RESUMEN

QUESTION: Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient and conflicting evidence regarding the effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient It is suggested that "early" surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined "early" surgery inconsistently, ranging from <8 h to <72 h after injury. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_10.

Asunto(s)

Vértebras Lumbares/lesiones , Vértebras Lumbares/cirugía , Neurocirugia/normas , Procedimientos Neuroquirúrgicos/métodos , Planificación de Atención al Paciente , Traumatismos Vertebrales/cirugía , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugía , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Fracturas de la Columna Vertebral/cirugía

RESUMEN

QUESTION 1: Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1: A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B. QUESTION 2: In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes? RECOMMENDATION 2: There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.

Asunto(s)

Vértebras Lumbares/cirugía , Neurocirugia/normas , Procedimientos Neuroquirúrgicos/métodos , Traumatismos Vertebrales/clasificación , Traumatismos Vertebrales/cirugía , Vértebras Torácicas/cirugía , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Neurocirujanos , Fracturas de la Columna Vertebral/cirugía , Resultado del Tratamiento

RESUMEN

QUESTION: Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_6.

Asunto(s)

Hemodinámica , Vértebras Lumbares/lesiones , Neurocirugia/normas , Traumatismos Vertebrales/terapia , Vértebras Torácicas/lesiones , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Traumatismos de la Médula Espinal/cirugía , Fracturas de la Columna Vertebral/fisiopatología , Fracturas de la Columna Vertebral/terapia , Traumatismos Vertebrales/fisiopatología

RESUMEN

QUESTION: Does the administration of a specific pharmacologic agent (eg, methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury? RECOMMENDATION: There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, that the complication profile should be carefully considered when deciding on the administration of methylprednisolone. Strength of recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_5.

Asunto(s)

Vértebras Lumbares/lesiones , Neurocirugia/normas , Traumatismos Vertebrales/tratamiento farmacológico , Vértebras Torácicas/lesiones , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Metilprednisolona/uso terapéutico , Fracturas de la Columna Vertebral/tratamiento farmacológico , Fracturas de la Columna Vertebral/cirugía

RESUMEN

BACKGROUND: The thoracic and lumbar ("thoracolumbar") spine are the most commonly injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is frequently associated with spinal cord injury and other visceral and bony injuries. Prolonged pain and disability after thoracolumbar trauma present a significant burden on patients and society. OBJECTIVE: To formulate evidence-based clinical practice recommendations for the care of patients with injuries to the thoracolumbar spine. METHODS: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar spinal injuries based on specific clinically oriented questions. Relevant publications were selected for review. RESULTS: For all of the questions posed, the literature search yielded a total of 6561 abstracts. The task force selected 804 articles for full text review, and 78 were selected for inclusion in this overall systematic review. CONCLUSION: The available evidence for the evaluation and treatment of patients with thoracolumbar spine injuries demonstrates considerable heterogeneity and highly variable degrees of quality. However, the workgroup was able to formulate a number of key recommendations to guide clinical practice. Further research is needed to counter the relative paucity of evidence that specifically pertains to patients with only thoracolumbar spine injuries. The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.

Asunto(s)

Vértebras Lumbares/lesiones , Vértebras Lumbares/cirugía , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/normas , Fracturas de la Columna Vertebral/diagnóstico , Fracturas de la Columna Vertebral/cirugía , Traumatismos Vertebrales/diagnóstico , Traumatismos Vertebrales/cirugía , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugía , Medicina Basada en la Evidencia , Humanos

RESUMEN

BACKGROUND: Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI). OBJECTIVE: To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes. METHODS: A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review. RESULTS: Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries. CONCLUSION: This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries. QUESTION 1: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention? RECOMMENDATION 1: Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery. Strength of Recommendation: Grade B. QUESTION 2: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2: Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.

Asunto(s)

Vértebras Lumbares/diagnóstico por imagen , Neurocirugia/normas , Procedimientos Neuroquirúrgicos/métodos , Traumatismos Vertebrales/diagnóstico por imagen , Vértebras Torácicas/diagnóstico por imagen , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Procesamiento de Imagen Asistido por Computador , Vértebras Lumbares/cirugía , Imagen por Resonancia Magnética , Traumatismos Vertebrales/cirugía , Vértebras Torácicas/cirugía , Tomografía Computarizada por Rayos X

RESUMEN

QUESTION 1: Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 1: There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient. QUESTION 2: Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 2: There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.

Asunto(s)

Vértebras Lumbares/lesiones , Neurocirugia/normas , Traumatismos Vertebrales/cirugía , Traumatismos Vertebrales/terapia , Vértebras Torácicas/lesiones , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Fracturas de la Columna Vertebral/fisiopatología , Fracturas de la Columna Vertebral/terapia

RESUMEN

QUESTION 1: Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures? RECOMMENDATION 1: There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 2: For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)? RECOMMENDATION 2: There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 3: Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures? RECOMMENDATION 3: There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. RECOMMENDATION 4: Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.

Asunto(s)

Vértebras Lumbares/lesiones , Neurocirugia/normas , Traumatismos Vertebrales/complicaciones , Traumatismos Vertebrales/terapia , Vértebras Torácicas/lesiones , Tromboembolia/etiología , Tromboembolia/terapia , Anticoagulantes/uso terapéutico , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Traumatismos de la Médula Espinal/complicaciones , Fracturas de la Columna Vertebral/complicaciones

RESUMEN

QUESTION 1: Which neurological assessment tools have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1: Numerous neurologic assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale and Frankel Scale for Spinal Cord Injury) have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specifically studied in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade C. QUESTION 2: Are there any clinical findings (eg, presenting neurological grade/function) in patients with thoracic and lumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2: Entry American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function can be used to predict neurological function and outcome in patients with thoracic and lumbar fractures (Table I https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4_table1). Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4.

Asunto(s)

Vértebras Lumbares/lesiones , Examen Neurológico , Neurocirugia/normas , Traumatismos Vertebrales/diagnóstico , Vértebras Torácicas/lesiones , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Traumatismos de la Médula Espinal/diagnóstico , Traumatismos de la Médula Espinal/fisiopatología , Traumatismos de la Médula Espinal/cirugía , Traumatismos Vertebrales/fisiopatología , Traumatismos Vertebrales/cirugía

RESUMEN

BACKGROUND: Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries. OBJECTIVE: To determine if the use of external bracing improves outcomes compared to no brace for neurologically intact patients with thoracic or lumbar burst fractures. METHODS: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically comparing external bracing to no brace for neurologically intact patients with thoracic or lumbar burst fractures were selected for review. RESULTS: Three studies out of 1137 met inclusion criteria for review. One randomized controlled trial (level I) and an additional randomized controlled pilot study (level II) provided evidence that both external bracing and no brace equally improve pain and disability in neurologically intact patients with burst fractures. There was no difference in final clinical and radiographic outcomes between patients treated with an external brace vs no brace. One additional level IV retrospective study demonstrated equivalent clinical outcomes for external bracing vs no brace. CONCLUSION: This evidence-based guideline provides a grade B recommendation that management either with or without an external brace is an option given equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures. The decision to use an external brace is at the discretion of the treating physician, as bracing is not associated with increased adverse events compared to no brace. QUESTION: Does the use of external bracing improve outcomes in the nonoperative treatment of neurologically intact patients with thoracic and lumbar burst fractures? RECOMMENDATION: The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_8.

Asunto(s)

Tirantes , Vértebras Lumbares/lesiones , Neurocirugia/normas , Traumatismos Vertebrales/cirugía , Traumatismos Vertebrales/terapia , Vértebras Torácicas/lesiones , Medicina Basada en la Evidencia , Guías como Asunto , Humanos , Fracturas de la Columna Vertebral/fisiopatología , Fracturas de la Columna Vertebral/terapia

RESUMEN

QUESTION: Does the choice of surgical approach (anterior, posterior, or combined anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS: In the surgical treatment of patients with thoracolumbar burst fractures, physicians may use an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. Strength of Recommendation: Grade B With regard to radiologic outcomes in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may use an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_11.

Asunto(s)

Vértebras Lumbares/lesiones , Vértebras Lumbares/cirugía , Neurocirugia/normas , Procedimientos Neuroquirúrgicos/métodos , Planificación de Atención al Paciente , Traumatismos Vertebrales/cirugía , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugía , Medicina Basada en la Evidencia , Fijación Interna de Fracturas , Guías como Asunto , Humanos , Vértebras Lumbares/diagnóstico por imagen , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/cirugía , Traumatismos Vertebrales/diagnóstico por imagen , Vértebras Torácicas/diagnóstico por imagen , Resultado del Tratamiento

RESUMEN

BACKGROUND: Treatment of thoracolumbar burst fractures has traditionally involved spinal instrumentation with fusion performed with standard open surgical techniques. Novel surgical strategies, including instrumentation without fusion and percutaneous instrumentation alone, have been considered less invasive and more efficient treatments. OBJECTIVE: To review the current literature and determine the role of fusion in instrumented fixation, as well as the role of percutaneous instrumentation, in the treatment of patients with thoracolumbar burst fractures. METHODS: The task force members identified search terms/parameters and a medical librarian implemented the literature search, consistent with the literature search protocol (see Appendix I), using the National Library of Medicine PubMed database and the Cochrane Library for the period from January 1, 1946 to March 31, 2015. RESULTS: A total of 906 articles were identified and 38 were selected for full-text review. Of these articles, 12 articles met criteria for inclusion in this systematic review. CONCLUSION: There is grade A evidence for the omission of fusion in instrumented fixation for thoracolumbar burst fractures. There is grade B evidence that percutaneous instrumentation is as effective as open instrumentation for thoracolumbar burst fractures. QUESTION: Does the addition of arthrodesis to instrumented fixation improve outcomes in patients with thoracic and lumbar burst fractures? RECOMMENDATION: It is recommended that in the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiological outcomes, and adds to increased blood loss and operative time. Strength of Recommendation: Grade A. QUESTION: How does the use of minimally invasive techniques (including percutaneous instrumentation) affect outcomes in patients undergoing surgery for thoracic and lumbar fractures compared to conventional open techniques? RECOMMENDATION: Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures as the evidence suggests equivalent clinical outcomes. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_12.

Asunto(s)

Vértebras Lumbares/lesiones , Vértebras Lumbares/cirugía , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/normas , Fracturas de la Columna Vertebral/diagnóstico , Fracturas de la Columna Vertebral/cirugía , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugía , Artrodesis , Medicina Basada en la Evidencia , Fijación Interna de Fracturas , Humanos , Tornillos Pediculares , Resultado del Tratamiento

RESUMEN

COMMENTARY ON: Munch JL, Zusman NL, Lieberman EG, Stucke RS, Bell C, Philipp TC, et al. A scoring system to predict postoperative medical complications in high-risk patients undergoing elective thoracic and lumbar arthrodesis. Spine J 2016:16:694-9 (in this issue).

Asunto(s)

Vértebras Lumbares/cirugía , Complicaciones Posoperatorias , Artrodesis , Humanos , Región Lumbosacra , Periodo Posoperatorio

RESUMEN

Blast wave-induced traumatic injury from terrorist explosive devices can occur at any time in either military or civilian environments. To date, little work has focused on the central nervous system response to a non-penetrating blast injury. We have evaluated the effect of a single 80-psi blast-overpressure wave in a rat model. Histological and immunochemical studies showed an early inflammatory response, tissue damage and the initiation of apoptosis. With regard to inflammation, polymorphonuclear leukocytes and lymphocytes infiltrated brain parenchyma within 1 h post-blast. Glial-fibrillary protein, cyclo-oxygenase-2ir, interleukin-1ß and tumor necrosis factor were present by 1 h and remained detectable at three weeks post-injury. High mobility group box-1 protein was detectable at three weeks. With regard to tissue damage, S100ß and 4-hydroxynonenal were present at 1 h and remained detectable at three weeks. Amyloid precursor protein was detectable at three weeks. As for apoptosis, Cleaved Caspase-3 was detectable at three weeks. Morris water maze assessment of cognitive function showed that blast injured animals required significantly more time to reach the platform on day 1 of training and traveled a greater distance to get to the platform on days 1 and 2. Blast-injured animals showed a significant increase in swimming speed (p<0.001), increased total distance traveled (p<0.001) and increased number of entries into the previous quadrant that had contained the escape platform (p<0.05). Magnetic resonance imaging showed hyperintense regions in the somatosensory area within 1 h. T2 relaxation times and apparent diffusion coefficients show increasing trends in both somatosensory and cortical regions. These data indicate an early and lasting response of brain tissue to non-penetrating blast over-pressure injury. This early inflammatory response is indicative of a mild traumatic brain injury. There is evidence of early hippocampal dysfunction.

Asunto(s)

Traumatismos por Explosión/fisiopatología , Lesiones Encefálicas/fisiopatología , Encéfalo/fisiopatología , Trastornos del Conocimiento/fisiopatología , Inflamación/fisiopatología , Animales , Biomarcadores/sangre , Biomarcadores/metabolismo , Traumatismos por Explosión/etiología , Traumatismos por Explosión/inmunología , Encéfalo/inmunología , Lesiones Encefálicas/etiología , Lesiones Encefálicas/inmunología , Trastornos del Conocimiento/etiología , Trastornos del Conocimiento/inmunología , Modelos Animales de Enfermedad , Hipocampo/inmunología , Hipocampo/lesiones , Hipocampo/fisiopatología , Inflamación/etiología , Inflamación/inmunología , Imagen por Resonancia Magnética , Masculino , Aprendizaje por Laberinto/fisiología , Ratas , Ratas Sprague-Dawley , Índice de Severidad de la Enfermedad , Factores de Tiempo

RESUMEN

The use of minimally invasive tubular retractor microsurgery for treatment of multilevel spinal epidural abscess is described. This technique was used in 3 cases, and excellent results were achieved. The authors conclude that multilevel spinal epidural abscesses can be safely and effectively managed using microsurgery via a minimally invasive tubular retractor system.

Asunto(s)

Infecciones Bacterianas del Sistema Nervioso Central/cirugía , Absceso Epidural/cirugía , Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Infecciones Estafilocócicas/cirugía , Vértebras Torácicas/cirugía , Adolescente , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento

RESUMEN

This case report describes an unusual case of a 55-year-old male, who presented with what appeared to be a pseudomeningocoele. The patient suffered a skull fracture secondary to a direct blow almost 30 years prior, and had been repaired with a calvarial implant at that time. He had been symptom free for most of that time, until he presented to our institution with a bulging cyst in his left frontal region. Computed tomography revealed a calvarial defect at the site of the cyst and a presumptive diagnosis of pseudomeningocoele was made. As part of his treatment, the patient underwent a lumbar puncture and lumbar peritoneal shunt. These procedures, although temporarily beneficial, ultimately proved unsuccessful in permanently decreasing the size of the cyst. After all conservative measures were exhausted, the team surgically explored the patient: while no communication between the cerebrospinal fluid and cyst could be found, which would be expected in a pseudomeningocoele, there was fibrinous exudates on the implant surface. Tissue cultures showed Staphylococcus epidermidis. This case emphasises the importance of surgical exploration to make a correct diagnosis, as in this case of a sub-clinical calvarial implant infection 30 years after insertion of the implant.

Asunto(s)

Infecciones Relacionadas con Prótesis/diagnóstico , Cráneo/cirugía , Infecciones Estafilocócicas/diagnóstico , Diagnóstico Diferencial , Humanos , Masculino , Meningocele/diagnóstico , Persona de Mediana Edad , Prótesis e Implantes , Infecciones Relacionadas con Prótesis/terapia , Cráneo/diagnóstico por imagen , Fracturas Craneales/cirugía , Infecciones Estafilocócicas/terapia , Staphylococcus epidermidis , Factores de Tiempo , Tomografía Computarizada por Rayos X

RESUMEN

Human aldo-keto reductase (AKR) 1C3, type 2 3α-hydroxysteroid dehydrogenase (HSC)/ type 5 17ß-HSD, is known to be involved in steroids, prostaglandins, and lipid aldehydes metabolism. The expression of AKR1C3 has been demonstrated in hormone-dependent normal tissues such as breast, endometrium, prostate, and testis; and de -regulated AKR1C3 expression has been shown in breast carcinoma, endometrial hyperplasia, endometrial carcinoma, and prostate carcinoma. AKR1C3 expression has also been demonstrated in hormone-independent normal tissues (renal tubules and urothelium) and neoplastic tissues (renal cell carcinoma, Wilm's tumor, and urothelial cell carcinoma). Extensive expression of AKR1C3 in normal and neoplastic as well as hormone-dependent and hormone-independent tissues indicates that AKR1C3 may have functions beyond steroid hormone metabolism. In this report, we describe a widespread expression of AKR1C3 in glial neoplasms and meningiomas, with limited expression in medulloblastoma and no expression in Schwannoma. These tumors, except meningioma, are not classically considered to be sex hormone-dependent or related brain tumors. The current results corroborate our earlier observations that AKR1C3 is expressed in both sex hormone-dependent and hormone-independent malignancies. Similar to AKR1C3 distribution in Wilm's tumor, we also demonstrate that expression of AKR1C3 is reduced in tumors with embryonic phenotypes.

Asunto(s)

3-Hidroxiesteroide Deshidrogenasas/metabolismo , Neoplasias Encefálicas/enzimología , Glioma/enzimología , Hidroxiprostaglandina Deshidrogenasas/metabolismo , Meduloblastoma/enzimología , Meningioma/enzimología , Neurilemoma/enzimología , Miembro C3 de la Familia 1 de las Aldo-Ceto Reductasas , Biomarcadores de Tumor/metabolismo , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/cirugía , Glioma/patología , Glioma/cirugía , Humanos , Inmunohistoquímica , Meduloblastoma/patología , Meduloblastoma/cirugía , Meningioma/patología , Meningioma/cirugía , Neurilemoma/patología , Neurilemoma/cirugía

Asunto(s)

Dolor de la Región Lumbar/etiología , Vértebras Lumbares/cirugía , Mitomicina/farmacología , Polietilenglicoles/farmacología , Adherencias Tisulares/prevención & control , Animales , Sistemas de Liberación de Medicamentos , Espacio Epidural/patología , Fibrosis , Humanos , Ratas , Insuficiencia del Tratamiento

RESUMEN

INTRODUCTION: Low back pain is one of the most common complaints for which patients seek medical attention. The differential for such a complaint is wide and therefore requires a thoughtful and thorough work-up. Anorectal disorders are an often-overlooked cause of low back pain. CASE PRESENTATION: We discuss the case of a 46-year-old male with history of dull aching back pain in the midline at the lumbosacral junction. The pain extended to the left of midline, into the region of the sacroiliac joint. There was no radiation into the buttock or leg. Physical exam was unremarkable. Upon soliciting further history, the patient reported a long history of anal pruritus and occasional hematochezia. Colonoscopy subsequently revealed anal fissures in various stages of healing. He was treated with Metamucil capsules and oral nifedipine with significant improvement of his symptoms. CONCLUSION: Low back pain is a challenging chief complaint to the primary care diagnostician due to its wide differential. In a careful and thorough work-up of this complaint, disorders of the anus and rectum should not be overlooked as possible culprits.

Asunto(s)

Fisura Anal/complicaciones , Dolor de la Región Lumbar/etiología , Administración Oral , Catárticos/administración & dosificación , Catárticos/uso terapéutico , Colonoscopía , Diagnóstico Diferencial , Quimioterapia Combinada , Fisura Anal/diagnóstico , Fisura Anal/tratamiento farmacológico , Estudios de Seguimiento , Humanos , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Nifedipino/administración & dosificación , Nifedipino/uso terapéutico , Psyllium/administración & dosificación , Psyllium/uso terapéutico , Vasodilatadores/administración & dosificación , Vasodilatadores/uso terapéutico

RESUMEN

Traumatic brain injury is characterized by neuroinflammatory pathological sequelae which contribute to brain edema and delayed neuronal cell death. Until present, no specific pharmacological compound has been found, which attenuates these pathophysiological events and improves the outcome after head injury. Recent experimental studies suggest that targeting peroxisome proliferator-activated receptors (PPARs) may represent a new anti-inflammatory therapeutic concept for traumatic brain injury. PPARs are "key" transcription factors which inhibit NFkappaB activity and downstream transcription products, such as proinflammatory and proapoptotic cytokines. The present review outlines our current understanding of PPAR-mediated neuroprotective mechanisms in the injured brain and discusses potential future anti-inflammatory strategies for head-injured patients, with an emphasis on the putative beneficial combination therapy of synthetic cannabinoids (e.g., dexanabinol) with PPARalpha agonists (e.g., fenofibrate).