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INTRODUCTION: The authors present the results of a series of 121 cases of posterior vertebral fixation carried out from Sept 2008 to Sept 2010 using Flouro 2D-TC assisted Vector Vision o Kolibri navigator. ( Brain LAB, Feldkirchen, Germany). MATERIAL: The sample included 68 males and 53 females. Age range was 24-75 with an average of 50.35., all with indication for instrumentation by different pathologies. METHOD: Patients presenting vertebral lesions of varying ethiology and lesion level with vertebral posterior fixation indication were included in the study. All underwent a CT before surgery, according to navigation protocol, and the images obtained were merged in the navigator with those obtained in the operating room with a Flouro 2D, which allowed a high quality 3D reconstruction to be performed and thus the capacity to navigate in a real-virtual manner. To evaluate the results of the implant a post-op CT was performed and the position of the implant was defined according to the Heary scale. The calabration time of the material was also evaluated, number of shots with the Flouro-2D, and for clinical evaluation VAS scales were employed, Oswestry and JOA (L), as well as the degree of satisfaction and acceptance of the procedure. RESULTS: A total of 580 screws were implanted, distributed in 62 cervicals of which 24 were in C1-C2, 38 dorsals, 370 lumbar and 110 sacral. Open surgery was performed in 42 cases, MIS in 28 and percutaneous in 51. The presision of the implant was 98.45% with a global deviation of 1.55%, that according to the Heary scale was distributed in grade ll: 2 (1 cervical, 1 lumbar) grade lll: 4 (1 cervical, 2 dorsal, 1 lumbar), grade IV: 3 (1 cervical, 2 lumbar). General average time of calibration per procedure was 2 min. 49 seconds and the mean flouroscopic exposure was one shot at cervical and dorsal and two shots at lumbar level. The clinical evaluation at one month of 121 patients was 8.6/3.0 in the VAS, 68.0% / 23.0% in Oswestry and 6.4/13.1 in JOA (L), with those parameters remaining stable at 3 months in 100 and at 6 months in 87 patients respectively, and the degree of satisfaction between being completely and very satisfied with the procedure was 94.9%, and those who would submit to another treatment was more than 94%. CONCLUSION: Navigation with Flouro-2D-CT is a high precision technique that reduces complications of varying severity according to the level operated well as number of reinterventions, radiation exposure and surgical time.

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OBJECTIVE: The stabilization of C1-C2 segment has evolved with the appearance of several techniques from sublaminar, transarticular or interarticular fixation and over recent years with the introduction of neuronavegation systems. The aim of the study was to review patients treated in our center with transarticular and interarticualr fixation and compare the results obtained with both techniques. METHODS: Thirty six patients with C1-C2 instability that required a surgical fixation between 1995-2008 were retrostpectively analized. The causes of instability were principaly traumatic (18 cases) or degeneritive (16) and two cases of neoplasic lesions. In the first period (1995-2001) 20 patients were treated with transarticular fixation (Magerl's technique), and later (2002-2008) with interarticular fixation (Goel-Harms technique) in another 16 patients. Data was obtainned regarding complications, radiological evolution and clinical results (EVA pain score) and functionals (PROLO score) at 3, 6, 12 and >12 months post-op, as well as post-op cervical mobility and signs of bone fusion. A good result was considered if clinical improvement exi ted with decrease in EVA pain score > 5 points and funcional if a PROLO score > 4, regular if EVA decreased but <5 and PROLO <3 , and bad if there was no clinical or functional improvement. The results were statistically compared between both techniques. RESULTS: Of the 20 patients treated with transarticular fixation, good results were obtained in 17 cases (85%) , regular in 2 (10%), and bad in 1 (5%). Complications included 1 case of vertebral artery lesion and 3 screw misplacements, one case in contact with vertebral artery. Regarding those treated with interarticualr fixation, in 14 (89%), good results were obtained, regular in 2 (12.5%) with 1 case of screw misplacement and another of postsurgical infection. No statistical significant differences were recorded between both techniques, although in those treated with interarticular fixation there was a higher rate of bone fusion and no cases of vertebral arterial lesions were recorded. CONCLUSIONS: Transarticular and interarticular C1- C2 fixation is safe and provides a high rate of good results with few complications. The introduction of neuronavigation systems can increase the efficacy and safety of these techniques.

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Objetivo. La estabilización del segmento C1-C2 ha ido evolucionando con la aparición de numerosas técnicas desde la fijación sublaminar, transarticular o interarticular y en los últimos tiempos con la introducción de sistemas de neuronavegación. El objetivo del estudio fue revisar los pacientes tratados en nuestro centro con fijación transarticular e interarticular y comparar los resultados obtenidos con las 2 técnicas. Métodos. Se analizaron retrospectivamente 36 pacientes con inestabilidad C1-C2 que requirieron fijación quirúrgica entre 1995-2008. Las causas de la inestabilidad fueron en su mayoría traumáticas (18 pacientes) o degenerativas (16 pacientes) y 2 casos de neoplasia. En un primer periodo (1995-2001) se trataron 20 pacientes mediante fijación transarticular (técnica Magerl), y posteriormente (2002-2008) con fijación interarticular (técnica Goel-Harms) en otros 16 pacientes. Se obtuvieron datos sobre las complicaciones, evolución radiológica y resultados clínicos (escala EVA dolor) y funcionales (Escala PROLO) a los 3, 6, 12 y >12 meses tras la cirugía, así como la movilidad cervical postquirúrgica y los signos de fusión ósea. Se consideró resultado bueno si existía mejoría clínica con disminución en la escala EVA de dolor >5 puntos y funcional si se obtenía PROLO ≥4, regular si disminución de EVA pero <5 y PROLO ≤3, y malo si no había mejoría clínica ni funcional. Se compararon los resultados estadísticamente entre una y otra técnica. Resultados. De 20 pacientes tratados con fijación transarticular se obtuvieron resultados buenos en 17 casos (85%), regular en 2 (10%) y malo en 1 (5%). Como complicaciones 1 caso de lesión de arteria vertebral y en 3 malposición de tornillos. En cuanto a los tratados con fijación interarticular en 14 (89%) se obtuvieron un buen resultado, y regular en 2 (12.5%), con 1 caso de malposición de tornillos y otro de infección postquirúrgica. No se registraron diferencias estadísticamente significativas entre ambas técnicas, aunque en los tratados con fijación interarticular hubo mayor tasa de fusión ósea y no se dieron casos de lesión de arteria vertebral. Conclusiones. La fijación C1-C2 transarticular e interarticular resulta segura, presentando altas tasas de buenos resultados con pocas complicaciones. La introducción de sistemas de neuronavegación podría incrementar la eficacia y la seguridad de éstas técnicas (AU)

Objective. The stabilization of C1-C2 segment has evolved with the appearance of several techniques from sublaminar, transarticular or interarticular fixation and over recent years with the introduction of neuronavegation systems. The aim of the study was to review patients treated in our center with transarticular and interarticualr fixation and compare the results obtained with both techniques. Methods. Thirty six patients with C1-C2 instability that required a surgical fixation between 1995-2008 were retrostpectively analized. The causes of instability were principaly traumatic (18 cases) or degeneritive (16) and two cases of neoplasic lesions. In the first period (1995-2001) 20 patients were treated with transarticular fixation (Magerl's technique), and later (2002-2008) with interarticular fixation (Goel-Harms technique) in another 16 patients. Data was obtainned regarding complications, radiological evolution and clinical results (EVA pain score) and functionals (PROLO score) at 3, 6, 12 and >12 months post-op, as well as post-op cervical mobility and signs of bone fusion. A good result was considered if clinical improvement existed with decrease in EVA pain score > 5 points and funcional if a PROLO score > 4, regular if EVA decreased but <5 and PROLO <3 , and bad if there was no clinical or functional improvement. The results were statistically compared between both techniques. Results. Of the 20 patients treated with transarticular fixation, good results were obtained in 17 cases (85%) , regular in 2 (10%), and bad in 1 (5%). Complications included 1 case of vertebral artery lesion and 3 screw misplacements, one case in contact with vertebral artery. Regarding those treated with interarticualr fixation, in 14 (89%), good results were obtained, regular in 2 (12.5%) with 1 case of screw misplacement and another of postsurgical infection. No statistical significant differences were recorded between both techniques, although in those treated with interarticular fixation there was a higher rate of bone fusion and no cases of vertebral arterial lesions were recorded. Conclusions. Transarticular and interarticular C1C2 fixation is safe and provides a high rate of good results with few complications. The introduction of neuronavigation systems can increase the efficacy and safety of these techniques (AU)

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Introducción. Los autores aportan una serie de 121 casos de instrumentación vertebral posterior realizadas desde septiembre del 2008 a diciembre del 2010 mediante la utilización de Fluoro 2D y TC asistida con neuronavegador Vector Visión o Kolibri. (Brain LAB, Feldkirchen, Germany). Material. La muestra fue de 68 varones y 53 mujeres con edades comprendidas entre 24 y 75 años con una media de 50,35 años, todos ellos con indicación para una instrumentación vertebral posterior por distintas patologías. Método. A todos se les realizó una TC previo al pro- cedimiento según protocolo específico de adquisición de imagen para navegación, estas se fusionaron en el navegador con las adquiridas en el quirófano con un Fluoro 2D, lo cual permitió realizar una reconstrucción de alta calidad y así poder navegar de forma real-virtual. Para valorar los resultados se realizó una TC postoperatorio y se clasificó la posición del implante según la escala tomográfica de Heary. Se valoró también el tiempo de calibración del material y número de disparos con el Fluoro-2D. Los resultados clínicos se valoraron con las escalas de VAS, Oswestry y JOA (L) así como el grado de satisfacción con el procedimiento y aceptación del mismo. Resultados. Se implantaron un total de 580 tornillos distribuidos en 62 cervicales (24 en C1-C2), 38 dorsales, 370 lumbares y 110 sacros. Se realizó cirugía abierta en 42 casos, MIS 28 y percutánea en 51. La precisión del implante fue del 98,45% con una desviación global del 1,55% que según escala de Heary se distribuyeron (..) (AU)

Introduction. The authors present the results of a series of 121 cases of posterior vertebral fixation carried out from Sept 2008 to Sept 2010 using Flouro 2D-TC assisted Vector Vision o Kolibri navigator. ( Brain LAB, Feldkirchen, Germany). Material. The sample included 68 males and 53 females. Age range was 24-75 with an average of 50.35., all with indication for instrumentation by different pathologies. Method. Patients presenting vertebral lesions of varying ethiology and lesion level with vertebral posterior fixation indication were included in the study. All under went a CT before surgery, according to navigation protocol, and the images obtained were merged in the navigator with those obtained in the operating room with a Flouro 2D, which allowed a high quality 3D reconstruction to be performed and thus the capacity to navigate in a real-virtual manner. To evaluate the results of the implant a post-op CT was performed and the position of the implant was defined according to the Heary scale. The calabration time of the material was also evaluated, number of shots with the Flouro-2D, and for clinical evaluation VAS scales were employed, Oswestry and JOA (L), as well as the degree of satisfac- tion and acceptance of the procedure. Results. A total of 580 screws were implanted, dis- tributed in 62 cervicals of which 24 were in C1-C2, 38 dorsals, 370 lumbar and 110 sacral. Open surgery was performed in 42 cases, MIS in 28 and percutaneous in 51. The presision of the implant was 98.45% with a global deviation of 1.55%, that according to the Heary scale was distributed in grade ll: 2 (1 cervical, 1 lumbar) grade lll: 4 (1 cervical, 2 dorsal, 1 lumbar), grade IV: 3 (1 cervical, 2 lumbar). General average time of calibration per procedure was 2 min. 49 seconds and the mean flo- uroscopic exposure was one shot at cervical and dorsal and two shots at (..) (AU)

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UNLABELLED: There are various surgical approaches to treat Chiari I malformation. In spite of the good clinical results that are reported with most of them, there is still controversy about the optimal treatment of this pathology. OBJECTIVE: To compare the clinical and radiological results of surgical treatment of the Chiari I malformation with suboccipital craniectomy, posterior arch of C1 resection with or without dural graft, analyzing clinical and radiological findings and describing the complications. MATERIAL AND METHODS: Retrospectively clinical cases series of patients who underwent Chiari I malformation surgery between 1998 and 2006 in the Hospital Germans Trias i Pujol in Badalona. The inclusion criteria consisted in: patients older than 18 years, who have had surgery in our hospital, detailed neurological examination before and after surgery (calculating the EDSS scale punctuation), craniospinal magnetic resonance imaging before and after surgery and minimal follow up period of 6 months. The election of the surgical approach was left to the discretion of the main surgeon. Patients were divided in two groups depending of the surgical technique: Group A (with dural graft) and Group B (without dural graft). To evaluate the morphological results in both groups, measurements of the position of the fastigium above a basal line in the midsagittal T1 weighted magnetic resonance images were obtained. In patients with syringomyelia, siringo-to-cord ratio was measured before and after surgery. To evaluate the clinical results, neurological examination was recorded in both groups before and after surgery. RESULTS: The mean age of Group A patients was 47 (-/+12.89) years, and of Group B was 38.3 (-/+7.77) years. Mean follow up period was 2.48 (-/+2.44) years in Group A and 4.2 (-/+4.46) in Group B. Creation of an artificial cisterna magna was observed en 35.7% of Group A patients and only in 3.5% of Group B patients (p=0.022). In 8 patients front Group A, 8 patients (28.6%) an upward migration of the cerebellum was seen, whereas any of the Group B patients presented it (p=0.022) Siringo-to-cord ratios were decreased in both groups without significant differences. All of the Group A patients improved their clinical exploration. In Group B, 60% of the patients improved and the 40% left maintained clinical stability. Any patient worsened. All patients that maintained clinical stability belonged to Group B, the differences between the two groups were statistically significant (p=0.04). Five patients presented immediate surgical complications (2 pseudomeningoceles, 2 meningitis and 1 hydrocephalus). All this patients where operated with dural graft (p=0.049). CONCLUSIONS: According to our study, suboccipital craniectomy with resection of the posterior arch of C1 and dural graft shows better clinical and radiological results than without dural graft. Nevertheless this technique can increase the incidence of surgical complications.

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Existen múltiples tratamientos descritos para la malformación de Chiari tipo I. Se reportan buenos resultados clínicos con la mayoría de las variantes. Aún así, sigue habiendo controversia acerca del tratamiento óptimo de esta entidad. Objetivo. Comparar los resultados clínico-radiológicos del tratamiento quirúrgico de la malformación de Chiari tipo I mediante craniectomía suboccipital, resección del arco posterior de C1 con o sin duroplastia, analizando las variables clínicas, radiológicas y describiendo las complicaciones. Material y métodos. Se realizó un estudio retrospectivo de los pacientes intervenidos en nuestro centro entre los años 1998 y 2006. La muestra cumplía los siguientes criterios de inclusión: pacientes mayores de 18 años, que hubieran sido intervenidos en nuestro centro en todas las ocasiones, examen neurológico preoperatorio y de control postoperatorio (calculando su puntuación en la escala EDSS), estudio de imagencraneo espinal preoperatorio y postoperatorio y tiempomínimo de seguimiento clínico de 6 meses. Los pacientes se intervinieron con una u otra técnicaen función del criterio del cirujano principal. Dividimosa los pacientes en dos grupos según la técnica utilizada: Grupo A (intervenidos mediante duroplastia) y grupo B (intervenidos sin duroplastia). Para evaluar los resultados radiológicos en los dos grupos se midieron en la resonancia magnética, antes y después de la cirugía: la migración cerebelos a siguiendo el método de Duddy y Williams y la ratio siringo espinal en los pacientes con siringomielia. Para evaluar el resultado clínico, se recogió en los dos grupos la exploración neurológica antes y después de la cirugía. Resultados. La edad media de los pacientes del grupo A fue de 47 (±12,89) años, mientras que la del grupo B fue de 38,30 (±7,77) años. El tiempo medio de seguimiento de los pacientes del grupo A fue de 2,48 (...)

There are various surgical approaches to treat ChiariI malformation. In spite of the good clinical results that are reported with most of them, there is still controversy about the optimal treatment of this patology.Objective. To compare the clinical and radiologicalresults of surgical treatment of the Chiari I malformation with suboccipital craniectomy, posterior arch of C1 resection with or without dural graft, analyzing clinical and radiological findings and describing the complications.Material and methods. Retrospectively clinical casesseries of patients who underwent Chiari I malformationsurgery between 1998 and 2006 in the Hospital GermansTrias i Pujol in Badalona. The inclusion criteriaconsisted in: patients older than 18 years, who have hadsurgery in our hospital, detailed neurological examination before and after surgery (calculating the EDSS scale punctuation), craniospinal magnetic resonanceimaging before and after surgery and minimal followup period of 6 months.The election of the surgical approach was left to thediscretion of the main surgeon.Patients were divided in two groups depending ofthe surgical technique: Group A (with dural graft)and Group B (without dural graft). To evaluate themorphological results in both groups, measurementsof the position of the fastigium above a basal line in the midsagittal T1 weighted magnetic resonance imageswere obtained. In patients with syringomyelia, siringoto-cord ratio was measured before and after surgery. Toevaluate the clinical results, neurological examinationwas recorded in both groups before and after surgery.Results. The mean age of Group A patients was 47(±12,89) years, and of Group B was 38,3 (±7,77) years.Mean follow up period was 2,48 (...)

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OBJECTIVE: C1-C2 transarticular fixation is an increasingly used surgical method of treating atlantoaxial instability. When properly performed, it can safely provide fusion rates near 100%, but techniques of fixation in this region allow only a small margin of error. We here report the results of C1-C2 transarticular fixation in a series of 20 patients in which different procedures were selected according to the presenting disorder in each case. METHODS: The study group included 9 men and 11 women with a mean age of 48 years (range 17 to 68 years). The causes of instabilities were rheumatoid arthritis in nine patients, type II and III Hangman's fracture of traumatic origin in nine (in association with other lesions in three cases), pseudoarthrosis after type II odontoid fracture in one, and type III complex C1 fracture in a patient with ankylosing spondylitis. Preoperative assessment included flexion and extension plain radiographs and computed tomography (CT) and magnetic resonance imaging (MRI) scans. Operations included transarticular screw fixation in all cases; in patients with rheumatoid arthritis it was associated with sublaminar fixation and bone grafting following Sonntag's technique in all but two cases. Postoperative results were evaluated in relation to the biomechanical stability and fusion was studied by flexion and extension radiographs and CT scans. Pain relief in patients with rheumatoid arthritis patients was assessed using a 0-10 visual analogic scale (V.A.S.). RESULTS: In the traumatic group, a consolidation of the fracture and radiologic stability was achieved in all cases. In patients with rheumatoid arthritis, pain improved in all but not the neurological deficit, and in all cases a C1-C2 biomechanical stability was reached despite interlaminar graft resorption in two (25%) cases. With respect to complications, a lesion of the vertebral artery occurred in one case, deviation of the screw in two cases, and breakage of the screw without clinical repercussion in two other cases. CONCLUSION: C1-C2 transarticular screw fixation was a useful technique to achieve satisfacory biomechanical stability in patients with atlatoaxial instability of both inflammatory and traumatic origin with a low rate of complications.

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Objetivo: La fijación transarticular C1-C2 es un procedimiento quirúrgico progresivamente más utilizado para el tratamiento de la inestabilidad de la columna cervical alta. Cuando dicha técnica se efectúa correctamente, es un procedimiento seguro que proporciona tasas de fusión cercanas al 100 por ciento, pero la fijación en esta región permite un escaso margen de error. Presentamos los resultados de la fijación transarticular C1-C2 en una serie de 20 pacientes en los que se seleccionaron diferentes técnicas según la causa de la inestabilidad cervical.Métodos: Se estudiaron a 9 varones y 11 mujeres con una media de edad de 48 años (rango 17 a 68 años). Las causas de la inestabilidad cervical fueron artritis reumatoide en nueve pacientes, fracturas tipo 11 y 111 de Hangman de origen traumático en nueve (con otras lesiones en tres casos), seudoartrosis tras fractura odontoide tipo 11 en un caso y fractura compleja tipo 111 de C1 en un paciente con espondilitis anquilopoyética. La evaluación preoperatoria incluyó radiografías cervicales en flexión y extensión, así como tomografía axial computadorizada (TAC) y resonancia magnética nuclear. En todos los casos se efectuó una fijación transarticular con tornillos (asociada a fijación sublaminar e injerto óseo según la técnica de Sonntag en siete de los nueve pacientes con artritis reumatoide). En el postoperatorio se evaluaron la estabilidad biomecánica y la fusión (por las radiografías cervicales y el TAC). Se utilizó una escala analógica visual (E.V.A.) de 0 a 10 para valorar la mejoría del dolor en el grupo con artritis reumatoide.Resultados: En todas las luxaciones traumáticas, se logró la consolidación de la fractura y la estabilidad radiológica. Todos los pacientes con artritis reumatoide experimentaron mejoría de dolor y en todos los casos se logró la estabilidad biomecánica C1-C2 a pesar de la reabsorción del injerto interlaminar en dos pacientes (25 por ciento). Con respecto a las complicaciones, hubo un caso de lesión de la arteria vertebral, desviación del tornillo Neurocirugía 2002; 13:429-436 en dos casos y rotura del tornillo sin repercusión clínica en otros dos casos.Conclusión: La fijación transarticular CI-C2 fue una técnica útil para lograr la estabilidad biomecánica en pacientes con inestabilidad de la columna cervical superior de origen traumático e inflamatorio, con un bajo porcentaje de complicaciones (AU)

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We present the case of a 73-year-old patient suffering dysphagia secondary to cervical osteophytosis as the clinical presentation of Forestier-Rotés disease. Although this is a frequent disease, there are few cases of dysphagia secondary to this condition it being the initial symptom exceptional. The diagnostic methodology is commented emphasizing cervical CT scan as well as the therapeutic attitude, suggesting starting with a conservative treatment since surgery is not always successful.

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A prospective comparative study was carried out between two anesthetic techniques for chemonucleolysis. Patients were divided into 2 groups of 50 patients each. Group A were submitted to general anesthesia and group B to epidural anesthesia with 0.5% bupivacaine, 2% mepivacaine and buprenorphine. Group B was divided into 2 subgroups: in B1, buprenorphine was administered with the local anesthetics, while in B2 buprenorphine was administered postoperatively when pain appeared. Postoperative pain and side effects like anaphylaxis were evaluated. No anaphylactic reactions occurred. Severe lumbar pain appeared in 22% of patients in group A in spite of systematic analgesics, while group B lumbalgia was not severe in any case. Patients in subgroup B1 did not have pain during the 24 first hours and 47.8% of patients in subgroup B2 needed in most of the cases only a dose of buprenorphine. We conclude that epidural anesthesia is a good technique in chemonucleolysis and that the association bupivacaine, mepivacaine and buprenorphine provides a good postoperative pain relief.

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Three cases of contralateral trigeminal neuralgia as a false localizing sign in intracranial tumors are reported. In each patient (meningioma, 2 cases; cholesteatoma, 1 case) the tumor was asymptomatic, so that intracranial tumor had not been suspected preoperatively. In all cases, tumors were large and firm. The tumor was supratentorial in two cases. In one case, a cortically mediated mechanism may have caused the neuralgia, whereas in the remaining two cases distortion and displacement of the brain stem and compression of the contralateral Meckel's cave would explain the trigeminal nerve signs.

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