Jefferson Braga Silva

Carpal tunnel syndrome - Part I (anatomy, physiology, etiology and diagnosis),

Carpal tunnel syndrome (CTS) is defined by compression of the median nerve in the wrist. It is the commonest of the compressive syndromes and its most frequent cause is idiopathic. Even though spontaneous regression is possible, the general rule is that the symptoms will worsen. The diagnosis is primarily clinical, from the symptoms and provocative tests. Electroneuromyographic examination may be recommended before the operation or in cases of occupational illnesses.

A Comparison of Wedge and Needle Hepatic Biopsy in Open Bariatric Surgery

Background: Morbidly obese patients, despite normal laboratory tests and no clinical evidence of liver disease, present a high prevalence of hepatic histological changes. Liver biopsy is able to provide the diagnosis, staging and assessment of follow-up of hepatic disease, thus helping to define clinical management. There is no agreement on which biopsy technique provides better material for analysis. Considering that subcapsular fibrosis is a common finding, sampling from deeper sites is necessary to achieve an adequate histological assessment. Methods: A study was done in 264 consecutive morbidly obese patients who underwent open Roux-en-Y gastric bypass between July 2001 and Sept 2004, in whom an intraoperative liver biopsy was taken. The first 107 were wedge biopsies, and the last 157 were needle biopsies. The histological degree of steatosis, presence of fibrosis and adequacy of material from the 2 biopsy techniques were compared. Results: Degree of steatosis in both sampling techniques showed no statistical difference (P=0.132). The presence of fibrosis in wedge biopsies (46.1% fibrosis, n 41) was significantly higher than in needle biopsies (13.7% fibrosis, n 20), P<0.001. As expected, sample size of needle biopsies was smaller than that obtained by the wedge technique (P<0.001), but there was no difference in the quality of material obtained (P=0.95). Conclusion: Needle biopsies were as effective as wedge biopsies in assessing the degree of steatosis in morbidly obese patients. More important, the presence of subcapsular fibrosis in needle biopsies was less than in wedge biopsies, suggesting an adequate tissue sample by the less invasive technique.

Carpal tunnel syndrome - Part II (treatment),

The treatments for non-deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini-open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long-term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2–0.5%.

Use of sodium fluorescein in skull base tumors.

Objective: The authors present this study using sodium fluorescein (SF) to enhance skull base tumors by performing a quantitative digital analysis of tumor enhancement. The purpose of this study is to observe the grade of SF enhancement by the tumors. Methods: A prospective experiment within-subjects study design was performed which included six patients with skull base lesions. Digital pictures were taken before and after the SF systemic injection, using the same light source of the microsurgical field. The pictures were analyzed by computer software which calculated the wavelength (WL) of the SF pre- and post-injection. Results: The group of tumors was as follows: one vestibular schwannoma, three meningiomas, one craniopharyngioma and one pituitary adenoma. The SF enhancement in all tumors was strongly positive. The digital analysis of the pictures, considering the SF WL pre- and post-injection, presented P = 0.028 (Wilcoxon T test). Conclusions: The enhancement of the tumors by SF was consistent and evident. The introductory results suggest the possibility of using SF as an adjuvant tool for the skull base surgery. Further studies should test the clinical application of the SF in skull base tumors.OBJECTIVE The authors present this study using sodium fluorescein (SF) to enhance skull base tumors by performing a quantitative digital analysis of tumor enhancement. The purpose of this study is to observe the grade of SF enhancement by the tumors. METHODS A prospective experiment within-subjects study design was performed which included six patients with skull base lesions. Digital pictures were taken before and after the SF systemic injection, using the same light source of the microsurgical field. The pictures were analyzed by computer software which calculated the wavelength (WL) of the SF pre- and post-injection. RESULTS THE GROUP OF TUMORS WAS AS FOLLOWS: one vestibular schwannoma, three meningiomas, one craniopharyngioma and one pituitary adenoma. The SF enhancement in all tumors was strongly positive. The digital analysis of the pictures, considering the SF WL pre- and post-injection, presented P = 0.028 (Wilcoxon T test). CONCLUSIONS The enhancement of the tumors by SF was consistent and evident. The introductory results suggest the possibility of using SF as an adjuvant tool for the skull base surgery. Further studies should test the clinical application of the SF in skull base tumors.

Regeneração de nervos periféricos: terapia celular e fatores neurotróficos

Traumatismos em nervos perifericos resultam na perda de funcao do orgao inervado e raramente apresentam recuperacao sem a intervencao cirurgica. Diversas tecnicas cirurgicas sao passiveis de serem empregadas para o reparo nervoso. Dentre elas, ressalta-se o uso da tecnica de tubulizacao, podendo ser acrescentados fatores com capacidade regenerativa na câmara. A terapia celular e engenharia de tecidos surgem como uma alternativa para estimular e auxiliar a regeneracao de nervos perifericos. Portanto, o objetivo desta revisao e fornecer um levantamento e uma analise de estudos experimentais e clinicos, quanto aos resultados obtidos, que utilizam a terapia celular e engenharia de tecidos como ferramentas para otimizar o processo de regeneracao. Os artigos utilizados sao oriundos de bases de dados cientificas LILACS e Medline, atraves de pesquisas realizadas no PubMed e SciELO. Artigos sobre o uso de celulas-tronco, celulas de Schwann, fatores de crescimento, colageno, laminina e plasma rico em plaquetas no reparo de nervos perifericos foram sintetizados ao longo da revisao. Com base nos diversos estudos pode-se concluir que a utilizacao de celulas-tronco derivadas de diferentes fontes apresentam resultados promissores na regeneracao nervosa, pois estas possuem capacidade de diferenciacao neuronal, demonstrando, assim, resultados funcionais eficazes. O uso de tubos acrescidos de elementos bioativos com liberacao controlada tambem otimiza o reparo nervoso, promovendo uma maior mielinizacao e crescimento axonal dos nervos perifericos. Outro tratamento promissor e o uso de plasma rico em plaquetas, que, alem de liberar fatores de crescimento importantes no reparo nervoso, ainda serve como um carreador para fatores exogenos estimulando a proliferacao de celulas especificas no reparo de nervo periferico.

Sodium fluorescein in skull base meningiomas: A technical note

Abstract Objectives Skull base meningiomas are a neurosurgical challenge due to the involvement of neurovascular structures. In this study, the authors present the first study of the trans-operative use of sodium fluorescein (SF) to enhance skull base meningiomas and perform a quantitative digital analysis of the tumors’ pigmentation. The goal of the study was to observe the SF enhancement of skull base meningiomas. Patients and methods A prospective, within-subjects study was designed and performed. This study included twelve patients with skull base meningiomas. After an initial dissection, digital pictures were taken before and after systematic injections of SF using the same light-source used for the surgical microscope. These pictures were analyzed with software that calculated the wavelengths of the sodium fluorescein before and after the injection of the dye. Results The meningiomas in the sample included the following types: 1 cavernous sinus, 1 olfactory groove, 3 petroclival, 1 tuberculum sellae, 3 sphenoid wings, 1 anterior clinoid, and 2 temporal floor. The SF enhancement in all tumors was strongly positive. Conclusions The low cost, universal availability and safety of SF indicate that this dye should be examined in further studies, and its applications in skull-base meningioma surgeries should be further assessed.

A ressonância magnética para o diagnóstico das lesões condrais, meniscais e dos ligamentos cruzados do joelho

OBJETIVO: Avaliar o valor diagnostico da ressonância magnetica (RM) do joelho. MATERIAIS E METODOS: Setenta e dois pacientes foram submetidos a RM previamente a artroscopia do joelho realizada por um unico cirurgiao e considerada como metodo padrao. Verificou-se a sensibilidade, a especificidade, os valores de verossimilhanca e a concordância entre o radiologista e o ortopedista em classificar as lesoes. RESULTADOS: O coeficiente de concordância kappa entre a RM e a artroscopia, em classificar as lesoes, foi muito bom para lesoes de ligamento cruzado anterior (0,84), bom para o menisco lateral (0,75), razoavel para o menisco medial (0,50) e baixo para lesoes condrais (menor que 0,50). A RM mostrou ter alta sensibilidade para rupturas de ligamento cruzado anterior (94%) e menisco medial (92%), boa sensibilidade para lesoes de menisco lateral (80%) e baixa sensibilidade para lesoes em todas as zonas condrais (menor que 50%), enquanto a especificidade foi excelente para todas as estruturas condrais, ligamentares e para o menisco lateral estudadas (maior que 97%) e razoavel para o menisco medial (65%). CONCLUSAO: A RM e uma ferramenta util para subsidiar o diagnostico clinico de lesoes intra-articulares do joelho, como ja foi mostrado em resultados semelhantes encontrados na literatura produzida no Brasil e no exterior.

Effect of platelet-rich plasma on rat Achilles tendon healing is related to microbiota

Background and purpose — In 3 papers in Acta Orthopaedica 10 years ago, we described that platelet-rich plasma (PRP) improves tendon healing in a rat Achilles transection model. Later, we found that microtrauma has similar effects, probably acting via inflammation. This raised the suspicion that the effect ascribed to growth factors within PRP could instead be due to unspecific influences on inflammation. While testing this hypothesis, we noted that the effect seemed to be related to the microbiota. Material and methods — We tried to reproduce our old findings with local injection of PRP 6 h after tendon transection, followed by mechanical testing after 11 days. This failed. After fruitless variations in PRP production protocols, leukocyte concentration, and physical activity, we finally tried rats carrying potentially pathogenic bacteria. In all, 242 rats were used. Results — In 4 consecutive experiments on pathogen-free rats, no effect of PRP on healing was found. In contrast, apparently healthy rats carrying Staphylococcus aureus showed increased strength of the healing tendon after PRP treatment. These rats had higher levels of cytotoxic T-cells in their spleens. Interpretation — The failure to reproduce older experiments in clean rats was striking, and the difference in response between these and Staphylococcus-carrying rats suggests that the PRP effect is dependent on the immune status. PRP functions may be more complex than just the release of growth factors. Extrapolation from our previous findings with PRP to the situation in humans therefore becomes even more uncertain.

Neurite growth acceleration of adult Dorsal Root Ganglion neurons illuminated by low-level Light Emitting Diode light at 645 nm

The effect of a 645 nm Light Emitting Diode (LED) light irradiation on the neurite growth velocity of adult Dorsal Root Ganglion (DRG) neurons with peripheral axon injury 4-10 days before plating and without previous injury was investigated. The real amount of light reaching the neurons was calculated by taking into account the optical characteristics of the light source and of media in the light path. The knowledge of these parameters is essential to be able to compare results of the literature and a way to reduce inconsistencies. We found that 4 min irradiation of a mean irradiance of 11.3 mW/cm(2) (corresponding to an actual irradiance reaching the neurons of 83 mW/cm(2)) induced a 1.6-fold neurite growth acceleration on non-injured neurons and on axotomized neurons. Although the axotomized neurons were naturally already in a rapid regeneration process, an enhancement was found to occur while irradiating with the LED light, which may be promising for therapy applications. Dorsal Root Ganglion neurons (A) without previous injury and (B) subjected to a conditioning injury.

Convexity meningiomas enhanced by sodium fluorescein.

BACKGROUND The resection of the meningiomas surrounding the dura is an important goal during the removal of a convexity meningioma. The authors present the first application of sodium fluorescein (SF) as a tool for tumor and dural tail identification in convexity meningiomas. METHODS Five frontal convexity meningiomas operated on between December 2012 and April 2013 were included. After initial dissection a dose of 1 g of the SF, 20% was injected into a peripheral vein. Tumor and dural tail were removed using the correlation between magnetic resonance imaging (MRI) findings and transoperative SF enhancement. RESULTS Simpson Grade 1 removal was obtained in three cases, grade 2 in one atypical meningioma and grade zero in one case. SF dural tail enhancement was positive in all cases and histologic analysis evidenced involvement of the dura by tumors. CONCLUSION SF enhancement was evident in meningiomas and dura surrounding the lesions. Histologic analysis confirmed dural involvement. SF could represent an universally available fluorescent tool for meningioma surgery.Background: The resection of the meningiomas surrounding the dura is an important goal during the removal of a convexity meningioma. The authors present the first application of sodium fluorescein (SF) as a tool for tumor and dural tail identification in convexity meningiomas. Methods: Five frontal convexity meningiomas operated on between December 2012 and April 2013 were included. After initial dissection a dose of 1 g of the SF, 20% was injected into a peripheral vein. Tumor and dural tail were removed using the correlation between magnetic resonance imaging (MRI) findings and transoperative SF enhancement. Results: Simpson Grade 1 removal was obtained in three cases, grade 2 in one atypical meningioma and grade zero in one case. SF dural tail enhancement was positive in all cases and histologic analysis evidenced involvement of the dura by tumors. Conclusion: SF enhancement was evident in meningiomas and dura surrounding the lesions. Histologic analysis confirmed dural involvement. SF could represent an universally available fluorescent tool for meningioma surgery.