Tratamento cirúrgico da epilepsia do córtex posterior : revisão sistemática e metanálise

Objetivo: As epilepsias do córtex posterior são pouco compreendidas e constituem um dos tipos mais desafiantes de epilepsia no que tange a programação e realização de tratamento cirúrgico. Neste estudo avaliamos o prognóstico pósoperatório da cirurgia para epilepsia do córtex posterior. Métodos: Foi realizada uma revisão sistemática da literatura envolvendo estudos avaliando o impacto do tratamento cirúrgico na epilepsia do córtex posterior publicados entre Janeiro de 1990 e Dezembro de 2012 com resumo disponível nas bases de dados do PubMed e Cochrane. Somente estudos com pelos menos 5 pacientes e com acompanhamento pós-operatório de pelo menos um ano foram incuídos. O prognóstico pós-operatório foi avaliado com a escala de controle de crises epilépticas de Engel. A amostra foi analisada através de técnicas estatísticas de metanálise visando avaliar fatores prognósticos associados com o controle de crises com o tratamento cirúrgico da epilepsia do córtex posterior. Resultados: Quarenta e dois estudos se enquadraram nos critérios de inclusão, totalizando 1049 pacientes com epilepsia refratária do córtex posterior submetidos a tratamento cirúrgico Todos os estudos documentavam séries de caso retrospectiva ou prospectiva. Dentre os 1049 pacientes incluídos 605 (57.7%) apresentaram adequado controle de crises. As etiologias encontradas foram: gliose (15.7%), displasia cortical (20.7%), tumores (17.7%), malformações vasculares (6.0%), cisto porencefálico (1.8%), esclerose tuberosa (0.9%) e outras (0.9%). Os fatores prognósticos associados com pior controle de crises foram: sexo feminino (OR=1.28; 95% CI=1.02 - 1.62; p<0.02), exame de imagem pré-operatório normal (OR=1.61; 95% CI=1.19–2.20; p<0.007), resecção incompleta da lesão (OR=1.82; 95% CI=1.33–2.51; p<0.0001) e gliose (OR=1.43; 95% CI=1.11–1.84; p<0.009). Além disso, as neoplasias estiveram associadas com melhor prognóstico pósoperatório (OR=1.30, 95% CI=1.06 – 1.58; p<0.02). Conclusão: Apesar dos desafios associados à terapêutica cirúrgica da epilepsia refratária do córtex posterior, nosso estudo evidenciou que o tratamento cirúrgico foi capaz de garantir adequado controle de crises em 57.7% dos pacientes. Além disso, identificamos que o sexo feminino, resecção incompleta, exame radiológico nomal e gliose estão associados com pior controle de crises no longo prazo. Outro dado importante foi a associação de etiologia neoplásica com um melhor prognóstico pós-operatório.Objective: Refractory posterior cortex epilepsy is poorly understood encompassing one of the most challenging epilepsy groups suitable for epilepsy surgery. Here we present a systematic review and meta-analysis emphasizing predictors and long-term surgical outcome after surgery for posterior cortex epilepsy. Methods: A systematic review of literature published between January 1990 and December 2012 was performed using Medline and Cochrane databases looking for articles evaluating long-term outcome after resection for posterior cortex epilepsy (PCE). Only studies with at least 5 patients and 1 year of follow-up were included. Outcome was evaluated according to Engel classification. Data was analysed using meta-analysis statistical tools looking for predictors of outcome. Results: Fourty-two articles met our inclusion criteria, totalizing 1049 patients with refractory posterior cortex epilepsy (rPCE) submitted to surgical treatment. Seizure freedom was observed in 605 (57.7%) from 1049 patients included. Ethiology were gliosis (15.7%), cortical dysplasia (20.7%), tumors (17.7%), vascular malformations (6.0%), porencephalic cyst (1.8%), tuberous Sclerosis (0.9%) and others (0.9%) Prognostic factors for worst surgical outcome were female sex (OR=1.28; 95% CI=1.02 - 1.62; p<0.02), normal preoperative neuroimaging (OR=1.61; 95% CI=1.19–2.20; p<0.007), subtotal resection (OR=1.82; 95% CI=1.33– 2.51; p<0.0001) and gliosis (OR=1.43; 95% CI=1.11–1.84; p<0.009). Also, patients with tumor-associated epilepsy had better surgical outcome when compared with other etiologies (OR=1.30, 95% CI=1.06 – 1.58; p<0.02). Conclusions: In this study epilepsy surgery for rPCE were associated with seizure freedom in 57.7% of patients. Prognostic factors associated with worst surgical outcome was the presence of normal preoperative neuroimaging, subtotal lesion resection, gliosis and female sex. Patients with neoplasia had better seizure outcome

The limbic system conception and its historical evolution

Throughout the centuries, scientific observers have endeavoured to extend their knowledge of the interrelationships between the brain and its regulatory control of human emotions and behaviour. Since the time of physicians such as Aristotle and Galen and the more recent observations of clinicians and neuropathologists such as Broca, Papez, and McLean, the field of affective neuroscience has matured to become the province of neuroscientists, neuropsychologists, neurologists, and psychiatrists. It is accepted that the prefrontal cortex, amygdala, anterior cingulate cortex, hippocampus, and insula participate in the majority of emotional processes. New imaging technologies and molecular biology discoveries are expanding further the frontiers of knowledge in this arena. The advancements of knowledge on the interplay between the human brain and emotions came about as the legacy of the pioneers mentioned in this field. The aim of this paper is to describe the historical evolution of the scientific understanding of interconnections between the human brain, behaviour, and emotions

Tratamento cirúrgico da epilepsia do córtex posterior : revisão sistemática e metanálise

Objetivo: As epilepsias do córtex posterior são pouco compreendidas e constituem um dos tipos mais desafiantes de epilepsia no que tange a programação e realização de tratamento cirúrgico. Neste estudo avaliamos o prognóstico pósoperatório da cirurgia para epilepsia do córtex posterior. Métodos: Foi realizada uma revisão sistemática da literatura envolvendo estudos avaliando o impacto do tratamento cirúrgico na epilepsia do córtex posterior publicados entre Janeiro de 1990 e Dezembro de 2012 com resumo disponível nas bases de dados do PubMed e Cochrane. Somente estudos com pelos menos 5 pacientes e com acompanhamento pós-operatório de pelo menos um ano foram incuídos. O prognóstico pós-operatório foi avaliado com a escala de controle de crises epilépticas de Engel. A amostra foi analisada através de técnicas estatísticas de metanálise visando avaliar fatores prognósticos associados com o controle de crises com o tratamento cirúrgico da epilepsia do córtex posterior. Resultados: Quarenta e dois estudos se enquadraram nos critérios de inclusão, totalizando 1049 pacientes com epilepsia refratária do córtex posterior submetidos a tratamento cirúrgico Todos os estudos documentavam séries de caso retrospectiva ou prospectiva. Dentre os 1049 pacientes incluídos 605 (57.7%) apresentaram adequado controle de crises. As etiologias encontradas foram: gliose (15.7%), displasia cortical (20.7%), tumores (17.7%), malformações vasculares (6.0%), cisto porencefálico (1.8%), esclerose tuberosa (0.9%) e outras (0.9%). Os fatores prognósticos associados com pior controle de crises foram: sexo feminino (OR=1.28; 95% CI=1.02 - 1.62; p<0.02), exame de imagem pré-operatório normal (OR=1.61; 95% CI=1.19–2.20; p<0.007), resecção incompleta da lesão (OR=1.82; 95% CI=1.33–2.51; p<0.0001) e gliose (OR=1.43; 95% CI=1.11–1.84; p<0.009). Além disso, as neoplasias estiveram associadas com melhor prognóstico pósoperatório (OR=1.30, 95% CI=1.06 – 1.58; p<0.02). Conclusão: Apesar dos desafios associados à terapêutica cirúrgica da epilepsia refratária do córtex posterior, nosso estudo evidenciou que o tratamento cirúrgico foi capaz de garantir adequado controle de crises em 57.7% dos pacientes. Além disso, identificamos que o sexo feminino, resecção incompleta, exame radiológico nomal e gliose estão associados com pior controle de crises no longo prazo. Outro dado importante foi a associação de etiologia neoplásica com um melhor prognóstico pós-operatório.Objective: Refractory posterior cortex epilepsy is poorly understood encompassing one of the most challenging epilepsy groups suitable for epilepsy surgery. Here we present a systematic review and meta-analysis emphasizing predictors and long-term surgical outcome after surgery for posterior cortex epilepsy. Methods: A systematic review of literature published between January 1990 and December 2012 was performed using Medline and Cochrane databases looking for articles evaluating long-term outcome after resection for posterior cortex epilepsy (PCE). Only studies with at least 5 patients and 1 year of follow-up were included. Outcome was evaluated according to Engel classification. Data was analysed using meta-analysis statistical tools looking for predictors of outcome. Results: Fourty-two articles met our inclusion criteria, totalizing 1049 patients with refractory posterior cortex epilepsy (rPCE) submitted to surgical treatment. Seizure freedom was observed in 605 (57.7%) from 1049 patients included. Ethiology were gliosis (15.7%), cortical dysplasia (20.7%), tumors (17.7%), vascular malformations (6.0%), porencephalic cyst (1.8%), tuberous Sclerosis (0.9%) and others (0.9%) Prognostic factors for worst surgical outcome were female sex (OR=1.28; 95% CI=1.02 - 1.62; p<0.02), normal preoperative neuroimaging (OR=1.61; 95% CI=1.19–2.20; p<0.007), subtotal resection (OR=1.82; 95% CI=1.33– 2.51; p<0.0001) and gliosis (OR=1.43; 95% CI=1.11–1.84; p<0.009). Also, patients with tumor-associated epilepsy had better surgical outcome when compared with other etiologies (OR=1.30, 95% CI=1.06 – 1.58; p<0.02). Conclusions: In this study epilepsy surgery for rPCE were associated with seizure freedom in 57.7% of patients. Prognostic factors associated with worst surgical outcome was the presence of normal preoperative neuroimaging, subtotal lesion resection, gliosis and female sex. Patients with neoplasia had better seizure outcome

Evolução clínica e funcional dos pacientes com infecção após artrodese de coluna lombar

OBJETIVOS: descrever a experiência dos autores no manejo da infecção após instrumentação da coluna lombar e suas consequências futuras. MÉTODOS: estudo de coorte prospectivo com pacientes portadores de infecção profunda pós-operatória, realizado entre janeiro de 1997 e janeiro de 2009. Todos os pacientes foram submetidos à revisão cirúrgica, coleta de material para exame microbiológico, lavagem exaustiva da região, debridamento dos tecidos desvitalizados, colocação de sistema de lavagem contínua, sutura primária e antibioticoterapia. Manteve-se a instrumentação em todos os pacientes. Os pacientes foram avaliados durante o seguimento por imagens radiográficas, estado clínico e funcional. Utilizaram-se a escala numérica da dor e o índice de incapacidade Oswestry. Os resultados numéricos foram submetidos a análises pareadas pelo teste de Wilcoxon. RESULTADOS: a incidência de infecção foi de 3,1% (15/485). O agente etiológico mais prevalente foi o Staphylococcus aureus. Todos os casos lograram consolidação. Em um seguimento médio de 47,6 meses, observaram-se mudanças nos escores da escala numérica da dor (p=0,001) e índice de incapacidade Oswestry (p=0,017). Na avaliação final, 64,2% dos pacientes (9/14) apresentaram incapacidade mínima e 35,8% (5/14), incapacidade moderada. CONCLUSÃO: o tratamento agressivo das infecções pós-operatórias de artrodese de coluna lombar permite evitar a retirada da instrumentação e manter a estabilidade vertebral. A despeito da complicação, os pacientes apresentaram melhoras em relação à dor e capacidade funcional pré-operatórias

Anterior approach to the cervicothoracic junction: case series and literature review

OBJECTIVES: the authors report their experience with the anterior approach to the cervicothoracic junction at C7 to T4 vertebral bodies, how the radiological investigation was performed in order to define the need for manubriotomy, how was the surgical pitfalls and the clinical evaluation. METHODS: prospective cohort study with 14 patients who underwent an anterior approach to the cervicothoracic surgery during the period of January 1996 to January 2009. The patients underwent radiographic evaluation with computed tomography and magnetic resonance before surgery in order to identify when the manubriotomy was necessary. The surgery was usually performed from the left side through an anterior Smith-Robinson approach and manubriotomy when necessary. Mesh and cervical plate system were used for stabilization when corpectomy was performed. Nevertheless, in the cases with discal herniation C7-T1, the reconstruction was done with PEEK and cervical plate system. RESULTS: the mean age was 63 years old (range, 30-77 years) and seven of the patients were men. The majority of cases had metastatic disease (n=8) or disc herniation (n=4). There were two complications related to the surgical procedures: one patient with dysphonia caused by a local hematoma and other one with lung infection. The mean surgical time, bleeding volume, pain intensity, medication intake and length of hospital stay were lower in the cases in which manubriotomy was not necessary. CONCLUSIONS: the anterior approach to the cervicothoracic junction is effective and presents low morbidity rate. In cases of injuries involving the C7 vertebral body and C7-T1 intervertebral disc herniation, a transcervical approach without the manubriotomy was indicated; when a T1 and/or T2 corpectomy was necessary, the transmanubrial approach usually was necessary in order to provide a good working space to perform a corpectomy and reconstruction. Performing manubriotomy increases surgical time, bleeding, pain intensity, analgesic drugs intake and the length of hospital stay

Is the lasègue sign a predictor of outcome in lumbar disc herniation surgery?

OBJECTIVE: Evaluate the predictive value of the Lasègue sign on self-reported quality of life measures (HRQoL) in patients who undergo microdiscectomy. METHODS: 95 patients with clinical and radiological diagnosis of LDH who underwent microdiscectomy were included. The patients were assessed by a neurological examination and answered validated instruments to assess pain, disability, quality of life, and mood disorder in the preoperative period, and 1, 6 and 12 months after surgery. RESULTS: Preoperative Lasègue sign was identified in 56.8% (n=54/95) of the cases. There was no difference between the groups in the preoperative period regarding HRQoL. At one year follow-up no statistically significant difference in HRQoL was observed in the Lasègue group. The discrimination capacity of the preoperative Lasègue sign to determinate variations in HRQoL outcomes one year postoperatively was low. CONCLUSION: Lasègue sign is not a good predictor of outcome after microdiscectomy for LDH