J. Lobo Antunes

Infections of the spine

SummaryA survey is made covering the pathophysiology, clinical symptoms, diagnosis, management, and results in cases with pyogenic or tuberculous spondylitis, disc space infection, spinal epidural abscess, subdural empyema or intramedullary abscess, and parasitic spinal infection.

Spontaneous cerebrospinal fluid fistula through the clivus: report of two cases.

There have been no previous reports of a spontaneous cerebrospinal fluid fistula through the clivus. We present two such cases, describe their management, and propose a physiopathological explanation. The pulsating effect of the basilar artery in Patient 1 and brisk increases in intracranial pressure through repeated Valsalva maneuvers, acting on a congenitally thin bone in Patient 2, seem to be the plausible causes for the clival leakage.

Renal tubular sodium and water metabolism in brain tumour patients submitted to craniotomy

SummaryPurposeTo evaluate the effect of Brain Tomour (BT) and Neurosurgery (NS) on the renal handling of H2O and Na, and the clinical importance of SIADH in this setting.MethodsFourteen patients with BT pre-op for NS and 6 controls (C) pre-op for general surgery, were assessed in a controlled prospective trial.All patients were normovolaemic, with normal renal function. They received 400 mg of lithium carbonate (Li) 8 hours before each of two test periods (I and II) and a standard water load only before period II. Clearances studies were performed pre-op (period I) and 24 hours post-op (period II).ResultsSerum Na was normal at all times. Despite normovolaemia, a 1% decrement in serum osmolality and the water load, ADH dramaticaly increased from time I to II mainly in the BT group (36.2±9.4 vs 7.1±0.6 pmol/L, p=0.02). FENa, FELi and FEUricA were significantly more elevated in the BT group pre and post-op (at time II respectively 4.6±1.6 vs 1.1±0.3%; 29.3±4.9 vs 22.6±5.5; 26.0±8.1 vs 11.3±2.2, p=0.03). Proximal and distal H2O re-absorption and distal fractional Na re-absorption were identical in both groups pre and post-operatively.Conclusions1-BT and NS always induce a SIADH. 2-There was a primary Na loss at the proximal tubule level not explained by ADH increment, that did not significantly changed H2O handling. 3-To prevent hyponatraemia, hypotonic I.V. fluids should be avoided, but more importantly saline must be provided to this potentially salt-wasting condition.

How Many Residents Shall We Train? The Iberian Experience

The basic features of neurosurgical training in Portugal and Spain are described. Data include demographic characteristics, training requirements and accreditation criteria.

Conflicts of interest in medical practice

It has become more and more apparent that some aspects of current medical practice can no longer be kept solely within the private preserve of the profession. Medical error is now treated in an open fashion because it is clear that frank debate over its incidence, causes and mechanisms are crucial to effective prevention. This has always been one of our worst kept secrets. Equally conflicts of interest [1] assume particular relevance in an occupation whose foundation values demand a robust ethical identity. This is the topic of this essay.

Anterior approaches to non-traumatic lesions of the thoracic spine.

The decision on which approach to choose when dealing with pathology involving the thoracic spine depends on a number of factors such as the topography of the lesion, its extension, its relationship with the neural structures, its probable nature, its texture and vascular supply, the degree of resection one wishes to accomplish, and the need to stabilize the spine. Furthermore, the age and clinical status of the patient, and the prognosis of the disease, as well as the experience of the surgeon, should also be taken in consideration. It is clear that the simpler and the less traumatic the procedure, the better it is tolerated by the patient, who, particularly in cases of infectious or neoplastic processes, is often quite sick.The decision on which approach to choose when dealing with pathology involving the thoracic spine depends on a number of factors such as the topography of the lesion, its extension, its relationship with the neural structures, its probable nature, its texture and vascular supply, the degree of resection one wishes to accomplish, and the need to stabilize the spine. Furthermore, the age and clinical status of the patient, and the prognosis of the disease, as well as the experience of the surgeon, should also be taken in consideration. It is clear that the simpler and the less traumatic the procedure, the better it is tolerated by the patient, who, particularly in cases of infectious or neoplastic processes, is often quite sick.

Obituary: António Vasconcelos Marques (1908–1996)

A positive result of re-operation in patients with recurrent symptoms after lumbar disc surgery is likely only if a new disc herniation is present. An improved ability to differentiate between recurrent disc herniation and scar tissue by contrast enhanced CT and MRI is suggested in earlier studies. In a prospective study 29 patients were selected for operation for suspected recurrent disc herniation. The inclusion of the patients was based on clinical symptoms and signs and myelography or non-enhanced CT. All patients were examined by CT and MRI both with and without intravenous contrast pre-operatively. The examinations were evaluated blind on a five point scale and statistical analysed by a regret function. Intravenous contrast improved the diagnostic power of both CT and MRI. MRI was superior to CT in both non-enhanced and enhanced examinations. MRI with intravenous contrast enhancement is proposed as the primary examination in patients with suspected recurrent disc herniation.

Metástase cerebral de melanoma com localização excepcional

Resumo Os autores descrevem o caso de urna doente com historia previa de melanoma maligno, que apresentou um quadro de febre, cefaleias, astenia, desiquilibrio e alteracoes do comportamento, cuja tomografia axial computorizada cranioencefalica revelou hidrocefalia activa devido a urna lesao no 3.° ventriculo sugestiva de um quisto coloide. A lesao foi removida por via transcalosa e o exame microscopico revelou tratarse de urna metastase de melanoma. Discutem-se os aspectos epidemiologicos, clinicos e terapeuticos desta afecao, destacando-se a localizacao excepcional no caso descrito.

Tumors of the vertebral column

The clinical is, in most instances, non-specific. Pain is a common symptom, and may be spontaneous or be of a mechanical nature. It may simulate all the clinical syndromes of the degenarative spinal disorders, and thus it is not surprising that the correct diagnosis is often quite delayed. An expanding mass, which may reach considerable size is another manifestation. Finally as the tumor encroaches upon the spinal canal, it may Tumors of the vertebral column, with the exception of bone metastase are uncommon. They represent however an important cause of morbidity and mortality and require clear understanding of their biology and thorough knowledge of the various management alternatives. Bone tumors represent less than 1% of all cancers; of those, less than 10% are localized in the axial skeleton. Metastases are the most common by far, followed by myeloma, primary bone neoplasms being much rarer. The vertebral column contains a variety of histological components -osteoid, cartilage, fibrous tissue, vascular elements and bone marrow. All these can give origin to neoplasms. Thus the histological variety sarcomas is remarkable. In addition, paraspinal tumors, particularly sarcomas may secondarily involve the vertebra and it is sometimes not possible to determine their exact site of origino In the following table from Dahlin (1978) are indicated the most common malignant tumors of the spine excluding metastases.