Archivos de la categoría Base de Cráneo

Journal of Neurosurgery March 2014

Featured Article

Nonfunctioning pituitary adenoma

Nonfunctioning pituitary adenomas (NFAs) are the most common type of pituitary adenoma and, when symptomatic, typically require surgical removal as an initial means of management.
Treatment

Gamma Knife radiosurgery (GKRS) is an alternative therapeutic strategy for patients whose comorbidities substantially increase the risks of resection. In

Lee et al, evaluated the efficacy and safety of initial GKRS for NFAs.

An international group of three academic Gamma Knife centers retrospectively reviewed outcome data in 569 patients with NFAs.

Forty-one patients (7.2%) underwent GKRS as primary management for their NFAs because of an advanced age, multiple comorbidities, or patient preference. The median age at the time of radiosurgery was 69 years. Thirty-seven percent of the patients had hypopituitarism before GKRS. Patients received a median tumor margin dose of 12 Gy (range 6.2-25.0 Gy) at a median isodose of 50%. The overall tumor control rate was 92.7%, and the actuarial tumor control rate was 94% and 85% at 5 and 10 years postradiosurgery, respectively. Three patients with tumor growth or symptom progression underwent resection at 3, 3, and 96 months after GKRS, respectively. New or worsened hypopituitarism developed in 10 patients (24%) at a median interval of 37 months after GKRS. One patient suffered new-onset cranial nerve palsy. No other radiosurgical complications were noted. Delayed hypopituitarism was observed more often in patients who had received a tumor margin dose > 18 Gy (p = 0.038) and a maximum dose > 36 Gy (p = 0.025).

GKRS resulted in long-term control of NFAs in 85% of patients at 10 years. This experience suggests that GKRS provides long-term tumor control with an acceptable risk profile. This approach may be especially valuable in older patients, those with multiple comorbidities, and those who have endocrine-inactive tumors without visual compromise due to mass effect of the adenoma1.

Spine

Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients.

Cervical arthroplasty

Cervical arthroplasty with an artificial disc (AD) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylosis.

It is an effective, reliable, and safe procedure for the treatment of cervical degenerative disc disease. However, there is no definitive evidence that DCI arthroplasty has better intermediate-term results than anterior cervical discectomy and fusion (ACDF).

3D motion analysis data comparing patients after ACDF and AD replacement in ten patients who underwent C5-6 ACDF and 7 who underwent C5-6 AD replacement were enrolled. Using biplanar fluoroscopy and a model-based track technique (accurate up to 0.6 mm and 0.6°), motion analysis of axial rotation and flexion-extension of the neck was performed. Three nonoperative segments (C3-4, C4-5, and C6-7) were assessed for both intervertebral rotation (coronal, sagittal, and axial planes) and facet shear (anteroposterior and mediolateral). Results There was no difference in total neck motion comparing ACDF and AD replacement for neck extension (43.3° ± 10.2° vs 44.3° ± 12.6°, p = 0.866) and rotation (36.0° ± 6.5° vs 38.2° ± 9.3°, p = 0.576). For extension, when measured as a percentage of total neck motion, there was a greater amount of rotation at the nonoperated segments in the ACDF group than in the AD group (p = 0.003). When comparing specific motion segments, greater normalized rotation was seen in the ACDF group at C3-4 (33.2% ± 4.9% vs 26.8% ± 6.6%, p = 0.036) and C6-7 (28.5% ± 6.7% vs 20.5% ± 5.5%, p = 0.009) but not at C4-5 (33.5% ± 6.4% vs 31.8% ± 4.0%, p = 0.562). For neck rotation, greater rotation was observed at the nonoperative segments in the ACDF group than in the AD group (p = 0.024), but the differences between individual segments did not reach significance (p ≥ 0.146). Increased mediolateral facet shear was seen on neck extension with ACDF versus AD replacement (p = 0.008). Comparing each segment, C3-4 (0.9 ± 0.5 mm vs 0.4 ± 0.1 mm, p = 0.039) and C4-5 (1.0 ± 0.4 mm vs 0.5 ± 0.2 mm, p = 0.022) showed increased shear while C6-7 (1.0 ± 0.4 mm vs 1.0 ± 0.5 mm, p = 0.767) did not.

This study illustrates increased motion at nonoperative segments in patients who have undergone ACDF compared with those who have undergone AD replacement. Further studies will be required to examine whether these changes contribute to adjacent-segment disease 2.

Pediatrics

The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants.

In infants with hydrocephalus, a greater 1-year CSF diversion failure rate may occur after ETV compared with shunt placement. This risk is most significant for procedures performed within the first 90 days of life. Further investigation of the need for multiple reoperations, cost, and impact of surgeon and hospital experience is necessary to distinguish which treatment is more effective in the long term3

  1. Lee CC, Kano H, Yang HC, Xu Z, Yen CP, Chung WY, Pan DH, Lunsford LD, Sheehan JP. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas. J Neurosurg. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24405068. []
  2. McDonald CP, Chang V, McDonald M, Ramo N, Bey MJ, Bartol S. Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients. J Neurosurg Spine. 2013 Dec 20. [Epub ahead of print] PubMed PMID: 24359000. []
  3. Jernigan SC, Berry JG, Graham DA, Goumnerova L. The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants. J Neurosurg Pediatr. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24404970. []

Curso Teórico-Práctico de Base del Cráneo

Tendrá lugar los próximos días 13 y 14 de Marzo de 2014 en Barcelona,

Organizado por los Drs. Pere Tresserres y Fernando Muñoz del Servicio de Neurocirugía del Hospital de Sant Pau de Barcelona.

Se trata de uno de los principales cursos a nivel nacional y que desde el año 2005 viene formando a los neurocirujanos especialistas en base de cráneo.

Para más información (programa, inscripciones, colaboradores y más información) le recomendamos visitar la web del curso.

Cambios en el manejo del Schwannoma del nervio vestibular

La  Oxford Skull Base Clinic describe en un artículo el cambio en el manejo del Schwannoma del nervio vestibular durante un período de 20 años y compara estos resultados con lo que se sabe acerca de las tendencias en la práctica a escala nacional e internacional.

Se centra sobre todo en pacientes tratados mediante cirugía versus observación versus radioterapia en cada año.

Significativamente más pacientes recibieron tratamiento con radiación (en lugar de la cirugía) , entre el año 2000 y 2009 en comparación con 1990 – 1999.

En comparación con datos nacionales se trata a una mayor proporción de pacientes con radioterapia y significativamente menor con cirugía.

El trabajo concluye que la cirugía seguirá siendo crucial en el manejo de algunos pacientes con Schwannomas del nervio vestibular
( generalmente aquellos con los tumores más grandes, donde la radiocirugía reconoce ser menos apropiada) , pero sugiere que el tratamiento no quirúrgico puede desempeñar un papel cada vez más importante en el futuro1

  1. Mackeith SA, Kerr RS, Milford CA. Trends in acoustic neuroma management: a 20-year review of the oxford skull base clinic. J Neurol Surg B Skull Base. 2013 Aug;74(4):194-200. doi: 10.1055/s-0033-1342919. Epub 2013 Apr 1. PubMed PMID:24436912. []