Archivos de la categoría Revistas

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. []

Neurosurgery March 2014

March 2014 Issue of Neurosurgery is Online

03 March 2014The March 2014 issue of Neurosurgery is now online and full-text access is available for print subscribers. Non-subscribers may access all article abstracts and the full-text of selected articles.

Read more 

 

 

Artículo especial

Tracking and Sustaining Improvement Initiatives: Leveraging Quality Dashboards to Lead Change in a Neurosurgical Department

Cada vez más, hospitales y  médicos  adquieren conocimiento de estrategias y herramientas para mejorar la calidad empresarial.

En el 2007 el departamento de Neurocirugía de la Universidad de California Los Angeles (UCLA) creó unos indicadores de calidad para ayudar a gestionar las medidas de proceso y resultados con la finalidad de mejorar el rendimiento clínico y la atención al paciente .

En el 2009 , la dirección del departamento y la dirección médica trabajó  para alinear las prioridades de mejora de calidad de inversión. El contenido se ha rediseñado para incluir 3 áreas de prioridades: calidad y seguridad,  satisfacción del paciente , eficiencia y uso de los recursos. A través del tiempo , la calidad de la neurocirugía ha sido reconocida por su claridad y su éxito en las estrategias de gestión.

Se describe la creación, el diseño y  un resumen de la evolución del proceso, e ilustra la forma en que se puede utilizar como una herramienta poderosa de mejora y cambio.

También se discuten los posibles retos y orientaciones futuras de este conjunto de estrategias y llaves enfocadas a la administración y creación de conocimiento sobre el medio, a través del análisis de los datos existentes en un servicio de neurocirugía.

Neurosurgery Febrero 2014

  • En el glioblastoma los reingresos en los primeros 30 días tuvieron una supervivencia significativamente más corta1.
  • El estrés por la inestabilidad iatrogénica introducida en segmentos espinales adyacentes a nivel cervical contribuyen a la patogénesis de la enfermedad del segmento adyacente2
  • La hemisferotomía lateral modificada es eficaz y segura.
    El uso de Avitene parece provocar  una mayor incidencia de hidrocefalia postoperatoria3

Genetic Predisposition to Lumbar Disc Degeneration

Carbohidrato sulfotransferasa 3

Existe una mutación genética que provoca la degeneración del disco lumbar

Se trata del gen mutado conocido como “carbohidrato sulfotransferasa 3 (CHST3)”, que parece ser el responsable de aumentar el riesgo de la degeneración del disco lumbar, favoreciendo la deshidratación y el desgaste del tejido.

En el estudio, publicado en el Journal of Clinical Investigation, los científicos analizaron mediante resonancia magnética la parte baja de la espalda de poco más de cuatro mil personas. Los pacientes –asiáticos y finlandeses– también fueron sometidos a un estudio de asociación genética (o del genoma completo)

  1. Nuño M, Ly D, Ortega A, Sarmiento JM, Mukherjee D, Black KL, Patil CG. Does 30-Day Readmission Affect Long-term Outcome Among Glioblastoma Patients? Neurosurgery. 2014 Feb;74(2):196-205. doi: 10.1227/NEU.0000000000000243. PubMed PMID: 24176955. []
  2. Bydon M, Xu R, Macki M, De la Garza-Ramos R, Sciubba DM, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Adjacent segment disease after anterior cervical discectomy and fusion in a large series. Neurosurgery. 2014 Feb;74(2):139-46.doi:10.1227/NEU.0000000000000204. PubMed PMID: 24149977. []
  3. Lew SM, Koop JI, Mueller WM, Matthews AE, Mallonee JC. Fifty consecutive hemispherectomies: outcomes, evolution of technique, complications, and lessons learned. Neurosurgery. 2014 Feb;74(2):182-95. doi: 10.1227/NEU.0000000000000241. PubMed PMID: 24176954. []