Basilar invagination: surgical results

Basilar invagination (BI) is a congenital craniocervical junction (CCJ) anomaly represented by a prolapsed spine into the skull-base that can result in severe neurological impairment. In this paper, we retrospective evaluate the surgical treatment of 26 patients surgically treated for symptomatic BI. BI was classified according to instability and neural abnormalities findings. Clinical outcome was evaluated using the Nürick grade system. A total of 26 patients were included in this paper. Their age ranged from 15 to 67 years old (mean 38). Of which, 10 patients were male (38%) and 16 (62%) were female. All patients had some degree of tonsillar herniation, with 25 patients treated with foramen magnum decompression. Nine patients required a craniocervical fixation. Six patients had undergone prior surgery and required a new surgical procedure for progression of neurological symptoms associated with new compression or instability. Most of patients with neurological symptoms secondary to brainstem compression had some improvement during the follow-up. There was mortality in this series, 1 month after surgery, associated with a late removal of the tracheal cannula. Management of BI requires can provide improvements in neurological outcomes, but requires analysis of the neural and bony anatomy of the CCJ, as well as occult instability. The complexity and heterogeneous presentation requires attention to occult instability on examination and attention to airway problems secondary to concomitant facial malformations.Basilar invagination (BI) is a congenital craniocervical junction (CCJ) anomaly represented by a prolapsed spine into the skull-base that can result in severe neurological impairment. Materials and Methods: In this paper, we retrospective evaluate the sur527884sem informaçãosem informaçã

Diagnosis Of Infant Synostotic And Nonsynostotic Cranial Deformities: A Review For Pediatricians

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Incidence Of Basilar Invagination In Patients With Tonsillar Herniation? A Case Control Craniometrical Study.

A retrospective case-control study based on craniometrical evaluation was performed to evaluate the incidence of basilar invagination (BI). Patients with symptomatic tonsillar herniation treated surgically had craniometrical parameters evaluated based on CT scan reconstructions before surgery. BI was diagnosed when the tip of the odontoid trespassed the Chamberlain's line in three different thresholds found in the literature: 2, 5 or 6.6 mm. In the surgical group (SU), the mean distance of the tip of the odontoid process above the Chamberlain's line was 12 mm versus 1.2 mm in the control (CO) group (p<0.0001). The number of patients with BI according to the threshold used (2, 5 or 6.6 mm) in the SU group was respectively 19 (95%), 16 (80%) and 15 (75%) and in the CO group it was 15 (37%), 4 (10%) and 2 (5%).72706-1

Avaliação dinâmica em epilepsias parciais utilizando imagens por ressonância magnética (RM) de alta resolução de rotina e reconstrução multiplanar (RMP)

Objective: To investigate the presence and type of lesions associated with partial epilepsies by routine high resolution MRI and multi-planar reconstruction (MPR) and correlate the MRI abnormalities with semiology and EEG findings. Methods: We studied 100 consecutive patients followed in the epilepsy clinic of our Hospital with partial epilepsy who underwent MRI investigation. The MRI protocol included 6 mm sagittal T1-weighted, 3-4 mm axial T1 and T2-weighted, 3 mm coronal T1 inversion recovery and T2-weighted images that were printed on a radiographic film for routine analysis. In addition, all patients had a volume T1-gradient echo acquisition with isotropic voxels (1-1.5 mm) for multiplanar reconstruction (MPR). The MRIs were examined in two different occasions: first using only the images printed on films, without volume T1-gradiente echo acquisition and in a second occasion in a computer workstation when all the available images and MPR were analyzed blindly to the clinical information. The clinical and EEG findings were tabulated independently, and results were compared using Chi-square of Fisher exact test when appropriate. Results: The patients were divided into 10 groups according to their etiological classification (structural lesions) established by MRI. Mesial temporal sclerosis (MTS) was the largest group (40%). There were 65 women and 35 men. Mean age was 23.9 (± 5.7) years and mean age of onset of recurrent seizures was 9.9 (± 0.8) years. The most frequent risk factors were family history of seizures (23%), head trauma (10%),peri-natal anoxia (5%) and infection (9%). High resolution MRI including thin coronal slices, in addition to a ?dynamic? analysis in a workstation with MPR, allowed a significant improvement in lesion detection compared to the traditional analysis with radiographic films (94% versus 80%) (p < 0.05). The lesions previously undetected were focal cortical dysplasia and subtle MTS. There was a good concordance between MRI lesions and clinical and EEG findings. Conclusion: High resolution MRI including thin coronal slices, in addition to a ?dynamic? analysis in a workstation with MPR allowed a significative improvement in lesion detection compared to the traditional analysis with radiographic films (94% versus 80%). Patients with partial epilepsy and ?normal? MRI need to be investigated further with thin slices and post-processing techniques using volume acquisitions that allow adequate multiplanar re-slicing.Objetivo: Investigar a presença e tipo de lesões em pacientes com epilepsias parciais utilizando imagens por ressonância magnética (RM) de alta resolução de rotina e reconstrução multiplanar (RMP) e correlacionar as anormalidades com semiologia e EEG. Casuística e métodos: Estudamos 100 pacientes consecutivos acompanhados no serviço de epilepsia com diagnóstico de epilepsia parcial que foram submetidos ao exame de RM. O protocolo de RM incluiu imagens sagitais ponderadas em T1 de 6 mm, axiais ponderadas em T1 e T2 de 3-4 mm, coronais ponderadas em T1-inversion recovery e ponderadas em T2 de 3 mm, que foram impressas em filmes radiográficos para análise de rotina. Além disso, todos exames de RM incluíram aquisi­ção volumétrica (3D) ponderada em T1-gradiente echo com voxel isotrópico (1-1.5 mm) para RMP. As RMs foram examinadas em duas ocasiões diferentes: primeiro utilizando apenas imagens impressas em filmes, sem as imagens 3D, e depois em uma estação de trabalho quando todas imagens estavam disponíveis, incluindo RMP, sem conhecimento prévio das informações clínicas ou da análise anterior da RM. Os dados clínicos e de EEG foram tabulados independentemente, e os resultados foram comparados utilizando teste do qui­quadrado ou teste de Fisher quando apropriado. Resultados: A casuística incluiu 65 mulheres e 35 homens. A idade media foi de 23.9 (± 5.7) anos e a idade média de início de crises recorrentes foi de 9.9 (± 0.8) anos. Os pacientes foram divididos em 10 grupos de acordo com a classificação do tipo de lesão estrutural estabelecida pela análise de RM em estação de trabalho com RMP. Esclerose mesial temporal (EMT) foi o maior grupo (40%). Os fatores de risco mais freqüentes foram história familiar de crises (23%), trauma de crânio (10%), anóxia perinatal (5%) e infecção (9%). Análise ?dinâmica? de RM incluindo cortes coronais finos e RMP em uma estação de trabalho permitiu uma maior detecção de anormalidades em comparação com análise tradicional em filmes radiográficos (94% versus 80%) (p < 0.05). As lesões não detectadas na análise com filmes radiográficos foram displasia cortical focal e formas sutis de EMT. Houve uma boa concor­dância entre anormalidades detectadas pela RM e achados clínicos e de EEG. Conclusão: RM incluindo cortes coronais finos e uma análise ?dinâmica? em uma estação de trabalho com RMP permitiu um aumento significativo na detecção de lesões em comparação com análise tradicional utilizando filmes radiográficos (94% versus 80%). Pacientes com epilepsia parcial e RM ?normal? precisam ser investigados com RM in­cluindo cortes finos e pós-processamento de aquisições volumétricas que permitem RMP.11111

Instrumentação do áxis: resultados cirúrgicos

OBJECTIVE: Evaluate the surgical results of axis screw instrumentation. METHODS: Retrospective evaluation of the clinical and radiological data of patients submitted to axis fixation using screws. RESULTS: Seventeen patients were surgically treated. The mean age was 41.8 years (range: 12-73). Spinal cord trauma was the most common cause of instability (8 patients - 47%). Bilateral axis fixation was performed in all cases, except one, with laminar screw (total of 33 axis screws). Seven patients (41.1%) underwent bilateral pars screws; laminar screws were used in six cases and pedicular screws were used in two. In two cases, we performed a hybrid construction (laminar + pars and pedicle + pars). There was no neurological worsening or death, nor complications directly related to use axis screws. CONCLUSION: Axis instrumentation was effective and safe, regardless of the technique used for stabilization. Based on our learnt experience, we proposed an algorithm to choose the best technique for axis screw fixation.OBJETIVO: Avaliar os resultados cirúrgicos da instrumentação com parafusos do áxis. MÉTODOS: Avaliação retrospectiva de dados clínicos e radiológicos de pacientes submetidos à instrumentação com parafusos do áxis. RESULTADOS: Dezessete pacientes foram tratados cirurgicamente. A média de idade foi de 41,8 anos (faixa: 12-73 anos). Trauma na coluna foi a causa mais comum de instabilidade (8 casos - 47%). Fixação bilateral do áxis foi realizada em todos os casos, exceto em um, com parafuso de lâmina (total de 33 parafusos). Em sete pacientes (41,1%), foram usados parafusos de pars; em seis, parafusos de lâmina; e em dois, de pedículos. Em dois casos, foi utilizada uma combinação de técnicas (pars + lâmina e pars + pedículo). Não houve piora neurológica nem complicações diretas em decorrência do uso dos parafusos. CONCLUSÃO: A instrumentação do áxis foi eficaz e segura independentemente da técnica escolhida para estabilização. Com base em nossa experiência, foi proposto um algoritmo para auxílio na escolha da melhor técnica a ser empregada.85786

Radiocirurgia estereotáxica para metástases de coluna vertebral: revisão de literatura

OBJECTIVE: The spine is the most common location for bone metastases. Since cure is not possible, local control and relief of symptoms is the basis for treatment, which is grounded on the use of conventional radiotherapy. Recently, spinal radiosurgery has been proposed for the local control of spinal metastases, whether as primary or salvage treatment. Consequently, we carried out a literature review in order to analyze the indications, efficacy, and safety of radiosurgery in the treatment of spinal metastases. METHODS: We havereviewed the literature using the PubMed gateway with data from the MEDLINE library on studies related to the use of radiosurgery in treatment of bone metastases in spine. The studies were reviewed by all the authors and classified as to level of evidence, using the criterion defined by Wright. RESULTS: The indications found for radiosurgery were primary control of epidural metastases (evidence level II), myeloma (level III), and metastases known to be poor responders to conventional radiotherapy - melanoma and renal cell carcinoma (level III). Spinal radiosurgery was also proposed for salvage treatment after conventional radiotherapy (level II). There is also some evidence as to the safety and efficacy of radiosurgery in cases of extramedullar and intramedullar intradural metastatic tumors (level III) and after spinal decompression and stabilization surgery. CONCLUSION: Radiosurgery can be used in primary or salvage treatment of spinal metastases, improving local disease control and patient symptoms. It should also be considered as initial treatment for radioresistant tumors, such as melanoma and renal cell carcinoma.OBJETIVO: A coluna vertebral é o local mais comum de metástases ósseas. Uma vez que a cura não pode ser obtida, o controle local e o alívio dos sintomas é a base do tratamento, sendo este fundamentado no uso de radioterapia convencional. Recentemente, a radiocirurgia espinhal foi proposta para o controle local das metástases na coluna, seja como tratamento primário ou de resgate. Dessa forma, realizamos uma revisão da literatura para analisar as indicações, a eficácia e a segurança da radiocirurgia no tratamento das metástases da coluna. MÉTODOS: A revisão de literatura foi realizada no portal PubMed - dados da biblioteca MEDLINE, sobre os estudos relacionados ao uso da radiocirurgia no tratamento para metástases ósseas na coluna vertebral. Os estudos foram revisados por todos os autores e classificados quanto ao nível de evidência, utilizando critério definido por Wright. RESULTADOS: As indicações encontradas para radiocirurgia foram: controle primário de metástases epidurais (nível II de evidência), mieloma (nível III) e metástases sabidamente pouco responsivas à radioterapia convencional - melanoma e carcinoma de células renais - (nível III). A radiocirurgia espinhal também foi proposta para o tratamento de resgate após falha da radioterapia convencional (nível II). Existe ainda alguma evidência quanto à segurança e a eficácia da radiocirurgia em casos de tumores metastáticos intradurais extramedulares e intramedulares (nível III), e após cirurgias de descompressão e estabilização da coluna. CONCLUSÃO: A radiocirurgia, portanto, pode ser usada no tratamento primário ou de resgate de metástases espinhais, melhorando o controle local da doença e dos sintomas dos pacientes. Deve ainda ser considerada como tratamento inicial para tumores radiorresistentes, como melanoma e carcinoma de células renais.24725

Há um período exato para cirurgia em pacientes com paraplegia secundária à compressão medular não traumática?

Paraplegia is a well-defined state of complete motor deficit in lower limbs, regardless of sensory involvement. The cause of paraplegia usually guides treatment, however, some controversies remain about the time and benefits for spinal cord decompression in nontraumatic paraplegic patients, especially after 48 hours of the onset of paraplegia. The objective of this study was to evaluate the benefits of spinal cord decompression in such patients. We describe three patients with paraplegia secondary to non-traumatic spinal cord compression without sensory deficits, and who were surgically treated after more than 48 hours of the onset of symptoms. All patients, even those with paraplegia during more than 48 hours, had benefits from spinal cord decompression like recovery of gait ability. The duration of paraplegia, which influences prognosis, is not a contra-indication for surgery. The preservation of sensitivity in this group of patients should be considered as a positive prognostic factor when surgery is taken into account.A paraplegia é uma condição de déficit motor completo dos membros inferiores, independente do envolvimento de sensibilidade. A causa da paraplegia normalmente guia o tratamento, porém existem controversas sobre o momento e o benefício da descompressão medular em pacientes paraplégicos, principalmente após 48 horas do início dessa condição. O objetivo deste trabalho foi avaliar o beneficio da descompressão medular nesses pacientes. Foram descritos três pacientes com paraplegia secundária à compressão medular não traumática, sem déficits sensoriais e que foram submetidos à cirurgia após 48 horas do início dessa condição. Todos os pacientes, inclusive aqueles com mais de 48 horas do início dos sintomas, apresentaram melhora neurológica com a descompressão medular, como a recuperação da habilidade de marcha. A duração da paraplegia, que influencia no prognóstico, não é uma contraindicação absoluta para o procedimento cirúrgico. A preservação de sensibilidade desse grupo de pacientes deve ser considerada como fator prognóstico positivo quando a cirurgia for levada em conta.50851

Formal training in two-dimensional standardized photographic documentation during residency in plastic surgery

Introduction: Plastic surgery requires diverse skills, knowledge, and competencies, and its scope is broad and challenging. Thus, all plastic surgeons go through extensive education/training, which begins during residency and continues throughout their lives. This study aims to outline a formal training program in 2-dimensional standardized photographic documentation ("photodocumentation") to complement surgical and scientific training during residency in Plastic Surgery. Methods: The components (strategies, topics covered, skills acquisition, and feedback processes) of training in photodocumentation during residency in Plastic Surgery were detailed. Results: Topics in the photodocumentation training program included resident activities, interactions among residents, professional photographers, and surgeons/preceptors, studio settings, cameras, lenses, principles (exposure, aperture, speed, ISO, and depth of field), lighting, preparation and positioning of patients and the camera, photoshoot conditions, photo views, photo database, image formats, computerized photogrammetry, and ethical and medical-legal issues. Conclusion: Training in photodocumentation complements the arsenal of skills needed by residents in Plastic Surgery for continuing education, in order to better prepare them for future careers

Formal training in scientific research increases the participation of plastic surgery residents in peer-reviewed articles

Introduction: The objectives of this study were as follows: (1) to outline a scientific research skills training program, (2) to evaluate the profile of participation of plastic surgery residents in articles, and (3) to analyze the impact of the implementation of the training program on quantitative bibliometric indexes. Methods: This was a bibliometric analysis of the participation of plastic surgery residents of a single institution in articles published in peer-reviewed journals between 2006 and 2014. The data collected were the number of authors, position of residents among authors, article titles, indexing databases and impact factor of the journals, study design, and levels of evidence. Two periods (January 2006 to January 2010 [A] and February 2010 to February 2014 [B]) were created to study the evolutionary profile of the impact of the implementation of the training program outlined in this study. Results: A significant predominance (p < 0.05) was observed among articles published in national journals in the Portuguese language and in the SciELO and LILACS databases, and articles without residents as corresponding author, without impact factor, without assumptions, and with a level of evidence III (retrospective studies). The inter-period comparative analysis revealed a significant increase (p < 0.05) in the numbers of published articles and residents with publications at the end of their residency, in the involvement of one or more residents, and in the articles published in English (period A < period B). Conclusion: The implementation of a scientific research skills training program led to an increase in research activity of (peer-reviewed articles) during the residency

Long-term postoperative atrophy of contralateral hippocampus and cognitive function in unilateral refractory MTLE with unilateral hippocampal sclerosis

Objective: This study aimed to evaluate long-term atrophy in contralateral hippocampal volume after surgery for unilateral MTLE, as well as the cognitive outcome for patients submitted to either selective transsylvian amygdalohippocampectomy (SelAH) or anterior temporal lobe resection (ATL). Methods: We performed a longitudinal study of 47 patients with MRI signs of unilateral hippocampal sclerosis (23 patients with right-sided hippocampal sclerosis) who underwent surgical treatment for MTLE. They underwent preoperative/postoperative high-resolution MRI as well as neuropsychological assessment for memory and estimated IQ. To investigate possible changes in the contralateral hippocampus of patients, we included 28 controls who underwent two MRIs at long-term intervals. Results: The volumetry using preoperative MRI showed significant hippocampal atrophy ipsilateral to the side of surgery when compared with controls (p b 0.0001) but no differences in contralateral hippocampal volumes. The mean postoperative follow-up was 8.7 years (±2.5 SD; median = 8.0). Our patients were classified as Engel I (80%), Engel II (18.2%), and Engel III (1.8%). We observed a small but significant reduction in the contralateral hippocampus of patients but no volume changes in controls. Most of the patients presented small declines in both estimated IQ and memory, which were more pronounced in patients with left TLE and in those with persistent seizures. Different surgical approaches did not impose differences in seizure control or in cognitive outcome. Conclusions: We observed small declines in cognitive scores with most of these patients, which were worse in patients with left-sided resection and in those who continued to suffer from postoperative seizures. We also demonstrated that manual volumetry can reveal a reduction in volume in the contralateral hippocampus, although this change was mild and could not be detected by visual analysis. These new findings suggest that dynamic processes continue to act after the removal of the hippocampus, and further studies with larger groups may help in understanding the underlying mechanisms