean in-hospital mortality was 25.7%, but was lower with increasing annual SAH volume: 29.5% in quartile 1 (range, 4-6.6), 27.0% in quartile 2 (range, 6.7-8.5), 24.1% in quartile 3 (range, 8.5-12.7), and 22.1% in quartile 4 (range, 12.9-94.5). Adjusting for patient and hospital characteristics, hospital SAH volume was independently associated with in-hospital mortality (adjusted odds ratio 0.79 for quartile 4 vs 1, 95% confidence interval, 0.67-0.92). The quartile of SAH volume also was associated with length of stay but not with discharge home or independent ambulatory status.

In a large nationwide registry, they observed that patients treated at hospitals with higher volumes of SAH patients have lower in-hospital mortality, independent of patient and hospital characteristics suggesting that experienced centers may provide more optimized care for SAH patients. 5)

Prabhakaran S, Fonarow GC, Smith EE, Liang L, Xian Y, Neely M, Peterson ED, Schwamm LH. Hospital case volume is associated with mortality in patients hospitalized with subarachnoid hemorrhage. Neurosurgery. 2014 Nov;75(5):500-8.
doi: 10.1227/NEU.0000000000000475. PubMed PMID: 24979097.


https://www.cns.org/education/browse-type/sans

Self-Assessment in Neurological Surgery (SANS) is a completely on-line educational tool. The teaching materials used in SANS consist of text, pictures, video clips and links to relevant Internet sites. Physicians participate in the learning process by answering questions in specific topic areas, reviewing their answers, and reading question critiques. The material is designed to be a self-instructional and self-assessment tool.

To apply for Continuing medical education (CME), users will need to complete SANS and fill out the CME survey. Partial CME credit will not be made available for incomplete participation in SANS.

 Asthagiri A. Instructions for Obtaining SANS Neurosurgery Continuing Medical Education (CME) Credit. Neurosurgery. 2014 Nov;75(5):N9. doi: 10.1227/01.neu.0000455970.98723.b9. PubMed PMID: 25328984.


Alperin N, Loftus JR, Oliu CJ, Bagci AM, Lee SH, Ertl-Wagner B, Green B,
Sekula R. Magnetic resonance imaging measures of posterior cranial fossa
morphology and cerebrospinal fluid physiology in Chiari malformation type I.
Neurosurgery. 2014 Nov;75(5):515-22. doi: 10.1227/NEU.0000000000000507. PubMed
PMID: 25328981.

Kuhn EN, Taksler GB, Dayton O, Loganathan A, Bourland D, Tatter SB, Laxton AW,
Chan MD. Is there a tumor volume threshold for postradiosurgical symptoms? A
single-institution analysis. Neurosurgery. 2014 Nov;75(5):536-45. doi:
10.1227/NEU.0000000000000519. PubMed PMID: 25171304.

McClendon J Jr. Response to journal club: the impact of body mass index on
hospital stay and complications after spinal fusion. Neurosurgery. 2014
Nov;75(5):602. doi: 10.1227/NEU.0000000000000520. PubMed PMID: 25121795.

Payne R, Bogason E, Anderson B, Brandmeir N, Church E, Cooke J, Davies G,
Hussain N, Patel A, Rohatgi P, Sieg E, Zalatimo O, Ziu E, Davanzo J. Journal
club: the impact of body mass index on hospital stay and complications after
spinal fusion. Neurosurgery. 2014 Nov;75(5):599-601. doi:
10.1227/NEU.0000000000000521. PubMed PMID: 25121794.

Binning MJ, Adel JG, Maxwell CR, Liebman K, Hakma Z, Diaz C, Silva R,
Veznedaroglu E. Early Postmarket Experience After US Food and Drug Administration
Approval With the Trevo Device for Thrombectomy for Acute Ischemic Stroke.
Neurosurgery. 2014 Nov;75(5):584-9. doi: 10.1227/NEU.0000000000000523. PubMed
PMID: 25121793.

Koutsarnakis C, Liakos F, Stranjalis G. Letter: the “over the wire” technique
for ventricular catheter revision and a proposed access kit for this purpose.
Neurosurgery. 2014 Nov;75(5):E605-6. doi: 10.1227/NEU.0000000000000516. PubMed
PMID: 25072114.

Gonzalez NR, Connolly M, Dusick JR, Bhakta H, Vespa P. Phase I clinical trial
for the feasibility and safety of remote ischemic conditioning for aneurysmal
subarachnoid hemorrhage. Neurosurgery. 2014 Nov;75(5):590-8. doi:
10.1227/NEU.0000000000000514. PubMed PMID: 25072112; PubMed Central PMCID:
PMC4205274.

Ellis JA, McDowell MM, Mayer SA, Lavine SD, Meyers PM, Connolly ES Jr. The
role of antiplatelet medications in angiogram-negative subarachnoid hemorrhage.
Neurosurgery. 2014 Nov;75(5):530-5. doi: 10.1227/NEU.0000000000000490. PubMed
PMID: 25072111.

Freidberg SR, Cosgrove R, David CA, Tarlov EC. Correspondence: obituary,
charles a. Fager, MD. Neurosurgery. 2014 Nov;75(5):603-4. doi:
10.1227/NEU.0000000000000511. PubMed PMID: 25050584.

Tarantino R, Donnarumma P, Nigro L, Rullo M, Santoro A, Delfini R. Surgery of
intradural extramedullary tumors: retrospective analysis of 107 cases.
Neurosurgery. 2014 Nov;75(5):509-14. doi: 10.1227/NEU.0000000000000513. PubMed
PMID: 25050582.

Phillips JL, Chalouhi N, Jabbour P, Starke RM, Bovenzi CD, Rosenwasser RH,
Wilent WB, Romo VM, Tjoumakaris SI. Somatosensory evoked potential changes in
neuroendovascular procedures: incidence and association with clinical outcome in
873 patients. Neurosurgery. 2014 Nov;75(5):560-7. doi:
10.1227/NEU.0000000000000510. PubMed PMID: 25050580.

Nelson KS, Brearley AM, Haines SJ. Evidence-based assessment of
well-established interventions: the parachute and the epidural hematoma.
Neurosurgery. 2014 Nov;75(5):552-9. doi: 10.1227/NEU.0000000000000504. PubMed
PMID: 25050576.

Paúl L, Casasco A, Kusak ME, Martínez N, Rey G, Martínez R. Results for a
series of 697 arteriovenous malformations treated by gamma knife: influence of
angiographic features on the obliteration rate. Neurosurgery. 2014
Nov;75(5):568-83. doi: 10.1227/NEU.0000000000000506. PubMed PMID: 25050575.

Iwata T, Mori T, Miyazaki Y, Tanno Y, Kasakura S, Aoyagi Y. Global oxygen
extraction fraction by blood sampling to anticipate cerebral hyperperfusion
phenomenon after carotid artery stenting. Neurosurgery. 2014 Nov;75(5):546-51.
doi: 10.1227/NEU.0000000000000485. PubMed PMID: 24991711.

 

Rosenthal G, Ng I, Moscovici S, Lee KK, Lay T, Martin C, Manley GT.
Polyetheretherketone implants for the repair of large cranial defects: a 3-center
experience. Neurosurgery. 2014 Nov;75(5):523-9. doi:
10.1227/NEU.0000000000000477. PubMed PMID: 24979096.

UpToDate:Outcome in idiopathic normal pressure hydrocephalus

To date, there is no standard outcome assessment scale for shunt treatment.

In designing such scale, the relative weight of each of the common presentations of the condition from the patient’s or his/her carer’s point of view should be taken into consideration.

Clinical improvement of patients with iNPH can be sustained for 5-7 years in some patients, even if shunt revision surgery is needed multiple times. With earlier diagnosis and treatment and the increasing lifespan of the ageing population, the need for long-term follow-up after shunt surgery may be greater than it was in the past. Monitoring, identification and treatment of shunt obstruction is a key management principle 1).

Gait and Incontinence

Postoperative improvement of Gait and Urinary incontinence is obtained at an early stage 2) 3). In contrast, Dementia tends to improve gradually from after the third postoperative month. The family satisfaction increases as the symptom of Dementia improve. The satisfaction of the medical personnel tends to remain high after the first postoperative month 4).

Independent predictors

Independent predictors of improvement are the presence of gait impairment as the dominant symptom and shorter duration of symptoms 5).

Caregiver Burden

Shunt operations reduced the caregiver burden of iNPH patients 6)7).

Thirty-seven patients (median age 70 years, range 50-89 years) with Idiopathic normal pressure hydrocephalus were evaluated before and 6 months after surgery. Symptoms and signs were assessed by the iNPH scale, activities of daily living (ADL) with the Functional Independence Measure (FIM) and Assessment of Motor and Process Skills (AMPS), autonomy and participation with Impact on Participation and Autonomy (IPA), and caregiver burden with the Caregiver Burden Scale (CBS). HRQOL was evaluated with the EQ-5D (EuroQol Group-5 Dimension health survey).

Twenty-four patients (65%) improved clinically (iNPH scale score) and 31 (86%) improved their HRQOL after surgery, almost to the same level as found in the normal population. The patients became more independent in physical and cognition, and participation and autonomy improved. The caregiver burden was decreased among caregivers to male patients but remained unchanged on the overall group level. After shunt surgery, patients with iNPH showed improvement in most aspects of social life, they became more independent, and their quality of life returned to nearly normal 8).

1) Pujari S, Kharkar S, Metellus P, Shuck J, Williams MA, Rigamonti D. Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008 Nov;79(11):1282-6. doi: 10.1136/jnnp.2007.123620. Epub 2008 Mar 20. PubMed PMID: 18356257.
2) Savolainen S, Hurskainen H, Paljärvi L, Alafuzoff I, Vapalahti M: Five-year outcome of normal pressure hydrocephalus with or without a shunt: predictive value of the clinical signs, neuropsychological evaluation and infusion test. Acta Neurochir (Wien) 144:515–523, 2002
3) , 4) Takeuchi T, Goto H, Izaki K, Tamura S, Sasanuma Z, Maeno K, Kikuchi Y, Tomii M, Koizumi Z, Watanabe Z, Numazawa S, Ito Y, Ohara H, Kowada M, Watanabe K. Postoperative patterns of improvement of symptoms and degrees of satisfaction in families of patients after operations for definite idiopathic normal pressure hydrocephalus: a long-term follow-up study]. No Shinkei Geka. 2007 Aug;35(8):773-9. Japanese. PubMed PMID: 17695775.
5) McGirt MJ, Woodworth G, Coon AL, Thomas G, Williams MA, Rigamonti D. Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005 Oct;57(4):699-705; discussion 699-705. PubMed PMID: 16239882.
6) Kazui H, Mori E, Hashimoto M, Ishikawa M, Hirono N, Takeda M. Effect of shunt operation on idiopathic normal pressure hydrocephalus patients in reducing caregiver burden: evidence from SINPHONI. Dement Geriatr Cogn Disord. 2011;31(5):363-70. doi: 10.1159/000328625. Epub 2011 May 27. PubMed PMID: 21625136.
7) , 8) Petersen J, Hellström P, Wikkelsø C, Lundgren-Nilsson A. Improvement in social function and health-related quality of life after shunt surgery for idiopathic normal-pressure hydrocephalus. J Neurosurg. 2014 Oct;121(4):776-84. doi:10.3171/2014.6.JNS132003. Epub 2014 Jul 18. PubMed PMID: 25036194.

Successful treatment of multiple intracranial meningiomas with the antiprogesterone receptor agent mifepristone (RU486).

Evidence suggests that female sex hormones play a role in the meningioma tumorigenesis. In particular, progesterone, has a receptor (PR) that is highly expressed in the majority of grade I meningiomas. Multiple meningiomas (diffuse meningiomatosis) are less frequent, but have a higher female predominance and a higher PR expression. They are, therefore, attractive candidates for anti-PR therapy.

Touat et al., treated three consecutive women with multiple meningiomas with mifepristone (RU 486).

The treatment was well tolerated, and they observed an important and long-lasting clinical (3/3) and radiological response (2/3) or stabilisation. All the three patients are now stable after five to nine years of treatment.

These encouraging results strongly support a prospective clinical trial in this preselected population 1).

1) Touat M, Lombardi G, Farina P, Kalamarides M, Sanson M. Successful treatment of multiple intracranial meningiomas with the antiprogesterone receptor agent mifepristone (RU486). Acta Neurochir (Wien). 2014 Oct;156(10):1831-5. doi: 10.1007/s00701-014-2188-4. Epub 2014 Jul 31. PubMed PMID: 25078073.