André Giacomelli Leal

Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti's syndrome

OBJECTIVE Bertolottis syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain. METHOD We analyzed the cases of Bertolottis syndrome that failed clinical treatment and reviewed the literature concerning this subject. RESULTS Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm. CONCLUSION There is still no consensus about the most appropriate therapy for Bertolottis syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.OBJETIVO: A sindrome de Bertolotti e uma desordem congenita da coluna vertebral caracterizada pela ocorrencia de uma mega-apofise transversa lombar em uma vertebra de aspecto transicional, que geralmente se articula com o sacro ou com o osso iliaco. Tal sindrome tem sido considerada possivel causa de dor lombar. METODO: Analise dos casos de sindrome de Bertolotti que apresentavam dor lombar sem melhora com tratamento conservador e revisao dos artigos publicados. RESULTADOS: Foram revisados cinco pacientes que nao apresentaram melhora com o tratamento clinico, sendo que dois foram submetidos a resseccao cirurgica da mega-apofise transversa. Considerando a experiencia adquirida com estes casos, os autores propoem um algoritmo para diagnostico e tratamento da Sindrome de Bertolotti. CONCLUSAO: Ainda nao ha consenso sobre qual e a terapia mais apropriada para a Sindrome de Bertolotti. Em pacientes em que a mega-apofise parece ser a origem da lombalgia, a resseccao cirurgica parece ser um procedimento seguro e efetivo.

Rapid prototyping of three-dimensional biomodels as an adjuvant in the surgical planning for intracranial aneurysms

PURPOSE To fabricate a three-dimensional biomodels of intracranial aneurysms, using rapid prototyping technology, to facilitate optimal anatomical visualization of aneurysms prior to and during surgery. METHODS Four intracranial aneurysms cases were selected for this study. Using CT angiography images, the rapid prototyping process was completed using a PolyJet technology machine. The size and morphology of the prototypes were compared to brain digital subtraction arteriography of the same patients. RESULTS The biomodels reproduced the exact location and morphology of the intracranial aneurysms, particularly the necks, in life-size dimensions and exactly the same as measured by digital subtraction arteriography. The arterial segments adjacent to the aneurysm and arteries anatomically known by the surgeon were also shown, which could guide the surgeon to the aneurysmal segment. The models showed an average unit cost of US

Primary filum terminale ependymoma: a series of 16 cases

130 and each one took an average of 20 hours to be fabricated. CONCLUSIONS It is possible to fabricate 3D physical biomodels of intracranial aneurysms from CT angiography images. These prototypes may be useful in the surgical planning for intracranial aneurysms to clarify the anatomy, define surgical techniques and facilitate the choice of suitable materials, such as clips and clip appliers.

Is preoperative occupation related to long-term pain in patients operated for lumbar disc herniation?

Filum terminale ependymomas are slow growing tumors of the cauda equina with a high incidence in young adults. Although a complete microsurgical resection can lead to a cure, recurrence is not uncommon. Sixteen cases of filum terminale ependymomas treated at the Instituto de Neurologia de Curitiba were analyzed. Eleven patients were females and 5 males, their age ranging from 7 to 84 years. Symptoms and signs included lumbar pain (31.25%), radicular pain (56.25%) and neurological deficits (12.5%). In three cases, patients had previously undergone surgery in other hospitals. All were tested through MRI and were operated on. Two underwent a laminoplasty and 14 a laminectomy. The last 8 patients of this series had neuro-physiological monitoring during surgery. In all patients a total microsurgical resection was achieved. Histologically, 2 cases were cellular ependymomas and 14 cases myxopapillary ependymomas. There was no recurrence during a 2 to 84 month follow-up period.

Surgical exposure of the internal auditory canal through the retrosigmoid approach with semicircular canals anatomical preservation

Lumbar disc herniation (LDH) is a common cause of back and sciatic pain. When clinical treatment fails, surgery may be indicated in selected patients. Although surgery is effective in most cases, some of these patients may have a poor outcome. Different factors may influence these results and poor adaptation at work is one well-known cause of treatment failure. This study examines 350 patients on long-term follow-up after surgery for first-time LDH. The relationship was analyzed between occupation before surgery and outcome (maintenance of lumbar and leg pain, satisfaction with the surgical treatment and return to work). The preoperative occupation (employed in public or private services, autonomous, unemployed, housewife, retired or student) and the exertion at work were analyzed as prognostic factors for different clinical outcomes. Although unemployed people had higher numerical analog scale for lumbar pain and retired patients had a higher leg pain, this difference was not statistically significant. Retired people were significantly less satisfied with the surgical result. Higher exertion at work showed a statistically insignificant higher level of pain and lower degree of satisfaction. The authors conclude that preoperative occupation was not a statistically significant factor in this series of patients.

Elastomers three-dimensional biomodels proven to be a trustworthy representation of the angiotomographic images

OBJECTIVE Evaluate the feasibility of an adequate exposure with anatomical preservation of labyrinth structures through retrosigmoid transmeatal approach (RSA) in surgeries for resection of acoustic neuromas/vestibular schwannomas (VS). METHOD Thirty patients underwent surgical resection and were preoperatively evaluated with fine slice high definition CT scans and 3D-MRI volumetric reconstructions. Extension of internal auditory canal (IAC) opening during surgery was measured using 3 mm right-angle calibrated hook and neuronavigation parameters. Postoperatively, the extension of IAC opening and integrity of the labyrinth were confirmed through preoperatively images procedures. RESULTS The preoperative length of IACs varied between 7.8 and 12.0 mm (mean 9.3 mm, SD 0.98, 95%CI 8.9 to 9.6, and median 9.0 mm). Postoperative images demonstrated adequate opening of the IAC and semicircular channels integrity. CONCLUSION A complete drilling of the posterior wall of IAC through the RSA is feasible and allows direct visualization of the IAC-fundus without damaging the semicircular canals.

Image-guided surgical planning using anatomical landmarks in the retrosigmoid approach

Methods 3D biomodels were printed with flexible material (elastomer) using angiotomographic DICOM acquired images and compared to 3D digital subtraction angiography (DSA) images. Results 3D biomodels represented the aneurysm angioarchitecture exactly, especially the neck and domus features. Conclusion Elastomers 3D biomodels proved to be a trustworthy representation of the angiotomographic images and could be used to help surgical planning in IA treatment.