Filipe Rodrigues Duarte

Surgical Removal of Giant Acoustic Neuromas

OBJECTIVE The authors present the outcome of radical surgical removal of giant acoustic neuromas. METHODS Twenty-nine patients with acoustic neuroma with maximum diameter greater than 40 mm, submitted to surgery between the years 2005 and 2010, were reviewed by a retrospective study. The extension of tumor removal, surgical morbidity, facial nerve function, hearing, and evolution after surgery of preoperative neurologic conditions were the studied parameters. RESULTS All tumors were completely removed by a retrosigmoid approach, without perioperative mortality. As complications related to the surgery, there were three cases of local cerebrospinal fluid leak, one case of nasal cerebrospinal fluid leak, two cases of meningitis, one pseudomeningocele, and one case of transient lower cranial nerve dysfunction. The anatomic integrity of the facial nerve was preserved in 86% and facial function in 72%. In the 21 patients who did not need hypoglossal-facial anastomosis (72%), facial function was excellent or good (HB I-II) in 13 cases (45%), fair (HB III) in 5 cases (17%), and poor (HB IV) in 3 cases (10%). Before surgery, 12 patients (41%) had useful (H2) or moderate (H3) hearing. In 7 of these 12 patients (58%), it was possible to preserve some hearing function (with moderate hearing), after surgical removal of the tumors. Six patients presented with radiologic signs of hydrocephalus, two of them with visual disturbances. Two patients presented with trigeminal neuralgia (one contralateral), three with facial sensory loss and one with swallowing problems, that disappeared after surgery. CONCLUSIONS Total removal of large acoustic neuroma can be achieved by retrosigmoid approach with acceptable morbidity and no mortality. Preoperative neurologic symptoms recovered after surgery in most cases. Facial function preservation was possible in the majority of cases. Even in large tumors, hearing preservation should be attempted if the patient has useful hearing preoperatively.

Measurement of Cytokines and Adhesion Molecules in the First 72 Hours after Severe Trauma: Association with Severity and Outcome

Introduction. Severity and outcome assessments are crucial in trauma. Our aim was to describe the role of a group of cytokines (TNFα, IL-6, IL-10, and HMGB-1) and ICAM-1 as severity and outcome assessment tools and their kinetics in the first 72 h after severe trauma. Materials and Methods. Authors designed a prospective cohort study of severe polytrauma patients (ISS > 15) in a level 1 Trauma Centre. Cytokines and ICAM-1 levels and Th1/Th2 ratios were assessed at admission, 24, 48, and 72 h. SIRS, SIRS with hypoperfusion, and shock were identified. Outcomes considered were ICU admission, ARDS, MODS, and death. Results. Ninety-nine patients were enrolled (median ISS: 29 and age 31). There was an early release of pro- and anti-inflammatory mediators with higher values at admission (except for ICAM-1). On admission, IL-6 was associated with ISS, IL-10 with SIRS with hypoperfusion, and HMGB-1 with shock. Several cytokines were associated with outcomes, especially IL-6 and IL-10 at 72 h with MODS and death. Low TNFα/IL-10 and IL-6/IL-10 ratios at 24 and 72 h were associated with MODS and death. Conclusions. Pro- and anti-inflammatory responses occur simultaneously and earlier after injury. Cytokines may be useful for outcome assessment, especially IL-6 and IL-10. Low Th1/Th2 ratio at 24 to 72 h is associated with MODS and death.

Neuralgia del trigémino provocada por un tumor del ángulo ponto-cerebeloso contralateral. Caso clínico

Summary In most cases, trigeminal neuralgia is due to compression of the trigeminal nerve in the zone of entrance at the pons by vascular structures. About 1% of cases, have trigeminal neuralgia associated with the presence of ipsilateral lesion of cerebellar-pontine angle. Rarely, trigeminal neuralgia may be due to contralateral posterior fossa tumors. We present a case of a 37-year- old patient who presented with right trigeminal neuralgia and harboured a left acoustic neuroma of significant dimension. Facial pain completely disappeared after tumor removal.

Impact and Weight of Trauma Load and Inflammation Load Variables on the Severity and Outcome of Major Trauma Patients

Background: Several conditions related to injury severity (trauma load) and systemic inflammatory response (SIRS) after major trauma could affect the outcome. The aim of this study was to assess the influence in the outcome of variables related to trauma and to systemic inflammation after major trauma. Materials and Methods: Prospective cohort study involving patients admitted to the trauma room of a level 1 trauma center. Variables related to the trauma load and to the inflammation load were collected in the first six hours after trauma. IL-6 was measured on admission and at 24, 48 and 72 hours. All variables were correlated with negative outcomes, namely ICU admission, ARDS development, MODS development and death. Univariate and multivariate analysis were performed. Results: Ninety nine patients (aged 31 years;, ISS-29) were enrolled. Regarding trauma load variables, in univariate analysis, severity scores were correlated with all the negative outcome variables, TBI severity with ICU admission and death and CT severity with development of ARDS. Regarding inflammation variables, hypothermia and lethal triad were correlated with MODS; SIRS with hypoperfusion, shock, hypothermia, hyperlactacidemia, coagulopathy and lethal triad with death. IL-6 and IL-10 also correlated with negative outcomes. In multivariate analysis, TRISS, hypothermia and shock in the first six hours and IL- 6 at 48 and 72 hours correlated either with MODS development or death. Conclusions: TRISS, shock and hypothermia in the first six hours and IL-6 level at 48 and 72 hours were independently and significantly associated with MODS development or with death. Avoidance or swift resolution of shock and hypothermia may well be the most important goal in the first six hours after major trauma.

Resultados da artroplastia de disco no tratamento da hérnia discal cervical

OBJETIVO: Evaluacion de los resultados a largo plazo de la artroplastia de disco cervical (ADC) y comparacion con la fusion en el tratamiento de la hernia discal. METODOS: Seleccionados pacientes con radiculopatia por hernia discal cervical a un nivel, sometidos sucesivamente a ADC entre junio de 2003 y julio de 2006 (grupo de artroplastia). Realizadas evaluaciones radiografica y clinica en el preoperatorio, al fin de un ano y por lo menos cinco anos despues del procedimiento. Como control, se considero a un grupo sometido a descompresion y artrodesis anterior, operado en el mismo periodo (grupo de fusion), evaluado en el periodo final de seguimiento. RESULTADOS: 22 pacientes del grupo de artroplastia y 12 del grupo de fusion, con periodo promedio de seguimiento de 5,4 anos. En la primera evaluacion, se obtuvo una movilidad promedio de 8,8o (2,2o-22o), habiendo esta disminuido en promedio 3,6o (-18o-3,8o) a la fecha final del acompanamiento. En la fecha final del seguimiento, 28% de los enfermos, sometidos inicialmente a artroplastia, habian perdido la movilidad pretendida; el NDI fue 21% en el grupo de artroplastia vs 36,5% en el grupo de fusion (p=0,008); se registro tendencia para EVA cervical (2,9 vs 4,6) y braquial (2,8 vs 4,9) mas bajo en el grupo de artroplastia (p>0,05). No se verificaron diferencias estadisticamente significativas entre las dos artroplastias que se utilizaron, con respecto a movilidad, scores funcionales o complicaciones. Todos los pacientes del grupo de artroplastia repitieron el procedimiento, en comparacion con solamente 67% del grupo de fusion (p=0,021). CONCLUSIONES: Ambas tecnicas demostraron ser seguras y eficaces en el tratamiento de la hernia discal cervical. La perdida de la movilidad no tuvo repercusion clinica. El grupo de artroplastia demostro una ligera superioridad en los resultados funcionales.Objective: Evaluation of long-term results of cervical disc arthroplasty (CDA) and comparison with fusion in the treatment of disc herniation. Methods: Patients with cervical radiculopathy due to single level disc herniation submitted to CDA between June 2003 and July 2006 (arthroplasty group). Clinical and radiographic evaluation was performed preoperatively, after one year and at least five years after the procedure. A fusion group, who underwent anterior decompression and fusion in the same period, was used as control and was evaluated at final follow-up. Results: 22 patients in the arthroplasty group and 12 in the fusion group, with mean follow-up of 5.4 years. In the first evaluation we obtained an average mobility of 8.8° (range 2.2°-22°), and this decreased on average 3.6o (range-18o-3.8o) to the final date of follow-up. At the time of final follow-up, 28% of patients who initially underwent arthroplasty lost the desired mobility; the NDI was 21% in the arthroplasty group vs 36.5% in the fusion group (p=0.008); there was a tendency for a lower cervical (2.9 vs 4.6) and arm VAS (2.8 vs 4.9) in the arthroplasty group (p>0.05). There were no statistically significant differences between the two arthroplasties used with respect to mobility, functional scores, or complications. All patients in the arthroplasty group would repeat the procedure in comparison to only 67% of the fusion group (p=0.021). Conclusions: Both techniques proved to be effective in the treatment of cervical disc herniation. The loss of mobility was not clinically significant.The arthroplasty group showed slightly superior results in the functional outcomes.

Results of disc arthroplasty for the treatment of cervical disc herniation

OBJETIVO: Evaluacion de los resultados a largo plazo de la artroplastia de disco cervical (ADC) y comparacion con la fusion en el tratamiento de la hernia discal. METODOS: Seleccionados pacientes con radiculopatia por hernia discal cervical a un nivel, sometidos sucesivamente a ADC entre junio de 2003 y julio de 2006 (grupo de artroplastia). Realizadas evaluaciones radiografica y clinica en el preoperatorio, al fin de un ano y por lo menos cinco anos despues del procedimiento. Como control, se considero a un grupo sometido a descompresion y artrodesis anterior, operado en el mismo periodo (grupo de fusion), evaluado en el periodo final de seguimiento. RESULTADOS: 22 pacientes del grupo de artroplastia y 12 del grupo de fusion, con periodo promedio de seguimiento de 5,4 anos. En la primera evaluacion, se obtuvo una movilidad promedio de 8,8o (2,2o-22o), habiendo esta disminuido en promedio 3,6o (-18o-3,8o) a la fecha final del acompanamiento. En la fecha final del seguimiento, 28% de los enfermos, sometidos inicialmente a artroplastia, habian perdido la movilidad pretendida; el NDI fue 21% en el grupo de artroplastia vs 36,5% en el grupo de fusion (p=0,008); se registro tendencia para EVA cervical (2,9 vs 4,6) y braquial (2,8 vs 4,9) mas bajo en el grupo de artroplastia (p>0,05). No se verificaron diferencias estadisticamente significativas entre las dos artroplastias que se utilizaron, con respecto a movilidad, scores funcionales o complicaciones. Todos los pacientes del grupo de artroplastia repitieron el procedimiento, en comparacion con solamente 67% del grupo de fusion (p=0,021). CONCLUSIONES: Ambas tecnicas demostraron ser seguras y eficaces en el tratamiento de la hernia discal cervical. La perdida de la movilidad no tuvo repercusion clinica. El grupo de artroplastia demostro una ligera superioridad en los resultados funcionales.Objective: Evaluation of long-term results of cervical disc arthroplasty (CDA) and comparison with fusion in the treatment of disc herniation. Methods: Patients with cervical radiculopathy due to single level disc herniation submitted to CDA between June 2003 and July 2006 (arthroplasty group). Clinical and radiographic evaluation was performed preoperatively, after one year and at least five years after the procedure. A fusion group, who underwent anterior decompression and fusion in the same period, was used as control and was evaluated at final follow-up. Results: 22 patients in the arthroplasty group and 12 in the fusion group, with mean follow-up of 5.4 years. In the first evaluation we obtained an average mobility of 8.8° (range 2.2°-22°), and this decreased on average 3.6o (range-18o-3.8o) to the final date of follow-up. At the time of final follow-up, 28% of patients who initially underwent arthroplasty lost the desired mobility; the NDI was 21% in the arthroplasty group vs 36.5% in the fusion group (p=0.008); there was a tendency for a lower cervical (2.9 vs 4.6) and arm VAS (2.8 vs 4.9) in the arthroplasty group (p>0.05). There were no statistically significant differences between the two arthroplasties used with respect to mobility, functional scores, or complications. All patients in the arthroplasty group would repeat the procedure in comparison to only 67% of the fusion group (p=0.021). Conclusions: Both techniques proved to be effective in the treatment of cervical disc herniation. The loss of mobility was not clinically significant.The arthroplasty group showed slightly superior results in the functional outcomes.

Resultados de la artroplastia de disco en el tratamiento de la hernia discal cervical

OBJETIVO: Evaluacion de los resultados a largo plazo de la artroplastia de disco cervical (ADC) y comparacion con la fusion en el tratamiento de la hernia discal. METODOS: Seleccionados pacientes con radiculopatia por hernia discal cervical a un nivel, sometidos sucesivamente a ADC entre junio de 2003 y julio de 2006 (grupo de artroplastia). Realizadas evaluaciones radiografica y clinica en el preoperatorio, al fin de un ano y por lo menos cinco anos despues del procedimiento. Como control, se considero a un grupo sometido a descompresion y artrodesis anterior, operado en el mismo periodo (grupo de fusion), evaluado en el periodo final de seguimiento. RESULTADOS: 22 pacientes del grupo de artroplastia y 12 del grupo de fusion, con periodo promedio de seguimiento de 5,4 anos. En la primera evaluacion, se obtuvo una movilidad promedio de 8,8o (2,2o-22o), habiendo esta disminuido en promedio 3,6o (-18o-3,8o) a la fecha final del acompanamiento. En la fecha final del seguimiento, 28% de los enfermos, sometidos inicialmente a artroplastia, habian perdido la movilidad pretendida; el NDI fue 21% en el grupo de artroplastia vs 36,5% en el grupo de fusion (p=0,008); se registro tendencia para EVA cervical (2,9 vs 4,6) y braquial (2,8 vs 4,9) mas bajo en el grupo de artroplastia (p>0,05). No se verificaron diferencias estadisticamente significativas entre las dos artroplastias que se utilizaron, con respecto a movilidad, scores funcionales o complicaciones. Todos los pacientes del grupo de artroplastia repitieron el procedimiento, en comparacion con solamente 67% del grupo de fusion (p=0,021). CONCLUSIONES: Ambas tecnicas demostraron ser seguras y eficaces en el tratamiento de la hernia discal cervical. La perdida de la movilidad no tuvo repercusion clinica. El grupo de artroplastia demostro una ligera superioridad en los resultados funcionales.Objective: Evaluation of long-term results of cervical disc arthroplasty (CDA) and comparison with fusion in the treatment of disc herniation. Methods: Patients with cervical radiculopathy due to single level disc herniation submitted to CDA between June 2003 and July 2006 (arthroplasty group). Clinical and radiographic evaluation was performed preoperatively, after one year and at least five years after the procedure. A fusion group, who underwent anterior decompression and fusion in the same period, was used as control and was evaluated at final follow-up. Results: 22 patients in the arthroplasty group and 12 in the fusion group, with mean follow-up of 5.4 years. In the first evaluation we obtained an average mobility of 8.8° (range 2.2°-22°), and this decreased on average 3.6o (range-18o-3.8o) to the final date of follow-up. At the time of final follow-up, 28% of patients who initially underwent arthroplasty lost the desired mobility; the NDI was 21% in the arthroplasty group vs 36.5% in the fusion group (p=0.008); there was a tendency for a lower cervical (2.9 vs 4.6) and arm VAS (2.8 vs 4.9) in the arthroplasty group (p>0.05). There were no statistically significant differences between the two arthroplasties used with respect to mobility, functional scores, or complications. All patients in the arthroplasty group would repeat the procedure in comparison to only 67% of the fusion group (p=0.021). Conclusions: Both techniques proved to be effective in the treatment of cervical disc herniation. The loss of mobility was not clinically significant.The arthroplasty group showed slightly superior results in the functional outcomes.

Descompresión e instrumentación en estenosis lumbar: relación entre los niveles operados y las complicaciones intra y postoperatorio inmediatas

OBJETIVO: En la cirugia lumbar, la instrumentacion pedicular proporciona la estabilizacion de los segmentos afectados y favorece la artrodesis. En la mayoria de las veces, se trata de procedimientos complejos en pacientes ancianos y que tienen varios comorbilidades. El numero de niveles a descomprimir/artrodesar no siempre es consensual. Los autores tuvieron la finalidad de determinar si existe relacion entre la cantidad de niveles operados y las complicaciones intra y posoperatorias. METODOS: Estudio retrospectivo que incluyo a 50 individuos con estenosis lumbar sometidos a descompresion y fijacion vertebral posterior, entre 2009 y 2010. Edad promedio de 65,98 ± 8,82 anos. Registro de los niveles instrumentados (NI) y de los niveles descomprimidos (ND). Variables analizadas: Tiempo de recuperacion en unidad posanestesica/intensiva (UPA); Unidades de globulos rojos transfundidos (GR); Variacion de la concentracion de Hemoglobina (Hgb); Tiempo quirurgico (minutos); Dias de internacion; ASA score (American Society of Anesthesiologists). Se registraron las complicaciones neurologicas, infecciosas, vasculares, mal posicionamiento de tornillos y enfermos operados de nuevo. Division en dos grupos: Grupo A: ≤3 NI y Grupo B: >3 NI. Estudio estadistico en SPSS® RESULTADOS: Relacion entre NI y ND con mas GR, mas tiempo de UPA, mas perdida de Hgb y menos tiempo quirurgico (p 3 niveles asociados a mas necesidad de transfusion (p<0,05), mas tiempo en la UPA (p<0,05), mas perdida hematica (p<0,05), mas tiempo quirurgico (p<0,05) y mas incidencias de complicaciones (p<0,05). CONCLUSION: En la estenosis lumbar, instrumentaciones/descompresiones, en mas de tres niveles, tienen tasa mas alta de complicaciones, por consiguiente, en el planeamiento preoperatorio, la relacion riesgo/beneficio debe ser ponderada, especialmente para los pacientes mas ancianos y con mas comorbilidades.

Decompression and vertebral instrumentation in lumbar stenosis: level related early complications after surgery

OBJETIVO: En la cirugia lumbar, la instrumentacion pedicular proporciona la estabilizacion de los segmentos afectados y favorece la artrodesis. En la mayoria de las veces, se trata de procedimientos complejos en pacientes ancianos y que tienen varios comorbilidades. El numero de niveles a descomprimir/artrodesar no siempre es consensual. Los autores tuvieron la finalidad de determinar si existe relacion entre la cantidad de niveles operados y las complicaciones intra y posoperatorias. METODOS: Estudio retrospectivo que incluyo a 50 individuos con estenosis lumbar sometidos a descompresion y fijacion vertebral posterior, entre 2009 y 2010. Edad promedio de 65,98 ± 8,82 anos. Registro de los niveles instrumentados (NI) y de los niveles descomprimidos (ND). Variables analizadas: Tiempo de recuperacion en unidad posanestesica/intensiva (UPA); Unidades de globulos rojos transfundidos (GR); Variacion de la concentracion de Hemoglobina (Hgb); Tiempo quirurgico (minutos); Dias de internacion; ASA score (American Society of Anesthesiologists). Se registraron las complicaciones neurologicas, infecciosas, vasculares, mal posicionamiento de tornillos y enfermos operados de nuevo. Division en dos grupos: Grupo A: ≤3 NI y Grupo B: >3 NI. Estudio estadistico en SPSS® RESULTADOS: Relacion entre NI y ND con mas GR, mas tiempo de UPA, mas perdida de Hgb y menos tiempo quirurgico (p 3 niveles asociados a mas necesidad de transfusion (p<0,05), mas tiempo en la UPA (p<0,05), mas perdida hematica (p<0,05), mas tiempo quirurgico (p<0,05) y mas incidencias de complicaciones (p<0,05). CONCLUSION: En la estenosis lumbar, instrumentaciones/descompresiones, en mas de tres niveles, tienen tasa mas alta de complicaciones, por consiguiente, en el planeamiento preoperatorio, la relacion riesgo/beneficio debe ser ponderada, especialmente para los pacientes mas ancianos y con mas comorbilidades.

Descompressão e instrumentação na estenose lombar: relação entre os níveis operados e as complicações intra e pós-operatórias imediatas

OBJETIVO: En la cirugia lumbar, la instrumentacion pedicular proporciona la estabilizacion de los segmentos afectados y favorece la artrodesis. En la mayoria de las veces, se trata de procedimientos complejos en pacientes ancianos y que tienen varios comorbilidades. El numero de niveles a descomprimir/artrodesar no siempre es consensual. Los autores tuvieron la finalidad de determinar si existe relacion entre la cantidad de niveles operados y las complicaciones intra y posoperatorias. METODOS: Estudio retrospectivo que incluyo a 50 individuos con estenosis lumbar sometidos a descompresion y fijacion vertebral posterior, entre 2009 y 2010. Edad promedio de 65,98 ± 8,82 anos. Registro de los niveles instrumentados (NI) y de los niveles descomprimidos (ND). Variables analizadas: Tiempo de recuperacion en unidad posanestesica/intensiva (UPA); Unidades de globulos rojos transfundidos (GR); Variacion de la concentracion de Hemoglobina (Hgb); Tiempo quirurgico (minutos); Dias de internacion; ASA score (American Society of Anesthesiologists). Se registraron las complicaciones neurologicas, infecciosas, vasculares, mal posicionamiento de tornillos y enfermos operados de nuevo. Division en dos grupos: Grupo A: ≤3 NI y Grupo B: >3 NI. Estudio estadistico en SPSS® RESULTADOS: Relacion entre NI y ND con mas GR, mas tiempo de UPA, mas perdida de Hgb y menos tiempo quirurgico (p 3 niveles asociados a mas necesidad de transfusion (p<0,05), mas tiempo en la UPA (p<0,05), mas perdida hematica (p<0,05), mas tiempo quirurgico (p<0,05) y mas incidencias de complicaciones (p<0,05). CONCLUSION: En la estenosis lumbar, instrumentaciones/descompresiones, en mas de tres niveles, tienen tasa mas alta de complicaciones, por consiguiente, en el planeamiento preoperatorio, la relacion riesgo/beneficio debe ser ponderada, especialmente para los pacientes mas ancianos y con mas comorbilidades.