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Delgado-López PD, Montalvo-Afonso A, Martín-Alonso J, Martín-Velasco V, Diana-Martín R, Castilla-Díez JM. Predicting histological grade in symptomatic meningioma by an objective estimation of the tumoral surface irregularity. Neurocirugia (Astur : Engl Ed) 2024; 35:113-121. [PMID: 38244923 DOI: 10.1016/j.neucie.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/03/2023] [Indexed: 01/22/2024]
Abstract
INTRODUCTION Predicting the histopathologic grade of meningioma is relevant because local recurrence is significantly greater in WHO grade II-III compared to WHO grade I tumours, which would ideally benefit from a more aggressive surgical strategy. It has been suggested that higher WHO grade tumours are more irregularly-shaped. However, irregularity is a subjective and observer-dependent feature. In this study, the tumour surface irregularity of a large series of meningiomas, measured upon preoperative MRI, is quantified and correlated with the WHO grade. METHODS Unicentric retrospective observational study of a cohort of symptomatic meningiomas surgically removed in the time period between January 2015 and December 2022. Using specific segmentation software, the Surface Factor (SF) was calculated for each meningioma. SF is an objective parameter that compares the surface of a sphere (minimum surface area for a given volume) with the same volume of the tumour against the actual surface of the tumour. This ratio varies from 0 to 1, being 1 the maximum sphericity. Since irregularly-shaped meningiomas present proportionally greater surface area, the SF tends to decrease as irregularity increases. SF was correlated with WHO grade and its predictive power was estimated with ROC curve analysis. RESULTS A total of 176 patients (64.7% females) were included in the study; 120 WHO grade I (71.9%), 43 WHO grade II (25.7%) and 4 WHO grade III (2.4%). A statistically significant difference was found between the mean SF of WHO grade I and WHO grade II-III tumours (0.8651 ± 0.049 versus 0.7081 ± 0.105, p < 0.0001). Globally, the SF correctly classified more than 90% of cases (area under ROC curve 0.940) with 93.3% sensibility and 80.9% specificity. A cutoff value of 0.79 yielded the maximum precision, with positive and negative predictive powers of 82.6% and 92.6%, respectively. Multivariate analysis yielded SF as an independent prognostic factor of WHO grade. CONCLUSION The Surface Factor is an objective and quantitative parameter that helps to identify aggressive meningiomas preoperatively. A cutoff value of 0.79 allowed differentiation between WHO grade I and WHO grade II-III with high precision.
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Affiliation(s)
| | | | | | | | - Rubén Diana-Martín
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, Spain
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Montalvo-Afonso A, Castilla-Díez JM, Martín-Velasco V, Martín-Alonso J, Diana-Martín R, Delgado-López PD. Perioperative risk factors for major complications after bone replacement in decompressive craniectomy. Neurocirugia (Astur : Engl Ed) 2024; 35:145-151. [PMID: 38452931 DOI: 10.1016/j.neucie.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.
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Affiliation(s)
| | | | | | | | - Rubén Diana-Martín
- Departamento de Neurocirugía, Hospital Universitario de Burgos, Burgos, Spain
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Delgado-López PD, Martín-Alonso J, Herrero-Gutiérrez AI, Martín-Velasco V, Castilla-Díez JM, Montalvo-Afonso A, Diana-Martín R, Pérez-Cabo EM. Barbed versus conventional suture in elective posterior spine surgery. Eur Spine J 2024:10.1007/s00586-024-08224-7. [PMID: 38649486 DOI: 10.1007/s00586-024-08224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/26/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Barbed sutures are tissue control devices that can reduce operating room time and costs. We analyzed the utility of barbed sutures in posterior spinal surgery in order to prove non-inferiority to conventional methods for wound closure. METHODS A cohort of patients undergoing elective posterior spinal surgery in which barbed (prospective) versus conventional sutures (retrospective) were used was analyzed. The primary endpoint was the occurrence of wound healing complications or the need for surgical revision. Secondary endpoints included postoperative stay, readmission rate, and duration and cost of wound closure. RESULT A total of 483 patients participated in the study, 183 in the Barbed group and 300 in the Conventional group. Wound dehiscence or seroma occurred in 3.8% and 2.7% of the Barbed and Conventional groups, respectively (p = 0.6588). Both superficial (1.6% versus 4.0%, P = 0.2378) and deep infections (2.7% versus 4.7%, p = 0.4124) occurred similarly in both groups. Overall, the rate of re-intervention due to wound healing problems was also similar (4.9% versus 5.3%, p = 0.9906), as well as, total median hospital stay, postoperative stay and 30-day re-admission rates. The average duration of wound closure (1.66 versus 4.16 min per level operated, p < 0.0001) strongly favored the Barbed group. The mean cost of wound closure per patient was higher in the Barbed group (43.23 € versus 22.67 €, p < 0.0001). CONCLUSIONS In elective posterior spinal procedures, the use of barbed sutures significantly reduced the duration of wound closure. The wound healing process was not hindered and the added cost related to the suture material was small.
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Affiliation(s)
- Pedro David Delgado-López
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain.
| | - Javier Martín-Alonso
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | | | - Vicente Martín-Velasco
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - José Manuel Castilla-Díez
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - Antonio Montalvo-Afonso
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - Rubén Diana-Martín
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
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Delgado-López PD, Fernández Carballal C, Paredes I, Roldan Delgado H, Suárez Fernández D, Vázquez Míguez A. Catastrophising in spinal surgery and the impact of radiology reports. Neurocirugia (Astur : Engl Ed) 2023; 34:217-220. [PMID: 37516278 DOI: 10.1016/j.neucie.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Affiliation(s)
- Pedro David Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, Spain; Sociedad Española de Cirugía Vertebral y Medular - Neurorraquis, Spain.
| | - Carlos Fernández Carballal
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Sociedad Española de Cirugía Vertebral y Medular - Neurorraquis, Spain
| | - Igor Paredes
- Servicio de Neurocirugía, Hospital Universitario 12 de Octubre, Madrid, Spain; Sociedad Española de Cirugía Vertebral y Medular - Neurorraquis, Spain
| | - Héctor Roldan Delgado
- Servicio de Neurocirugía, Complejo Hospitalario universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Sociedad Española de Cirugía Vertebral y Medular - Neurorraquis, Spain
| | - David Suárez Fernández
- Servicio de Neurocirugía, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain; Sociedad Española de Cirugía Vertebral y Medular - Neurorraquis, Spain
| | - Alfonso Vázquez Míguez
- Servicio de Neurocirugía, Hospital Universitario de Pamplona, Pamplona, Navarra, Spain; Sociedad Española de Cirugía Vertebral y Medular - Neurorraquis, Spain
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Diana-Martín R, Delgado-López PD. Scientific authorship in neurosurgery. Neurocirugia (Astur : Engl Ed) 2022:S2529-8496(22)00077-6. [PMID: 36456463 DOI: 10.1016/j.neucie.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/06/2022] [Accepted: 08/21/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Assessment of scientific bibliographic production is a complex issue, mainly based on the impact factor (IF) of the journals and the h index, that quantifies the number of cites an author receives. In order to estimate the bibliographic production and the influence of co-authorship among Spanish neurosurgeons, we performed a PubMed search aimed to identify all papers published by a sample of neurosurgeons. METHODS Cross-sectional observational and regional study. We identified a sample of 183 neurosurgeons from Madrid and Castilla y León Autonomous Communities. The bibliometric information was gathered in March 2022 via PubMed free access website. For each author we registered the type of journal, total number of articles, order of appearance in the authors' list, total IF, the proportion of articles signed as first or second author (Personal Authorship Quotient [PAQ]) and the percentage of IF attributable to those articles (Personal Impact Quotient [PIQ]). RESULTS A total of 3,592 articles from 183 authors were published in 412 different journals, of which only 9.9% were pure neurosurgical journals. Only 17 neurosurgeons (9,3%) had published at least one article as unique author. The average number of articles per neurosurgeon was 20 (median 9) of which 57.7% were published in neurosurgical journals, and 22,2% in Neurocirugía (official publication of the SENEC). The average PAQ was 0.367 (median 0.364) and the average PIQ was 0.317 (median 0.251). Both proportions tended to decrease as the number of publications increased. CONCLUSIONS On average, Spanish neurosurgeons publish half of their articles in neurosurgical journals, appear as first or second author in one third of the cases, and the IF attributable to these papers comprise 25% of the total IF. The PAQ and PIQ provide bibliometric information that minimizes the enlarging effect on curriculum of massive co-authorship and allow comparisons among authors and different scientific fields.
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Affiliation(s)
- Rubén Diana-Martín
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, Spain
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Delgado-López PD, Montalvo-Afonso A, Araus-Galdós E, Isidro-Mesa F, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A. Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery. Neurocirugia (Astur : Engl Ed) 2022; 33:209-218. [PMID: 36084957 DOI: 10.1016/j.neucie.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/14/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.
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Affiliation(s)
| | | | - Elena Araus-Galdós
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
| | - Francisco Isidro-Mesa
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
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Delgado-López PD, González-Bernal JJ. [Feasibility of a screening program for the detection of intracranial meningiomas.]. Rev Esp Salud Publica 2021; 95:e202109118. [PMID: 34538871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/18/2021] [Indexed: 06/13/2023] Open
Abstract
Meningioma is a common slow-growing intra-cranial neoplasm affecting 2-3% of the population, with the potential for irreversible brain damage. The widespread availability of modern neuroimaging allows early detection of small asymptomatic meningiomas. Given that morbidity and mortality rates associated to treatment of small asymptomatic meningiomas is remarkably lower than that of symptomatic, it can be hypothesized whether active search for meningiomas in the general population is warranted. In this paper we explore the justifications and rationale of an eventual screening program for the detection of small asymptomatic meningiomas and discuss its feasibility. Cost-effectiveness, applicability, and ethical issues are also analyzed. Screening for meningiomas would secondarily identify other incidental findings (brain aneurysms, pituitary adenomas, and many others) that would also benefit from surveillance and/or treatment. A broad screening protocol, based on magnetic resonance, with specific calculations for a regional area in Spain, is also provided. Meningiomas are prevalent lesions with a prolonged pre-symptomatic period in which early detection is possible. Magnetic resonance is simple, accurate, innocuous, and serves as screening and confirmatory test. Although screening for asymptomatic meningiomas seems to be clinically well-substantiated and no ethical issues a priori preclude its implementation, its cost-effectiveness needs to be further studied and confirmed.
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DE Santiago BG, López-Gómez M, Delgado-López PD, Gordo AJ, Neria F, Thuissard-Vasallo IJ, Gómez-Raposo C, Tevar FZ, Moreno-Rubio J, Hernández AM, Iglesias I, Casado E. RAS Mutational Status in Advanced Colorectal Adenocarcinoma Treated With Anti-angiogenics: Preliminary Experience With Liquid Biopsy. In Vivo 2021; 35:2841-2844. [PMID: 34410976 PMCID: PMC8408740 DOI: 10.21873/invivo.12571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/31/2021] [Accepted: 06/05/2021] [Indexed: 02/07/2023]
Abstract
AIM To determinate molecular changes in the downstream epidermal growth factor receptor signaling pathway using serial liquid biopsies in patients with metastatic colorectal tumors (mCRC) under anti-angiogenic treatment. PATIENTS AND METHODS Determination of RAS mutation in primary tissue samples from colorectal tumors was performed in the 23 patients included in the study at diagnosis using quantitative-polymerase chain reaction. Sequential mutations were studied in circulating tumor (ct) DNA obtained from plasma samples. RESULTS Twenty-three patients with RAS-mutated primary tumors were included. In the first ctDNA determination, 17 of these patients were found to have wild-type RAS status. Remarkably, three out of these 17 wild-type cases changed to RAS-mutated in subsequent ctDNA assays. CONCLUSION Serial liquid biopsies in patients with mCRC might be a useful tool for identifying changes in the RAS mutation status in patients who had undergone previous anti-angiogenic therapy. The understanding of these changes might help to better define the landscape of mCRC and be the path to future randomized studies.
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Affiliation(s)
| | - Miriam López-Gómez
- Department of Oncology, Infanta Sofía University Hospital, FIIB HUIS HHEN, Madrid, Spain
| | | | - Ana Jiménez Gordo
- Department of Oncology, Infanta Sofía University Hospital, FIIB HUIS HHEN, Madrid, Spain
| | - Fernando Neria
- Faculty of Biomedical Science and Health, Universidad Europea, Madrid, Spain
| | | | - César Gómez-Raposo
- Department of Oncology, Infanta Sofía University Hospital, FIIB HUIS HHEN, Madrid, Spain
| | | | - Juan Moreno-Rubio
- Clinical Oncology Group, IMDEA Food Institute, CEI UAM+CSIC, Madrid, Spain
| | | | - Irene Iglesias
- Department of Pharmacology, Pharmacognosy and Botany, Faculty of Pharmacy, Complutense University Madrid, Madrid, Spain
| | - Enrique Casado
- Department of Oncology, Infanta Sofía University Hospital, FIIB HUIS HHEN, Madrid, Spain
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Delgado-López PD, Montalvo-Afonso A, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero AM, Ortega-Cubero S, Sánchez-Rodríguez A, Rodríguez-Salazar A. Volumetric growth rate of incidental asymptomatic meningiomas: a single-center prospective cohort study. Acta Neurochir (Wien) 2021; 163:1665-1675. [PMID: 33751215 DOI: 10.1007/s00701-021-04815-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Decision about treatment of incidentally found intracranial meningiomas is controversial and conditioned by the growth potential of these tumors. We aimed to evaluate the growth rate of a cohort of incidentally found asymptomatic meningiomas and to analyze their natural course and the need for eventual treatment. METHODS A total of 193 patients harboring intracranial meningiomas (85 with 109 incidental and 108 with 112 symptomatic) were included between 2015 and 2019. In the prospective cohort of incidental meningiomas, we measured size at diagnosis, volumetric growth rate (by segmentation software), appearance of symptoms, and need for surgery or radiotherapy. Progression-free survival and risk factors for growth were assessed with Kaplan-Meier survival and Cox regression analyses. RESULTS Among incidental meningiomas, 94/109 (86.2%) remained untreated during a median follow-up of 49.3 months. Tumor growth was observed in 91 (83.5%) and > 15% growth in 40 (36.7%). Neurological symptoms developed in 1 patient (1.2%). Volume increased an average of 0.51 cm3/year (95% CI, 0.20-0.82). Nine patients were operated (9.2%) and 4 underwent radiotherapy (4.7%). Treatment-related complication rates of incidental and symptomatic meningiomas were 0% and 35.4%, respectively. Persistent neurological defects occurred in 46 (40.7%) of symptomatic versus 2 (2.3%) of incidental meningiomas. Among covariates, only brain edema resulted in an increased risk of significant tumor growth in the female subgroup (Cox regression HR 2.96, 95% CI 1.02-8.61, p = 0.046). Size at diagnosis was significantly greater in the symptomatic meningioma group (37.33 cm3 versus 4.74 cm3, p < 0.001). CONCLUSIONS Overall, 86% of incidentally found meningiomas remained untreated over the first 4 years of follow-up. The majority grew within the 20% range, yet very few developed symptoms. Treatment-related morbidity was absent in the incidental meningioma group.
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Affiliation(s)
- Pedro David Delgado-López
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain.
| | - Antonio Montalvo-Afonso
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - Javier Martín-Alonso
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - Vicente Martín-Velasco
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - José Manuel Castilla-Díez
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | | | - Sara Ortega-Cubero
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - Antonio Sánchez-Rodríguez
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
| | - Antonio Rodríguez-Salazar
- Neurosurgery Department, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain
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Delgado-López PD, Montalvo-Afonso A, Araus-Galdós E, Isidro-Mesa F, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A. Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00031-2. [PMID: 33875378 DOI: 10.1016/j.neucir.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/10/2021] [Accepted: 03/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.
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Affiliation(s)
| | | | - Elena Araus-Galdós
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
| | - Francisco Isidro-Mesa
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
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Delgado-López PD, Buzón-Martín L, Montero-Baladia M, Astigarraga I. Etoposide for Cytokine Storm Because of Coronavirus Disease 2019. Chest 2021; 159:1678-1679. [PMID: 34021998 PMCID: PMC8021941 DOI: 10.1016/j.chest.2020.10.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/12/2022] Open
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Iglesias-Julián E, López-Veloso M, de-la-Torre-Ferrera N, Barraza-Vengoechea JC, Delgado-López PD, Colazo-Burlato M, Ubeira-Iglesias M, Montero-Baladía M, Lorenzo-Martín A, Minguito-de-la-Iglesia J, García-Muñoz JP, Sanllorente-Sebastián R, Vicente-González B, Alemán-Alemán A, Buzón-Martín L. High dose subcutaneous Anakinra to treat acute respiratory distress syndrome secondary to cytokine storm syndrome among severely ill COVID-19 patients. J Autoimmun 2020; 115:102537. [PMID: 32843231 PMCID: PMC7439828 DOI: 10.1016/j.jaut.2020.102537] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Severely ill COVID-19 patients may end in acute respiratory distress syndrome (ARDS) and multi-organ failure. Some of them develop a systemic hyperinflammatory state produced by the massive release of inflammatory agents, known as cytokine storm syndrome (CSS). Inhibition of IL-1 by Anakinra (ANK) is a potential life-saving therapy for severe CSS cases. We propose a rationale for the use of subcutaneous ANK and review our initial experience in a small cohort of severe COVID-19 CSS patients. METHODS Retrospective cohort study of COVID-19 patients developing ARDS (PaO2/FiO2 <300) and exhibiting signs of hyperinflammation (ferritin >1000 ng/mL and/or d-dimers > 1.5 μg/mL, plus IL-6 < 40 mg/mL) that received ANK. For comparison, a propensity score matched historical cohort of patients treated with IL-6 inhibitor Tocilizumab (TCZ) was used. Patients had previously received combinations of azithromycin, hydroxy-chloroquine, and methyl-prednisolone. Laboratory findings, respiratory function and adverse effects were monitored. Resolution of ARDS within the first 7 days of treatment was considered a favorable outcome. RESULTS Subcutaneous ANK (100 mg every 6 h) was given to 9 COVID-19 ARDS CSS patients (77.8% males). Median age was 62 years (range, 42 to 87). A TCZ cohort of 18 patients was selected by propensity score matching and treated with intravenous single dose of 600 mg for patients weighing >75 Kg, or 400 mg if < 75 Kg. Prior to treatment, median PaO2/FiO2 ratio of the ANK and TCZ cohorts were 193 and 249, respectively (p = 0.131). After 7 days of treatment, PaO2/FiO2 ratio improved in both groups to 279 (104-335) and 331 (140-476, p = 0.099) respectively. On day 7, there was significant reduction of ferritin (p = 0.046), CRP (p = 0.043), and IL-6 (p = 0.043) levels in the ANK cohort but only of CRP (p = 0.001) in the TCZ group. Favorable outcome was achieved in 55.6% and 88.9% of the ANK and TCZ cohorts, respectively (p = 0.281). Two patients that failed to respond to TCZ improved after ANK treatment. Aminotransferase levels significantly increased between day 1 and day 7 (p = 0.004) in the TCZ group. Mortality was the same in both groups (11%). There were not any opportunistic infection in the groups nor other adverse effects attributable to treatment. CONCLUSION Overall, 55.6% of COVID-19 ARDS CSS patients treated with ANK exhibited favorable outcome, not inferior to a TCZ treated matched cohort. ANK may be a potential alternative to TCZ for patients with elevated aminotransferases, and may be useful in non-responders to TCZ.
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Affiliation(s)
- Enrique Iglesias-Julián
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Burgos University Hospital, Spain.
| | - María López-Veloso
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Burgos University Hospital, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | - Luis Buzón-Martín
- Infectious Diseases Unit, Department of Internal Medicine, Burgos University Hospital, Spain
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13
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Montalvo-Afonso A, Delgado-López PD, Lista-Araujo MT, Rodríguez-Salazar A. Angiographically occult and spontaneously thrombosed large brain arteriovenous malformation. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30102-0. [PMID: 33060023 DOI: 10.1016/j.neucir.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients.
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Affiliation(s)
- Antonio Montalvo-Afonso
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España. C/Doctor Esquerdo 46, 28009 Madrid, Spain
| | - Pedro David Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España, Avda Islas Baleares 3, 09006 Burgos, Spain.
| | - María Teresa Lista-Araujo
- Servicio de Anatomía Patológica, Hospital Universitario de Burgos, Burgos, España, Avda Islas Baleares 3, 09006 Burgos, Spain
| | - Antonio Rodríguez-Salazar
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España, Avda Islas Baleares 3, 09006 Burgos, Spain
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Delgado-López PD, Ortega-Cubero S, González Bernal JJ, Cubo-Delgado E. Seizure prophylaxis in meningiomas: A systematic review and meta-analysis. Neurologia 2020; 38:S0213-4853(20)30225-5. [PMID: 32896461 DOI: 10.1016/j.nrl.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION No formal indication currently exists for seizure prophylaxis in neurosurgical oncology patients. Neither have specific recommendations been made on the use of antiepileptic drugs (AED) in seizure-free patients with meningiomas scheduled for surgery. AEDs are generally prescribed on a discretionary basis, taking into consideration a range of clinical and radiological risk factors. We present a systematic review and meta-analysis exploring the effectiveness of antiepileptic prophylaxis in patients with meningioma and no history of seizures. METHODS We performed a systematic review of the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and clinicaltrials.gov databases. Of a total of 4368 studies initially identified, 12 were selected for extraction of data and qualitative analysis. Based on the clinical data presented, we were only able to include 6 studies in the meta-analysis. We performed heterogeneity studies, calculated a combined odds ratio, evaluated publication bias, and conducted a sensitivity analysis. RESULTS AED prophylaxis in patients with meningioma and no history of seizures did not significantly reduce the incidence of post-operative seizures in comparison to controls (Mantel-Haenszel combined odds ratio, random effects model: 1.26 [95% confidence interval, 0.60-2.78]; 2041 patients). However, we are unable to establish a robust recommendation against this treatment due to the lack of prospective studies, the presence of selection bias in the studies reviewed, the likelihood of underestimation of seizure frequency during follow-up, and the strong influence of one study on the overall effect. CONCLUSIONS Despite the limitations of this review, the results of the meta-analysis do not support the routine use of seizure prophylaxis in patients with meningioma and no history of seizures.
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Affiliation(s)
- P D Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España.
| | - S Ortega-Cubero
- Servicio de Neurología, Hospital Universitario de Burgos, Burgos, España
| | - J J González Bernal
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, España
| | - E Cubo-Delgado
- Servicio de Neurología, Hospital Universitario de Burgos, Burgos, España
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15
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Delgado-López PD, Martín-Alonso J. Prophylactic anticonvulsant therapy in high-grade glioma: A systematic review and meta-analysis of longitudinal studies. Neurocirugia (Astur) 2020; 31:268-278. [PMID: 32265156 DOI: 10.1016/j.neucir.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION It is common practice to prescribe prophylactic antiepileptic drugs (AED) to high-grade glioma (HGG) patients without a history of seizures, yet with limited evidence supporting its use. Ideally, the effectiveness of prophylactic anticonvulsants must outweigh the occurrence of adverse effects and interactions related to AED. The authors conducted a systematic review and metanalysis of longitudinal studies regarding the effectiveness of prophylactic AED in seizure-naïve HGG patients. MATERIALS AND METHODS PubMed/MEDLINE, Cochrane Central Register of Controlled trials, Embase and clinicaltrials.gov databases were systematically searched. Of the initial 1773 studies identified, 15 were finally selected for data extraction and analysis. Heterogeneity among studies, pooled hazard ratios, publication bias and sensitivity analyses were performed separately for a 15-study group (HGG patients within larger series of brain tumors) and a 6-study group (exclusively HGG patients). RESULTS AED prophylaxis did not significantly reduce the incidence of postoperative seizures compared with controls, both in the 15-study group (Mantel-Haenszel random-effects pooled OR 1.08, 95% CI 0.82-1.43, 2123 patients) and in the 6-study group (pooled OR 1.22, 95% CI 0.77-1.92, 540 patients). However, some issues (paucity of prospective trials, overall moderate-risk of bias, and few studies addressing HGG patients exclusively) preclude firm conclusions against routine prophylactic AED prescription. Reported adverse effects attributable to AED were acceptable in the majority of studies. CONCLUSIONS Within the limitations of this review, the results of this metanalysis do not support the routine administration of prophylactic AED to HGG patients without a history of seizures.
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Castrillo-Fraile V, Peña EC, Galán JMTGY, Delgado-López PD, Collazo C, Cubo E. Author Response to Letter to the Editor. Tremor Other Hyperkinet Mov (N Y) 2020; 10:tre-10-770. [PMID: 32149015 PMCID: PMC7052429 DOI: 10.7916/tohm.v0.770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Victoria Castrillo-Fraile
- Department of Rehabilitation, Burgos University Hospital, Burgos, ES,Department of Health Science, University of Valladolid, Valladolid, ES,To whom correspondence should be addressed. E-mail:
| | | | | | | | - Carla Collazo
- Department of Health Science, University of Burgos, Burgos, ES
| | - Esther Cubo
- Department of Neurology, Burgos University Hospital, Burgos, ES,Department of Health Science, University of Burgos, Burgos, ES
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Castrillo-Fraile V, Peña EC, Gabriel Y Galán JMT, Delgado-López PD, Collazo C, Cubo E. Tremor Control Devices for Essential Tremor: A Systematic Literature Review. Tremor Other Hyperkinet Mov (N Y) 2019; 9:tre-09-688. [PMID: 31867136 PMCID: PMC6898897 DOI: 10.7916/tohm.v0.688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/04/2019] [Indexed: 12/01/2022]
Abstract
Background There is a growing interest in nonpharmacological approaches for essential tremor (ET), including tremor cancelation devices. However, the true efficacy of such devices in ET remains unclear. Methods A systematic literature review was conducted using standardized criteria regarding efficacy and comfortability. Devices focused on design or experimental testing in which tremor was simulated in a robot were excluded. Results Out of 324 articles initially identified, 12 articles were included. Orthoses using biomechanical loading and neuromodulation with electrical stimulation, and external tremor cancelation devices, were the main interventions used to suppress tremor. All devices were designed to control tremor of the upper limbs at different anatomical locations. Overall, an average tremor attenuation of 50–98% was reported (level of evidence III). Interference with voluntary movements and portability was described as the main drawback. Discussion In conclusion, this review highlights the growing interest in emerging tremor control devices and the importance of assessing comfort without affecting voluntary movements. However, the level of evidence regarding the efficacy of these tremor control devices remains low. An integrated multidisciplinary combination approach of engineering, robotics, physiology, physiotherapy, and clinical assessment is needed to improve the quality of non-pharmacological interventions for ET.
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Affiliation(s)
- Victoria Castrillo-Fraile
- Department of Rehabilitation, Burgos University Hospital, Burgos, ES.,Department of Health Science, University of Valladolid, Valladolid, ES
| | | | | | | | - Carla Collazo
- Department of Health Science, University of Burgos, Burgos, ES
| | - Esther Cubo
- Department of Neurology, Burgos University Hospital, Burgos, ES.,Department of Health Science, University of Burgos, Burgos, ES
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Delgado-López PD, Roldán-Delgado H, Corrales-García EM. Stereotactic body radiation therapy and minimally invasive surgery in the management of spinal metastases: a change in the paradigm. Neurocirugia (Astur) 2019; 31:119-131. [PMID: 31668627 DOI: 10.1016/j.neucir.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/26/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
Abstract
The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2 to 3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies.
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Affiliation(s)
| | - Héctor Roldán-Delgado
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Canarias, Tenerife, España
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19
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Delgado-López PD, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero A, Ortega-Cubero S, Herrero-Gutiérrez AI, Rodríguez-Salazar A. Vancomycin powder for the prevention of surgical site infection in posterior elective spinal surgery. Neurocirugia (Astur) 2019; 31:64-75. [PMID: 31611139 DOI: 10.1016/j.neucir.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/05/2019] [Accepted: 07/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of vancomycin powder as surgical site infection (SSI) prophylaxis in posterior bilateral elective spinal surgery. MATERIALS AND METHODS Single-center quasi-experimental pre and postintervention comparative cohort study. The post-intervention group received standard intravenous antibiotic prophylaxis plus 1g of vancomycin powder into the surgical field before wound closure, and the pre-intervention group only the intravenous prophylaxis. RESULTS 150 patients were included in each group. Twelve SSI (7 superficial and 5 deep) occurred in the post-intervention group and 16 SSI (7 superficial and 9 deep) in the pre-intervention group. The risk of deep SSI decreased from 6.0% to 3.3% (OR 0,54, 95%CI 0.17-1.65, p=0.411) with vancomycin powder. The percentage of deep SSI due to gram negative-positive germs were 80%-20% and 33%-67% for the post- and pre-intervention groups, respectively (p=0.265). No local or systemic adverse effects occurred attributable to vancomycin powder. CONCLUSION In posterior elective spinal surgery, prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI. There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin.
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Affiliation(s)
| | | | | | | | | | - Sara Ortega-Cubero
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España
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20
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Cubo E, Gallego-Nieto C, Elizari-Roncal M, Barroso-Pérez T, Collazo C, Calvo S, Delgado-López PD. Is Restless Legs Syndrome Associated with an Increased Risk of Mortality? A Meta-Analysis of Cohort Studies. Tremor Other Hyperkinet Mov (N Y) 2019; 9:650. [PMID: 31413895 PMCID: PMC6691746 DOI: 10.7916/tohm.v0.650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/06/2019] [Indexed: 12/01/2022]
Abstract
Background Restless legs syndrome (RLS) is a common sleep disorder,. although controversial, growing evidence relates the presence of RLS to an increased risk of mortality, mainly due to cardiovascular events. The aim of this article was to review the role of RLS as a risk factor of mortality according to independent cohort studies. Methods We performed a literature review via PubMed database for articles relating RLS and mortality. We used the random-effects model to calculate the pooled effect estimates on mortality. Heterogeneity between studies was assessed using quantitative and qualitative analysis. Results Out of 100 articles identified, 13 were finally included. Although studies were heterogeneous (p = 0.001), no significant publication bias was found. When all cohort studies were considered, the random-effects model yielded a significantly increased risk of mortality in RLS versus non-RLS patients (13 studies, hazard ratio [HR] = 1.52, 95% confidence interval [CI] 1.28-1.80). However, this association was not statistically significant when only cohort studies using the international RLS diagnostic criteria were considered (5 studies, HR = 1.63, 95% CI 0.94-2.81). Discussion The results of this meta-analysis suggest that RLS seems to be a risk factor of mortality, although this association is conditioned by the diagnostic criteria used in the studies. Future long-term follow-up standardized mortality studies are needed to address this important question that carries potential impact on population global health.
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Affiliation(s)
- Esther Cubo
- Neurology Department, Hospital Universitario Burgos, ES.,Health Science Department, University of Burgos, ES
| | | | | | | | | | - Sara Calvo
- Research Unit, Hospital Universitario Burgos, ES
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Delgado-López PD, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero A, Ortega-Cubero S, Rodríguez-Salazar A. Cauda equina syndrome due to disk herniation: Long-term functional prognosis. Neurocirugia (Astur) 2019; 30:278-287. [PMID: 31167720 DOI: 10.1016/j.neucir.2019.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Cauda equina syndrome (CES) caused by lumbar disk extrusion is classically considered an indication of urgent surgery. CES can be subdivided into CESI (incomplete CES) and CESR (complete CES with urinary retention and incontinence). This paper evaluates the long-term functional outcome of a CES cohort operated on due to disk herniation. METHODS Single-center retrospective observational study. CES patients due to disk herniation that underwent surgery between 2000 and 2016 were included in the study. Demographic data, time intervals to diagnosis and surgery, preoperative neurologic status and outcome at the end of follow up were recorded. RESULTS Twenty-two patients were included (median age 44 years). Eight patients were CESR and 14 CESI. Median time from symptom onset to diagnosis was 78h (range, 12-720h), and from diagnosis to surgery 24h (range, 5-120h). Median follow up was 75 months (range, 20-195 months). At the end of follow up, in the CESR group (median time from diagnosis to surgery, 23h) only pain significantly improved after surgery (p=0.007). In the CESI group (median time from diagnosis to surgery 23h) low back pain, sciatica and urinary sphincter function significantly improved (p<0.001). There were no significant differences between early (<48h) operation (n=4) and late (n=18) in terms of sphincter recovery (Fisher's Exact Test, p=0.076). CONCLUSION Pain associated to CES improved both in the CESI and CESR groups. However, urinary sphincter impairment significantly improved only in the CESI group. No significant differences were found regarding long-term functional outcome between early and late surgery.
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Delgado-López PD, Garcés-Pérez G, García-Carrasco J, Alonso-García E, Gómez-Menéndez AI, Martín-Alonso J. Posterior Reversible Encephalopathy Syndrome with Status Epilepticus Following Surgery for Lumbar Stenosis and Spondylolisthesis. World Neurosurg 2018; 116:309-315. [PMID: 29864559 DOI: 10.1016/j.wneu.2018.05.174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism. CASE DESCRIPTION We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures. CONCLUSIONS Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.
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Affiliation(s)
| | - Gloria Garcés-Pérez
- Department of Anesthesiology, Hospital Universitario de Burgos, Burgos, Spain
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23
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Delgado-López PD, Corrales-García EM. Influence of Internet and Social Media in the Promotion of Alternative Oncology, Cancer Quackery, and the Predatory Publishing Phenomenon. Cureus 2018; 10:e2617. [PMID: 30027009 PMCID: PMC6044480 DOI: 10.7759/cureus.2617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In the last decade, electronic media has irrupted physician's clinical practice. Patients increasingly use Internet and social media to obtain enormous amounts of unsupervised data about cancer. Blogs, social networking sites, online support groups and forums are useful channels for medical education and experience sharing but also perfect environments for misinformation, quackery, violation of privacy and lack of professionalism. The widespread availability of such electronic resources allows some followers of the alternative oncology to spread useless irrational and controversial remedies for cancer, like false medicaments, miraculous diets, electronic devices, and even psychic therapies, as did charlatans in the past, providing false expectations about cancer treatments. Moreover, so-called predatory journals have introduced confusion and malpractice within the academic biomedical publishing system. This is a rising editorial phenomenon affecting all fields of biomedicine, including oncology that jeopardizes the quality of scientific contribution and damages the image of open access publication.
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Delgado-López PD, Sánchez-Jiménez J, Herrero-Gutiérrez AI, Inclán-Cuesta MT, Corrales-García EM, Martín-Alonso J, Galacho-Harriero AM, Rodríguez-Salazar A. [Radiation protection measures: Implications on the design of neurosurgery operating rooms]. Neurocirugia (Astur) 2018; 29:187-200. [PMID: 29636275 DOI: 10.1016/j.neucir.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/27/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe pros and cons of some radiation protection measures and the implications on the design of a neurosurgery operating room. MATERIAL AND METHODS Concurring with the acquisition and use of an O-arm device, a structural remodeling of our neurosurgery operating room was carried out. The theater was enlarged, the shielding was reinforced and a foldable leaded screen was installed inside the operating room. Radiation doses were measured in front of and behind the screen. RESULTS The screen provides whole-body radiation protection for all the personnel inside the theater (effective dose <5μSv at 2,5 m from the gantry per O-arm exploration; 0,0μSv received behind the screen per O-arm exploration; and undetectable cumulative annual radiation dose behind the screen), obviates the need for leaded aprons and personal dosimeters, and minimizes the circulation of personnel. Enlarging the size of the operating room allows storing the equipment inside and minimizes the risk of collision and contamination. Rectangular rooms provide greater distance from the source of radiation. CONCLUSION Floor, ceiling and walls shielding, a rectangular-shaped and large enough theater, the presence of a foldable leaded screen, and the security systems precluding an unexpected irruption into the operating room during irradiation are relevant issues to consider when designing a neurosurgery operating theater.
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Delgado-López PD, Pi-Barrio J, Dueñas-Polo MT, Pascual-Llorente M, Gordón-Bolaños MC. Recurrent non-functioning pituitary adenomas: a review on the new pathological classification, management guidelines and treatment options. Clin Transl Oncol 2018; 20:1233-1245. [PMID: 29623588 DOI: 10.1007/s12094-018-1868-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/26/2018] [Indexed: 11/25/2022]
Abstract
At least 50% of surgically resected non-functioning pituitary adenomas (NFPA) recur. Either early or late adjuvant radiotherapy is highly efficacious in controlling recurrent NFPA but associates potentially burdensome complications like hypopituitarism, vascular complications or secondary neoplasm. Reoperation is indicated in bulky tumor rests compressing the optic pathway. To date, no standardized medical therapy is available for recurrent NFPA although cabergoline and temozolomide show promising results. Guidelines on the management of recurrent NFPAs are now available. The new 2017 WHO pituitary tumor classification, based on immunohistochemistry and transcription factor assessment, identifies a group of aggressive NFPA variants that may benefit from earlier adjuvant therapy. Nevertheless, NFPA patients exhibit a reduced overall life expectancy largely due to hypopituitarism and treatment-related morbidity. The management of recurrent NFPA benefits from a multidisciplinary teamwork of surgeons, endocrinologists, radiation oncologists, ophthalmologists, pathologists and neuro-radiologists in order to provide individualized therapy and anticipate deterioration.
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Affiliation(s)
- P D Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain.
| | - J Pi-Barrio
- Servicio de Endocrinología Y Nutrición, Hospital Universitario de Burgos, Burgos, Spain
| | - M T Dueñas-Polo
- Servicio de Oncología Radioterápica, Hospital Universitario de Burgos, Burgos, Spain
| | - M Pascual-Llorente
- Servicio de Anatomía Patológica, Hospital Universitario de Burgos, Burgos, Spain
| | - M C Gordón-Bolaños
- Servicio de Oftalmología, Hospital Universitario de Burgos, Burgos, Spain
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Delgado-López PD, Corrales-García EM. Predatory journals: una amenaza emergente para autores y editores de publicaciones biomédicas. Neurocirugia (Astur) 2017; 29:39-43. [PMID: 28965806 DOI: 10.1016/j.neucir.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/29/2017] [Indexed: 11/28/2022]
Abstract
So-called predatory publishing is a new and rising phenomenon presenting as an intellectual fraud that jeopardises the quality of scientific contribution, compromises the activity of authors, reviewers and editors of legitimate journals, damages the image of open access publications and is a very profitable business. In this paper, we review the concept and relevance of predatory journals and the characteristics that differentiate them from legitimate publications. Neurosurgical and general neuroscience journals are not immune to this problem. Academic institutions and ethics committees have a duty to raise awareness of this phenomenon and provide information and support to authors and the whole scientific community to avoid its propagation and potential control of biomedical publishing.
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Delgado-López PD, Castilla-Díez JM. [Impact of obesity in the pathophysiology of degenerative disk disease and in the morbidity and outcome of lumbar spine surgery]. Neurocirugia (Astur) 2017; 29:93-102. [PMID: 28750870 DOI: 10.1016/j.neucir.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/17/2017] [Accepted: 06/26/2017] [Indexed: 01/05/2023]
Abstract
Obesity (BMI>30Kg/m2) is a pandemic with severe medical and financial implications. There is growing evidence that relates certain metabolic processes within the adipose tissue, preferentially abdominal fat, with a low-intensity chronic inflammatory state mediated by adipokines and other substances that favor disk disease and chronic low back pain. Obesity greatly conditions both the preoperative evaluation and the spinal surgical technique itself. Some meta-analyses have confirmed an increase of complications following lumbar spine surgery (mainly infections and venous thrombosis) in obese subjects. However, functional outcomes after lumbar spine surgery are favorable although inferior to the non-obese population, acknowledging that obese patients present with worse baseline function levels and the prognosis of conservatively treated obese cohorts is much worse. The impact of preoperative weight loss in spine surgery has not been prospectively studied in these patients.
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Delgado-López PD, Rodríguez-Salazar A, Martín-Velasco V, Martín-Alonso J, Castilla-Díez JM, Galacho-Harriero A, Araús-Galdós E. [Rationale and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable thoracolumbar fractures: Experience in 86 consecutive patients]. Neurocirugia (Astur) 2017; 28:218-234. [PMID: 28342638 DOI: 10.1016/j.neucir.2017.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe the rationale, pros and cons, and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable (TLICS>4) thoracolumbar fractures. PATIENTS AND METHODS Clinical and radiological data and outcomes from a cohort treated surgically via said approach were retrospectively reviewed. All patients were operated on exclusively by 5 neurosurgeons trained in spine surgery. RESULTS Between June 1999 and December 2015, 86 patients underwent surgery (median age 42years, most common level: L1). Approximately 32.5% presented with a preoperative neurological defect. After surgery (mean duration: 275minutes), 75.6% presented with no neurological sequelae and only one-third required blood transfusion. Median postoperative stay was 7days. Correction of kyphosis was considered adequate and suboptimal but acceptable in 91% and 9% of the patients, respectively. Complications occurred in 36 patients, the majority being transient. We observed failure of the construct in 2 cases (collapse of an expandable cage and extrusion of a locking screw). No infections, vascular or visceral lesions, permanent neurological worsening or mortality occurred during hospitalisation. One patient ultimately needed additional posterior fixation due to persistence of pain. Median follow-up was 252days (27.9% was lost to follow-up). CONCLUSIONS The extrapleural extraperitoneal approach provides solid anterior reconstruction, allows wide decompression of the spinal canal, and permits adequate and long-lasting correction of kyphosis. The rates of infection, construct failure, need for reoperation and vascular or visceral lesions are minimal.
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Affiliation(s)
| | | | | | | | | | | | - Elena Araús-Galdós
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, España
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Delgado-López PD, Corrales-García EM, Martino J, Lastra-Aras E, Dueñas-Polo MT. Diffuse low-grade glioma: a review on the new molecular classification, natural history and current management strategies. Clin Transl Oncol 2017; 19:931-944. [PMID: 28255650 DOI: 10.1007/s12094-017-1631-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/14/2017] [Indexed: 01/01/2023]
Abstract
The management of diffuse supratentorial WHO grade II glioma remains a challenge because of the infiltrative nature of the tumor, which precludes curative therapy after total or even supratotal resection. When possible, functional-guided resection is the preferred initial treatment. Total and subtotal resections correlate with increased overall survival. High-risk patients (age >40, partial resection), especially IDH-mutated and 1p19q-codeleted oligodendroglial lesions, benefit from surgery plus adjuvant chemoradiation. Under the new 2016 WHO brain tumor classification, which now incorporates molecular parameters, all diffusely infiltrating gliomas are grouped together since they share specific genetic mutations and prognostic factors. Although low-grade gliomas cannot be regarded as benign tumors, large observational studies have shown that median survival can actually be doubled if an early, aggressive, multi-stage and personalized therapy is applied, as compared to prior wait-and-see policy series. Patients need an honest long-term therapeutic strategy that should ideally anticipate neurological, cognitive and histopathologic worsening.
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Affiliation(s)
- P D Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain.
| | - E M Corrales-García
- Servicio de Oncología Radioterápica, Hospital Universitario de Burgos, Burgos, Spain
| | - J Martino
- Servicio de Neurocirugía, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - E Lastra-Aras
- Servicio de Oncología Médica, Hospital Universitario de Burgos, Burgos, Spain
| | - M T Dueñas-Polo
- Servicio de Oncología Radioterápica, Hospital Universitario de Burgos, Burgos, Spain
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Delgado-López PD, Gil-Polo C, Martín-Velasco V, Martín-Alonso J, Galacho-Harriero AM, Araus-Galdós E. Spinal cord herniation repair with microstaples: case report. J Neurosurg Spine 2017; 26:384-387. [DOI: 10.3171/2016.8.spine16318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Idiopathic spinal cord herniation (ISCH) is a relatively rare and frequently misdiagnosed condition. It preferentially affects women and causes progressive thoracic myelopathy that presents as a Brown-Séquard syndrome or as spastic paraparesis. Although its etiology and pathogenesis are controversial, ISCH is characterized by the presence of an anterior dural defect that allows the incarceration of a segment of the cord. Typically, a C-shaped ventral displacement and kinking of the cord are visible on sagittal MRI. Surgery aimed at stopping or reversing myelopathic symptoms is usually recommended for symptomatic patients. Surgical options include reduction of the hernia and direct suturing, or enlargement of the dural defect, with or without patching. Suturing under the cord in a very tight space can be troublesome and may lead to neurological deterioration. The authors present the case of a symptomatic ISCH in which nonpenetrating titanium microstaples were used to close the dural defect after cord reduction. The patient experienced a good outcome, and the follow-up MRI study showed adequate cord repositioning and stability of the suture. The use of microstaples, which allows for an easier and faster dural closure than conventional suturing, is a novel technical adjunct that has not been previously reported for this condition. In addition, microstaples produce minimal metallic artifact that does not hinder the quality of follow-up MR images.
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Delgado-López PD, Rodríguez-Salazar A, Martín-Alonso J, Martín-Velasco V. [Lumbar disc herniation: Natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests]. Neurocirugia (Astur) 2017; 28:124-134. [PMID: 28130015 DOI: 10.1016/j.neucir.2016.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/26/2016] [Accepted: 11/24/2016] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Indication for surgery in lumbar disc herniation (LDH) varies widely depending on the geographical area. DEVELOPMENT A literature review is presented on the natural history, role of physical examination, timing of surgery, evidence-based treatment, and conflicts of interests in LDH. Surgery is shown to provide significant faster relief of pain compared to conservative therapy, although the effect fades after a year. There is no treatment modality better than the rest in terms of pain control and neurological recovery, nor is there a surgical technique clearly superior to simple discectomy. The lack of sound scientific evidence on the surgical indication may contribute to its great geographical variability. CONCLUSIONS Since LDH has a favourable natural history, neuroimaging and surgery should not be considered until after a 6-week period. It is necessary to specify and respect the surgical indications for LDH, avoiding conflicts of interests.
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Delgado-López PD, Rodríguez-Salazar A, Martín-Velasco V, Castilla-Díez JM, Martín-Alonso J, Galacho-Harriero A, Gil-Polo C, Araus-Galdós E. [Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details]. Neurocirugia (Astur) 2016; 28:51-66. [PMID: 27639666 DOI: 10.1016/j.neucir.2016.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/24/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES). METHODS A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes. RESULTS A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance. CONCLUSION TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation.
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Affiliation(s)
| | | | | | | | | | | | - Cecilia Gil-Polo
- Servicio de Neurología, Hospital Universitario de Burgos, Burgos, España
| | - Elena Araus-Galdós
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, España
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Delgado-López PD, López-Martínez JL, Gero-Escapa M, Martín-Alonso J, Castaño-Blazquez M, Ossa-Echeverri S, Martín-Velasco V, Castilla-Díez JM. [Aneurysmal subarachnoid haemorrhage: Results after introducing endovascular therapy in a medium-low volume centre]. Neurocirugia (Astur) 2016; 27:207-19. [PMID: 26975879 DOI: 10.1016/j.neucir.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the impact of introducing endovascular therapy for patients with aneurysmal subarachnoid haemorrhage (aSAH) in a medium-low volume centre. MATERIAL AND METHODS A retrospective observational study was conducted by comparing the clinical outcome of patients with aSAH before and after introducing endovascular therapy in our centre. The main variables analysed were: type of treatment, hospital and late mortality, intra-procedural morbidity, rate of re-bleeding and vasospasm, and clinical outcome according to the Glasgow Outcome Score (GOS). RESULTS Seventy-one patients were treated in two periods: 2010-2011 (32 patients; 19 clipped, 6 coiled, 7 untreated), and 2012-2013 (39 patients, 3 clipped, 34 coiled, 2 untreated). No significant differences were found in age, sex, clinical grade at admission, type and location of aneurysm, Fisher score, or in hospital mortality (28.1% vs 25.6%, P=.35), GOS (except for GOS 5: 43.37% vs 53.8%, P=.045), rate of hydrocephalus and rate of vasospasm. The second cohort obtained better results for aggregated GOS 1+2+3 (36.3% vs 43.75%, P=.034) and for GOS 4+5 (61.5% vs 56.25%, P=.078). The percentage of patients left untreated was significantly lower in the second period (5.1% vs 21.8%, P<.01), as well as the rate of re-bleeding (0% vs 9.4%, P<.01). Patients were treated earlier (2.51 vs 3.95 days), and hospital and total stay were lower (15.2 and 24.6 vs 10.3 and 18 days) in the second period, these differences not reaching statistical significance. CONCLUSIONS Endovascular therapy allowed treating more patients with aSAH, and with a lower re-bleeding rate. This led to a modest reduction in morbidity and mortality.
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Affiliation(s)
| | - José Luis López-Martínez
- Servicio de Radiología, Sección de Neurorradiología Intervencionista, Hospital Universitario de Burgos, Burgos, España
| | - María Gero-Escapa
- Servicio de Cuidados Intensivos, Hospital Universitario de Burgos, Burgos, España
| | | | - Miguel Castaño-Blazquez
- Servicio de Radiología, Sección de Neurorradiología Intervencionista, Hospital Universitario de Burgos, Burgos, España
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Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A, Galacho-Harriero AM, Fernández-Arconada O. Dexamethasone treatment in chronic subdural haematoma. Neurocirugia (Astur) 2009; 20:346-59. [PMID: 19688136 DOI: 10.1016/s1130-1473(09)70154-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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.
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Delgado-López PD, Martín-Velasco V, Galacho-Harriero AM, Castilla-Díez JM, Rodríguez-Salazar A, Echevarría-Iturbe C. Large chondroma of the dural convexity in a patient with Noonan's syndrome. Case report and review of the literature. Neurocirugia (Astur) 2007; 18:241-6. [PMID: 17622464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Intracranial chondromas are extremely rare intracranial tumours that usually arise from the skull base synchondrosis. Exceptionally, they may grow from cartilage rests within the dura mater of the convexity or the falx. They may be part of Ollier's multiple enchondromatosis or Maffuci's syndrome. We describe the case of a young male diagnosed of Noonan's syndrome that underwent resection of a large intracranial chondroma arising from the dural convexity. To our best knowledge this is the first report of such association. CASE REPORT An 18-year-old male presented with a single generalized seizure. The patient was previously diagnosed of Noonan's syndrome on the basis of his special phenotype (Turner-like), low stature, cardiac malformation, retarded sexual and bone development and normal karyotype. He harboured mild psychomotor retardation. Physical and neurological examinations were unremarkable. Brain Magnetic Resonance image showed a large well-circumscribed intracranial mass in the dural convexity of the left frontal-parietal lobes, with heterogeneous contrast enhancement and no peritumoural oedema. The patient was initiated on valproic acid and underwent craniotomy and complete excision of the tumour. The tumour was firm, white-greyish, avascular and could be finely dissected away from the cortex. Postoperative seizures required additional anticonvulsant therapy. He was discharged uneventfully. The pathological study revealed a mature chondroma. Subsequent brain MRI studies have shown no evidence of recurrence after 33 months of follow up. DISCUSSION Chondromas comprise less than 0.3% of intracranial tumours. Only twenty-five cases of intracranial dural convexity chondromas are reported in the literature. Several hystopathogenetic theories have been proposed: metaplasia of meningeal fibroblasts and perivascular meningeal tissue, traumatic or inflammatory cartilaginous activation of fibroblasts and growth of aberrant embryonal cartilaginous rests in the dura mater. Chondromas present clinical features similar to meningiomas. CT scan imaging shows a mass of variable density due to different degrees of calcification with minimum to moderate contrast enhancement. MRI studies show a well-circumscribed lesion without surrounding tissue oedema, that exhibit heterogeneous signal with intermediate to low intensity on T1-weighted images and mixed intensity on T2-weighted images with minimum enhancement. Angiogram is clue to differentiate from meningiomas since chondromas are completely avascular. Complete tumour resection including its dural attachment is the treatment of choice. Long-term prognosis is favourable. Radiation therapy is currently not recommended for residual tumours or inoperable patients due to risk of malignization. Noonan's syndrome (also known as pseudo-Turner syndrome) is a complex familial genetic disorder with a phenotype that resembles that of Turner's syndrome but exhibits no chromosomal defect. No predisposition of Noonan's syndrome for tumoural development is reported in the literature. Association of a dural convexity chondroma with Noonan's syndrome is unique as far as the literature is concerned.
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Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Velasco-Oses A. [Symptomatic cervical stenosis due to calcification of the ligamentum flavum after mild cervical trauma]. Neurocirugia (Astur) 2007; 18:141-6. [PMID: 17497062 DOI: 10.1016/s1130-1473(07)70302-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The calcification of ligamentum flavum (CLF) is a rare disease mainly affecting middle or advanced aged Japanese women. Several clinical and radiological features differentiate CLF from the ossification of the ligamentum flavum (OLF). We present a case of symptomatic cervical-dorsal stenosis presenting after mild cervical trauma in a patient with a remarkable CLF who underwent decompressive laminectomy. The literature regarding CLF is reviewed. CASE REPORT A 65 year-old female suffered mild cervical trauma as a consequence of a car accident. A year later she referred progressive cervical and upper dorsal pain without any sensory or motor defect. Spinal magnetic resonance images showed a well-delineated posterior epidural mass, from C2 to T2, which compressed the spinal cord, without signal of myelopathy. She underwent bilateral laminectomy of the affected levels but no clear improvement occurred. The pathological study of the resected pieces showed a remarkable calcification of the ligamentum flavum. DISCUSSION The CLF is a kind of dystrophic calcification of unknown pathogenesis but likely related to the spinal degenerative changes. It usually presents in Japanese females. A definite relation between CLF and cervical trauma has not been established so far, although the latter may possibly trigger the symptoms. Typically, CLF presents in women in the seventh decade, affects preferably the cervical region, it shows nodular or diffuse pattern in the computerized tomography, it is hypointense in TI and T2-weighted MR sequences and exhibits minimum enhancement after gadolinium administration. CLF differentiates from OLF easily by demonstrating the presence of mature bone formation in the latter. Clinically, CLF may present as radiculopathy or myelopathy. The treatment of choice in symptomatic patients is posterior decompression. Excellent results after laminectomy are reported. Future similar observations will be important from a medical-legal point of view if a relation between CLF and cervical trauma is established since CLF may potentially turn into a severe condition.
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Affiliation(s)
- P D Delgado-López
- Servicios de Neurocirugía, Anatomía Patológica, Hospital General Yagüe, Burgos
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Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Fernández-Arconada O, Corrales-García EM, Galacho-Harnero A, Rodríguez-Salazar A, Pérez-Mies B. Metastatic meningioma to the eleventh dorsal vertebral body: total en bloc spondylectomy. Case report and review of the literature. Neurocirugia (Astur) 2006; 17:240-9. [PMID: 16855782 DOI: 10.1016/s1130-1473(06)70346-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION One in every thousand intracranial meningiomas metastatize extracranially. Lung and intraabdominal organs are most frequently affected. Only 7% involve vertebrae and just a dozen cases have been reported in the literature. To our knowledge, this is the first description of a total en bloc spondylectomy through a posterior approach for the treatment of an intraosseous metastatic meningioma to the eleventh dorsal vertebra. CASE REPORT In March 1996, a 37 year-old male underwent surgical resection for a left occipital intraventricular benign meningioma (WHO I). He was reoperated in February 2002 due to local recurrence. By the end on 2003 he developed progressively invalidating dorsolumbar pain. MRI studies revealed a T11 intraosseous mass. In March 2004, a percutaneous biopsy and vertebroplasty were performed. The pathological specimen was identified as adenocarcinoma and he initiated chemotherapy. Advice from a second pathologist was seeked, who suggested the diagnosis of intraosseous meningioma. Workup studies failed to reveal any primary tumor. In May 2004 the patient was admitted to our department and a new transpedicular biopsy confirmed the diagnosis. In June 2004 he underwent T11 total en bloc spondylectomy (Tomita's procedure), fusion with bone and calcium substitute-filled stackable carbon-fiber cages, and T9 to L1 transpedicular screw fixation. No postoperative complications ocurred and he is, so far, free from primary and secondary disease. Definite pathology: benign meningioma (WHO I). DISCUSSION Distant metastases from intracranial meningiomas are rare entities, arising from benign lesions in, at least, 60% of cases. Enam et al proposed a specific pathological score to differentiate benign, atypic and malignant meningiomas. Such score correlates with the chance of metastatizing: more than 40% in malignant meningiomas compared to 3.8% of brain tumors overall. The ability to metastatize seems to be linked to vascular or lifatic invasiveness. Metastases ocurr more frequently in angioblastic, papillary and meningothelial variants. Hematogenous (especially venous; Batson's perivertebral plexus), linfatic and cerebrospinal fluid are the main routes involved in the spreading of the tumor. Craniotomy itself may also play a role, for the majority of patients have been previously operated on repeatedly. The interval between the onset of the intracranial disease and the appearance of the metastasis varies from months to many years. The value of transpedicular biopsy is widely recognized (efficacy over 80%) and the suitability of the specimen for pathological examination improves when wide inner caliber trephines are used. In the case presented we applied the oncologic concept of vertebral en bloc resection. We believe this case represents a paradigmatic indication of this technique because it respects the concepts of radical resection and spinal stability, and offers an opportunity for the curation of the disease.
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Mateo-Sierra O, Delgado-López PD, García-Leal R, Carrera-Fernández J, Traba-López A, Carrillo-Yagüe R. [Massive intratumoral haemorrhage as a clinical presentation of acoustic neuroma]. Rev Neurol 2002; 35:656-60. [PMID: 12389153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Acoustic neurinoma presenting as massive intratumoural hemorrhage is quite an uncommon entity, with less than 40 clinical reports in the literature. Secondary mass effect compressing the brain stem may be a life threatening condition. CASE REPORT A 38 years old male was admitted at our hospital with several cranial nerve palsies on the right side and decreased level of consciousness (GCS 5) of acute onset. On cranial computed tomography a great haematoma was found in the right cerebello pontine angle, appearing to be an intratumoural bleeding. Emergency surgery was performed with complete removal of the haematoma and of the tumour related to the VIII cranial nerve, which was diagnosed as hypervascularized schwannoma. Clinical outcome was good. CONCLUSIONS Intratumoural hemorrhage in acoustic neurinomas is rare, appearing mostly in those tumours measuring more than 3 cm and with increased vascularity. In general they manifest with subtle neurological deficits. Acute neurological deterioration with decrease in consciousness level although exceptional may be associated to great mortality rates. The treatment of choice is the complete removal of the haematoma and the tumour, in one surgery if possible. Prognosis is good in most cases, with morbidity consisting on cranial nerve palsies. Hypoglossal facial anastomosis may restore at least partial facial function. Neurophysiology tests give a clear measurement of cranial nerve lesions and their evolution with treatments.
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Affiliation(s)
- O Mateo-Sierra
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañon, Madrid, España.
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Delgado-López PD, Carrera-Fernández J, Carrillo-Yagüe R. [Spontaneous tension pneumocephalus as complication of a posterior frontal sinus wall osteoma]. Rev Neurol 2002; 34:497-8. [PMID: 12040524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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