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Background: We analyzed the role of hypoalbuminemia, dialysis, and other risk factors that increase morbidity/ mortality following surgery for primary pyogenic spinal infections (PSIs). The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) that included 627 patients was utilized as our database. Methods: Primary spinal surgery for spondylodiscitis was evaluated in a ACS-NSQIP database involving 627 patients between 2010 and 2019. Outcome assessment included evaluation of 30-day postoperative morbidity, and mortality rates. Results: Within 30 postoperative days, complications occurred in 14.6% (92/627) of patients; 59 (9.4%) required readmission, and 39 (6.2%) required additional surgery. The most common complications were: wound infections, pneumonia, septic shock, and death (1.8%). Hypoalbuminemia (i.e., significantly associated with unplanned readmission and reoperation), and dialysis were the two major risk factors contributing to increased perioperative morbidity and mortality. Conclusion: Among 627 ACS-NSQIP patients undergoing primary surgery for PSIs, hypoalbuminemia and dialysis were associated with higher risks of major perioperative morbidity (i.e., within 30 postoperative days - mostly readmissions and reoperations) and mortality.

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BACKGROUND: Intraoperative neurophysiological monitoring (IOM) has become valuable in spine surgery. Unfortunately, it is not always available in many spine centers, especially in developing countries. Our aim was to evaluate the accessibility and barriers to IOM in spine surgery in Latin America. METHODS: We designed a questionnaire to evaluate the characteristics of surgeons and their opinions on the usefulness of IOM for different spine operations. The survey was sent to 9616 members and registered users of AO Spine Latin America (AOSLA) from August 1, 2019, to August 21, 2019. Major variables studied included nationality, years of experience, specialty (orthopedics or neurosurgery), level of complexity of the hospital, number of spine surgeries performed per year by the spine surgeon, the types of spinal pathologies commonly managed, and how important IOM was to the individual surgeon. General questions to evaluate use included accessibility, limitations of IOM usage, management of IOM changes, and the legal value of IOM. The results were analyzed and compared between neurosurgeon and orthopedics, level of surgeon experience, and country of origin. RESULTS: Questionnaires were answered by 200 members of AOSLA from 16 different countries. The most common responses were obtained from orthopedic surgeons (62%), those with more than 10 years of practice (54%); majority of surgeons performed more than 50 spine surgeries per year (69%) and treated mainly spine degenerative diseases (76%). Most surgeons think that IOM has a real importance during surgeries (92%) and not just a legal value. Although surgeons mostly considered IOM essential to scoliosis surgery in adolescents (70%), thoracolumbar kyphosis correction (68%), and intramedullary tumors (68%), access to IOM was limited to 57% for economic reasons. Of interest, in 64% of cases, where IOM was available and significant change occurred, the actual operative procedures were significantly altered. CONCLUSION: Despite the fact that 68% of spine surgeons believe IOM to be indispensable for complex spine surgery, cost remains the main barrier to its use/availability in Latin America.

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We present the case of a meningioma of the foramen magnum, in a patient of age 62 yr, who presented at the time of surgery a hemiparesis on the right side at 2 mo of evolution. The patient gave his informed consent for the publication of the case, and approval was obtained from the research department of the hospital where the procedure was performed. The magnetic resonance imaging (MRI) in the mid-sagittal view shows a meningioma of the foramen magnum, with an extension in the posterior fossa and in the upper part of the cervical canal. In the coronal view and in the axial view, we can identify that although it is a meningioma of the anterior part of the foramen magnum, it is observed that the lesion has a displacement towards the right side. In a cadaveric specimen, we show the normal anatomy and the key landmarks for performing the approach. The patient was treated by a far lateral approach with a partial removal of the condyle. We show the craniectomy and the microsurgical technique for the tumor resection step by step. We paid particular attention in the anatomy surrounding the tumor and the tips and tricks for a safe resection. We reached a total resection with a good outcome; the result of the anatomopathological study confirmed the diagnosis of meningothelial meningioma. The dura was closed in a hermetic manner with a synthetic dura patch; then sealant was placed. The bone defect was corrected by placing a mesh in titanium. Then the flap was closed as usual. The patient has a good evolution with 1 yr of follow-up and without lesion in the control MRI.

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BACKGROUND: The central sulcus may be located through magnetic resonance imaging (MRI) by identifying the ipsilateral inverted Omega shape. In a brain with a lesion in this area, its identification becomes a hard task irrespective of the technique applied. The aim of this study is to show the usefulness of the contralateral Omega sign for the location of tumors in and around the central sulcus. We do not intend to replace modern techniques, but to show an easy, cheap and relatively effective way to recognize the relationship between the central sulcus and the lesion. METHODS: From July 2005 through December 2010, 43 patients with lesions in and around the central sulcus were operated using the contralateral Omega sign concept. Additionally, 5 formalin-fixed brains (10 hemispheres) were studied to clarify the anatomy of the central sulcus where the Omega shape is found. RESULTS: The central sulcus has three genua. The middle genu is characterized by an inverted Omega-shaped area in axial sections known as the Omega sign. On anatomical specimens, Omega was 11.2 ± 3.35 mm in height, on average, and 18.7 ± 2.49 mm in width, at the base. The average distance from the medial limit of the Omega to the medial edge of the hemisphere was 24.5 ± 5.35 mm. Identification of the Omega sign allowed for the topographic localization of the contralateral central sulcus in all our surgical cases but one. CONCLUSION: The contralateral Omega sign can be easily and reliably used to clarify the topographic location of the pathology. Hence, it gives a quick preoperative idea of the relationships between the lesion and the pre- and post-central gyri.

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UNLABELLED: Epineural stitches are a means to avoid tension in a nerve suture. We evaluate this technique, relative to interposed grafts and simple neurorraphy, in a rat model. METHOD: Twenty rats were allocated to four groups. For Group 1, sectioning of the sciatic nerve was performed, a segment 4 mm long discarded, and epineural suture with distal anchoring stitches were placed resulting in slight tension neurorraphy. For Group 2, a simple neurorraphy was performed. For Group 3, a 4 mm long graft was employed and Group 4 served as control. Ninety days after, reoperation, latency of motor action potentials recording and axonal counts were performed. Inter-group comparison was done by means of ANOVA and the non-parametric Kruskal-Wallis test. RESULTS: The mean motor latency for the simple suture (2.27±0.77 ms) was lower than for the other two surgical groups, but lower than among controls (1.69±0.56 ms). Similar values were founding in both group 1 (2.66±0.71 ms) and group 3 (2.64±0.6 ms). When fibers diameters were compared a significant difference was identified between groups 2 and 3 (p=0.048). CONCLUSION: Good results can be obtained when suturing a nerve employ with epineural anchoring stitches. However, more studies are needed before extrapolating results to human nerve sutures.

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We aimed to determine the position, number and variability of the sphenoid sinus ostia. A total of 32 dry skulls were examined under x6 magnification. The septum and nasal turbinates were removed to expose the anterior wall of the sphenoid sinus. A caliper was used for measurements. We found 2 ostia per skull, except for one (3%), in which the left ostium was absent. The inferior edges of both ostia were found at the same height in only four skulls (12.5%), and the superior edges of both ostia were found at the same height in only one skull (3%). Thus, in 27 skulls (84%) the lower and upper margins of both ostia were at different levels. The distance from the internal edge of the right ostium to the midline was 2.04mm on average (range: 0.3-5.3mm). The distance from the internal edge of the left ostium to the midline was 2.18mm on average (range: 0.2 to 5.1mm). In most skulls, the sphenoid ostia are located at different heights on each side; also a great variability in the distance from the internal border of the ostia to the midline was found. We found this anatomical knowledge useful when performing a transsphenoidal approach to the sella turcica.

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Objetivo. Documentar la utilidad de una técnica de sutura epineural bajo tensión, en comparación con la sutura mediante injerto interpuesto y la neurorrafia termino-terminal, en un estudio realizado en un modelo experimental animal (rata Wistar). Material y Método. Un lote de 20 animales, considerados como 40 unidades fisiológicas independientes a nivel del miembro inferior, fueron separados en 4 grupos de 10: en el primero se realizó una sutura bajo tensión con puntos epineurales a nivel del nervio ciático luego de resecar 4 mm de nervio. En el segundo se realizó una sutura término-terminal sin tensión, en el tercero se colocó un puente de injerto autólogo de 4 mm de extensión y el cuarto fue utilizado como control. A los 90 días de efectuados los procedimientos, se reexpusieron las zonas operadas y se documentaron las respuestas fisiológicas a los diferentes tipos de sutura mediante potenciales de acción de músculo (PAM) y nervio (PAN). Resultados. El promedio de la velocidad de conducción para la sutura simple fue el mejor de los tres grupos operados (14,60 mm/ ms), aunque peor que el control (19,31 mm/ms). La sutura a tensión mediante puntos epineurales (12,02 mm/ms) demostró resultados neurofisiológicos superiores que cuando se utilizó injerto autólogo (11,09 mm/ms). Conclusión. El presente estudio demuestra que si se logra coaptar un nervio ciático de rata mediante sutura epineural con puntos distales a la línea de neurorrafia, sus resultados son mejores que al emplear injerto. Sin embargo, estos resultados, obtenidos en un modelo de animal pequeño, deben ser cuidadosamente extrapolados a la práctica quirúrgica habitual.

Objective. To measure the utility of this technique, in comparison with interposed grafts and termino-terminal neuroraphy, all applied in an experimental model (Wistar rat).Materials and method. 20 rats were used in both sides (40 legs, each one considered as independent physiological units, were grouped in four groups: in the first one, a section of thesciatic nerve was performed, a segment 4mm long was discarded and an epineural suture with distal anchoring stitches was done under slight tension. In the second group a tensionlesstermino-terminal neuroraphy was performed after sciatic nerve section. In the third group a 4 mm long graft was employed and the fourth was used as control. 90 days after this procedure, the animals were reoperated and muscle and nerve action potentialswere recorded in both sides. Results. The mean conduction velocity for the simple suture was higher than the other two groups, but lower than the control(19,31 mm/ms). Neuroraphy with epineural stitches (12,02 mm/ms) was better than when an autologous nerve graft was employed (11,09 mm/ms).Conclusion. This study demonstrates that a good result can be obtained if a nerve is sutured under slight tension, employing epineural anchoring stitches. Nevertheless, more studies shouldbe performed before applying these results to human nerve suture.

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Objetivo. Documentar la utilidad de una técnica de sutura epineural bajo tensión, en comparación con la sutura mediante injerto interpuesto y la neurorrafia termino-terminal, en un estudio realizado en un modelo experimental animal (rata Wistar). Material y Método. Un lote de 20 animales, considerados como 40 unidades fisiológicas independientes a nivel del miembro inferior, fueron separados en 4 grupos de 10: en el primero se realizó una sutura bajo tensión con puntos epineurales a nivel del nervio ciático luego de resecar 4 mm de nervio. En el segundo se realizó una sutura término-terminal sin tensión, en el tercero se colocó un puente de injerto autólogo de 4 mm de extensión y el cuarto fue utilizado como control. A los 90 días de efectuados los procedimientos, se reexpusieron las zonas operadas y se documentaron las respuestas fisiológicas a los diferentes tipos de sutura mediante potenciales de acción de músculo (PAM) y nervio (PAN). Resultados. El promedio de la velocidad de conducción para la sutura simple fue el mejor de los tres grupos operados (14,60 mm/ ms), aunque peor que el control (19,31 mm/ms). La sutura a tensión mediante puntos epineurales (12,02 mm/ms) demostró resultados neurofisiológicos superiores que cuando se utilizó injerto autólogo (11,09 mm/ms). Conclusión. El presente estudio demuestra que si se logra coaptar un nervio ciático de rata mediante sutura epineural con puntos distales a la línea de neurorrafia, sus resultados son mejores que al emplear injerto. Sin embargo, estos resultados, obtenidos en un modelo de animal pequeño, deben ser cuidadosamente extrapolados a la práctica quirúrgica habitual.(AU)

Objective. To measure the utility of this technique, in comparison with interposed grafts and termino-terminal neuroraphy, all applied in an experimental model (Wistar rat).Materials and method. 20 rats were used in both sides (40 legs, each one considered as independent physiological units, were grouped in four groups: in the first one, a section of thesciatic nerve was performed, a segment 4mm long was discarded and an epineural suture with distal anchoring stitches was done under slight tension. In the second group a tensionlesstermino-terminal neuroraphy was performed after sciatic nerve section. In the third group a 4 mm long graft was employed and the fourth was used as control. 90 days after this procedure, the animals were reoperated and muscle and nerve action potentialswere recorded in both sides. Results. The mean conduction velocity for the simple suture was higher than the other two groups, but lower than the control(19,31 mm/ms). Neuroraphy with epineural stitches (12,02 mm/ms) was better than when an autologous nerve graft was employed (11,09 mm/ms).Conclusion. This study demonstrates that a good result can be obtained if a nerve is sutured under slight tension, employing epineural anchoring stitches. Nevertheless, more studies shouldbe performed before applying these results to human nerve suture.(AU)

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Objetivo: Determinar la utilidad de la identificación del surco central contralateral a la lesión, a través de Omega invertida, como método para localizar la corteza sensitivomotora adyacente al proceso tumoral. Método: Desde julio de 2005 hasta abril de 2007, fueron operadas por el primer autor (AC) 15 pacientes con lesiones cercanas o a nivel de la corteza sensitivomotora, utilizando el signo de Omega contralateral a la lesión. Además, fueron estudiados 5 cerebros (10 hemisferios) de cadáveres adultos fijados en formol. Resultados: El surco central separa la corteza motora de la sensitiva. Presenta tres rodillas o curvas. La rodilla media, es la resposable de la forma de Omega invertida que muestra el surco central en un corte axial. En promedio, la altura de Omega fue de 11.2mm +/- 3.35mm, y el ancho, en su base, de 15.7mm +/- 2.48mm. Por otro lado, la distancia promedio desde el borde medial de Omega hasta la línea media fue de 24.5mm +/- 5.35mm. En los 15 casos se estudió detenidamente la resonancia magnética (corte axial) antes de la cirugía, para poder identificar el surco central a través del signo de Omega, en el hemisferio contralateral a la lesión. En todos los casos excepto uno, fue posible identificar dicho signo. De los quince pacientes operados, siete mostraron déficit motor previo a la cirugía (1 plejía, 1 paresia severa, 1 paresia moderada y 4 paresias leves). En todos los casos hubo una mejoría en el postoperatorio. Los ocho pacientes restantes no presentaron déficit motor antes de la cirugía. Luego del procedimiento quirúrgico, dichos enfermos continuaron sin presentar déficit motor. Conclusión: El signo de Omega contralateral puede, fácil y eficientemente, ser utilizado para identificar la relación entre una lesión y el surco central ipsilateral.

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La diastematomielia es una forma rara de disrafia espinal (menos del tres por ciento de los casos con disrafismo espinal oculto), más frecuente en el sexo femenino y en los niños. Clínicamente se manifiesta por tres grupos de sínfromes: alteraciones cutáneas, deformidades ortopédicas y síntomas o signos de disfunción neurológica, La asociación con otras malformaciónes raquimedulares está claramente documentada. Presentamos nuestra experiencia de los últimos treinta y seis meses con seis casos de diastomatomielia, de las cuales cuatro se presentaron asociadas a otra patología malformativa raquimedular. A pesar de ser una entidad poco frecuente debe tenerse presente a la hora de la resolución quirúrgica de las distintas malformaciones raquimedulares ya que tratada oportunamente la presencia de diastematomielia no empeora el pronóstico de la patología de base. (AU)

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La diastematomielia es una forma rara de disrafia espinal (menos del tres por ciento de los casos con disrafismo espinal oculto), más frecuente en el sexo femenino y en los niños. Clínicamente se manifiesta por tres grupos de sínfromes: alteraciones cutáneas, deformidades ortopédicas y síntomas o signos de disfunción neurológica, La asociación con otras malformaciónes raquimedulares está claramente documentada. Presentamos nuestra experiencia de los últimos treinta y seis meses con seis casos de diastomatomielia, de las cuales cuatro se presentaron asociadas a otra patología malformativa raquimedular. A pesar de ser una entidad poco frecuente debe tenerse presente a la hora de la resolución quirúrgica de las distintas malformaciones raquimedulares ya que tratada oportunamente la presencia de diastematomielia no empeora el pronóstico de la patología de base. (AU)

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La diastematomielia es una forma rara de disrafia espinal (menos del tres por ciento de los casos con disrafismo espinal oculto), más frecuente en el sexo femenino y en los niños. Clínicamente se manifiesta por tres grupos de sínfromes: alteraciones cutáneas, deformidades ortopédicas y síntomas o signos de disfunción neurológica, La asociación con otras malformaciónes raquimedulares está claramente documentada. Presentamos nuestra experiencia de los últimos treinta y seis meses con seis casos de diastomatomielia, de las cuales cuatro se presentaron asociadas a otra patología malformativa raquimedular. A pesar de ser una entidad poco frecuente debe tenerse presente a la hora de la resolución quirúrgica de las distintas malformaciones raquimedulares ya que tratada oportunamente la presencia de diastematomielia no empeora el pronóstico de la patología de base.

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