Neurocirugia 

About: Neurocirugia is an academic journal published by Elsevier BV. The journal publishes majorly in the area(s): Medicine & Hydrocephalus. It has an ISSN identifier of 0047-9411. Over the lifetime, 1969 publications have been published receiving 8319 citations.

Dexamethasone treatment in chronic subdural haematoma

Abstract: Introduction Neurosurgeons are familiar with chronic subdural haematoma (CSH), a well-known clinical entity, which is usually treated by some modality of trepanation. Despite the excellent outcomes obtained by surgery, complications may occur, some of which may be potentially severe or fatal. Furthermore, up to 25% recurrence rate is reported. The authors present a novel approach to the management of CSH based on the use of dexamethasone as the treatment of choice in the majority of cases. Patients and methods Medical records of 122 CSH patients were retrospectively reviewed. At admission, symptomatic patients were classified according to the Markwalder Grading Score (MGS). Those scoring MGS 1-2 were assigned to the Dexamethasone protocol (4 mg every 8h, re-evaluation after 48-72 h, slow tapering), and those scoring MGS 3-4 were, in general, assigned to the Surgical protocol (single frontal twistdrill drainage to a closed system, without irrigation). Patients were followed in the Outpatient Office with neurological assessment and serial CT scans. RESULTS. Between March 2001 and May 2006, 122 consecutive CSH patients (69% male, median aged of 78, range 25-97) were treated. Seventy-three percent of the patients exhibited some kind of neurological defect (MGS 2-3-4). Asymptomatic patients (MGS 0) were left untreated. Initial treatment assignment was: 101 dexamethasone, 15 subdural drain, 4 craneotomy and 2 untreated. Twenty-two patients on dexamethasone ultimately required surgical drain (21.8%). Favourable outcome (MGS 0-1-2) was obtained in 96% and 93.9% of those treated with dexamethasone and surgical drain, respectively. Median hospital stay was 6 days (range 1- 41) for the dexamethasone group and the whole series, and 8 days (range 5-48) for the surgical group. Overall mortality rate was 0.8% and re-admissions related to the haematoma reached 14.7% (all maintained or improved their MGS). Medical complications occurred in 34 patients (27.8%), mainly mild hyperglycemic impairments. Median outpatient follow up was 25 weeks (range 8-90), and two patients were lost. Discussion The rationale for the use of dexamethasone in CSH lies in its anti-angiogenic properties over the subdural clot membrane, as it is derived from experimental studies and the very few clinical observations published. Surgical evacuation of CSH is known to achieve excellent results but no well-designed trials compare medical versus surgical therapies. The experience obtained from this series lets us formulate some clinical considerations: dexamethasone is a feasible treatment that positively compares to surgical drain (and avoided two thirds of operations); the natural history of CSH allows a 48-72 h dexamethasone trial without putting the patient at risk of irreversible deterioration; eliminates all morbidity related to surgery and recurrences; does not provoke significant morbidity itself; reduces hospital stay; does not preclude ulterior surgical procedures; it is well tolerated and understood by the patient and relatives and it probably reduces costs. The authors propose a protocol that does not intend to substitute surgery but to offer a safe and effective alternative. Conclusion Data obtained from this large retrospective series suggests that dexamethasone is a feasible and safe option in the management of CSH. In the author's experience dexamethasone was able to cure or improve two thirds of the patients. This fact should be confirmed by others in the future. The true effectiveness of the therapy as compared to surgical treatment could be ideally tested in a prospective randomized trial.

Surgical treatment of isolated and syndromic craniosynostosis: Results and complications in 283 consecutive cases

Abstract: Results. The mortality rate of the series was 2 out of 283 cases (0.7%). These 2 patients died one year after surgery. All complications were resolved without permanent deficit. Mean age at surgery was 6.75 months. According to Whitaker et al’s classification, 191 patients were classified into Category I (67.49%), 51 into Category II (18.02%), 30 into Category III (10.6%) and 14 into Category IV (4.90%). Regarding to craniofacial conformation, 85.5 % of patients were considered as a good result and 15.5% of patients as a poor result. Of the patients with poor results, 6.36% were craniofacial syndromes, 2.12% had anterior plagiocephaly and 1.76% belonged to non-syndromic craniosynostosis. The most frequent complication was postoperative hyperthermia of undetermined origin (13.43% of the cases), followed by infection (7.5%), subcutaneous haematoma (5.3%), dural tears (5%), and CSF leakage (2.5%). The number of complications was higher in the group of re-operated patients (12.8% of all). In this subset of reoperations, infection accounted for 62.5%, dural tears for 93% and CSF leaks for 75% of the total. In regard to the surgical procedures, endoscopic assisted osteotomies presented the lowest rate of complications, followed by standard fronto-orbital advancement in multiple synostosis, trigonocephaly and plagiocephaly. The highest number of complications occurred in complete cranial vault remodelling (holocranial dismantling) in scaphocephaly and multiple synostoses and after the use of internal osteogenic distractors. Of note, are two cases of iatrogenic basal encephalocele that occurred after combined fronto-facial distraction. Conclusions. The best results were obtained in patients with isolated craniosynostosis and the worst in cases with syndromic and multi-suture craniosynostosis. The rate and severity of complications were related to the type of surgical procedure and was higher among patients undergoing re-operations. The mean time of hospitalization was also modified by these factors. Finally, we report our considerations for the management of craniosynostosis taking into account each specific tech

Preliminary report on surgical mask induced deoxygenation during major surgery

Abstract: Objetivos. Este estudio se realizo para determinar si la saturacion de oxigeno del cirujano se afectaba por el uso de la mascarilla, durante intervenciones de larga duracion. Metodos. Se hizo un estudio longitudinal y prospectivo en 53 cirujanos con medidas de la hemoglogina realizadas con un oximetro para medir la saturacion del pulso arterial. Se hicieron estudios antes y despues de la operacion. Resultados. Nuestro estudio puso de manifiesto una disminucion de la saturacion de oxigeno de las pulsaciones arteriales (SpO2) y un ligero aumento de las pulsaciones en comparacion con el estado preoperatorio en todos los grupos de cirujanos. La disminucion era mayor en el grupo de edad superior a los 35 anos. Conclusiones. Segun nuestros hallazgos, el ritmo del pulso aumenta y la concentracion de SpO2 disminuye despues de la primera hora de la operacion. Este cambio temprano de SpO2 puede deberse a la mascarilla o al estres de la intervencion. Puesto que un ligero descenso en la saturacion a este nivel refleja una mayor disminucion de la PaO2, nuestros datos pueden tener un valor clinico para la salud del personal sanitario y para los cirujanos.

Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement

Abstract: Background Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty. Methods We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72 h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement. Results Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5–149.5) cm2. The time elapsed between decompressive craniectomy and cranioplasty was 309 (25–1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel ≤70 (Odds ratio [OR] 22; 2.5–192; P = 0.005), age over 45 years (OR 13.5; 1.5–115; P = 0.01) and early surgery (≤85 days; OR 8; 1.69–37.03, P = 0.004). After multivariate analysis, Barthel ≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery ( Conclusions The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.

[System of dynamic neutralization in the lumbar spine: experience on 94 cases].

Abstract: Objective To assess the results obtained using the Dynesys system (Dynamic Neutralisation System for the spine), in a group of 94 patients. This new system for treating lumbar degenerative pathologies is based on lumbar stabilisation and preservation of articular function, as opposed to traditional arthrodesis restrictions. Material and methods We analyze series of 94 patients in whom this system was used. 62 were males and 32 females with an average age of 46.4 years. The pathologies treated were disc herniation in 27 cases, degenerative discopathy in 54 cases and lumbar channel stenosis in 13 cases. Follow-up was carried out between 14 and 24 months, assessing the clinical picture according to the Oswestry scale and the return to work. Results The final results on the Oswestry scale were 21.4% with respect to 56.8% prior to the treatment and the return to work was 82%. There was a remission of the sciatica symptoms in almost all the cases, as well as of the lumbar pain, and there was a 60% improvement in the claudication cases. With regard to complications, we would like to point out two cases due to the technique, one because of the wrong positioning of the screws and the other due to the rupture of the pedicle. There were two cases of subcutaneous seroma and two late subclinical infections. Conclusions The dynamic neutralisation obtained using this system, should not be considered as an arthrodesis. Treatment using Dynesys enlarges the population of patients candidates for surgery to who initially do not apparently need a standard fixation, but who raise doubt regarding the application of techniques without instrumental support, incorporating the functionality concept as opposed to restricting movement. This system can be defined as a disc prosthesis fitted externally to the disc. We have obtained good results in the majority of our patients, although we believe that the follow-up should be increased.