Ricardo Ramina

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.

Esthesioneuroblastoma with Intracranial Extension

The authors present five cases of olfactory neuroblastoma with intracranial extension operated on in the Department of Neurosurgery in collaboration with otorhinolaryngologists. This tumor is most frequently reported as growing inside the nasal cavities, and it can extend to the paranasal sinuses. Cases presenting initially as intracranial tumors have been infrequently reported. At present, histological diagnosis of this tumor is aided by the use of electron microscopy and immunocytochemistry. Total resection combined with radiation therapy remains the most satisfactory treatment.

Supraorbital eyebrow approach to skull base lesions

We report our experience with a supraorbital eyebrow minicraniotomy. This technique is suitable to lesions situated in the region of the anterior fossa, suprasellar cisterns, parasellar region and Sylvian fissure. A 50 mm incision in the eyebrow and a supraorbital minicraniotomy is performed. Sixteem patients harboring different lesions were operated on with good postoperative and cosmetic results. We conclude that this approach is safe and useful in selected cases.

Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases.

Trauma to the soft palate is a uncommon event during childhood. Stroke following intraoral trauma is also rare, but has been well documented by the current literature as a potentially serious complication. In this article, we report 2 cases of posttraumatic internal carotid artery thrombosis depicted by imaging studies. We discuss pathogenesis, and the literature is reviewed.

Surgical management of brainstem cavernous malformations

Bleeding from brainstem cavernomas may cause severe deficits due to the absence of non-eloquent nervous tissue and the presence of several ascending and descending white matter tracts and nerve nuclei. Surgical removal of these lesions presents a challenge to the most surgeons. The authors present their experience with the surgical treatment of 43 patients with brainstem cavernomas. Important aspects of microsurgical anatomy are reviewed. The surgical management, with special focus on new intraoperative technologies as well as controversies on indications and timing of surgery are presented. According to several published studies the outcome of brainstem cavernomas treated conservatively is poor. In our experience, surgical resection remains the treatment of choice if there was previous hemorrhage and the lesion reaches the surface of brainstem. These procedures should be performed by experienced neurosurgeons in referral centers employing all the currently available technology.

Imaging features and treatment of an intradural lumbar cystic schwannoma

Spinal schwannomas are frequently observed among patients treated in a reference neurosurgery center. Cystic spinal schwannomas, however, are very scantly found. Due to its indolent behavior and benign course, the diagnosis of schwannomas may pose a challenge to the care giver, and the imaging findings can be misleading. In this article, we illustrate an example of a pauci-symptomatic 55 year-old male patient whose complaint was solely a non specific lumbar pain. Investigation revealed a large cystic lesion comprising the lower lumbar intradural space. He was then treated with microneurosurgical technique involving complete removal of the tumor and reconstruction of the dura mater. Histological and immunohistochemical diagnosis were consistent with cystic schwannoma. The patient presented with complete recovery of his symptom. In this article we aim to emphasize the clinical presentation and treatment of lumbar spine schwannomas, and to illustrate the imaging findings within this uncommon case.

Doença de Creutzfeldt-Jakob forma Heidenhain: relato de caso com achados de ressonância magnética e DWI

A doenca de Creutzfeldt-Jakob (CJD) e uma forma de demencia pre-senil de rapida evolucao, geralmente fatal em um ano. Casos autoctones no Brasil tem sido raramente descritos assim como achados de ressonância magnetica. Mulher, natural de Ponta Grossa PR, branca , 54 anos , foi admitida no servico em outubro de 2001 com quadro de amaurose bilateral cortical progressiva desde ha 1 mes do internamento. Nunca viajou ao exterior e foi somente submetida a uma cirurgia de reducao do estomago, para obesidade. Historia familial sem relato de casos semelhantes. Logo apos o internamento a paciente desenvolveu quadro de disfasia mista, hemiparesia flacida direita, com movimentos coreoatetoticos e crises parciais motoras. Paciente evoluiu com quadro demencial progressivo; atualmente, acamada, torporosa, dependente de alimentacao enteral, recebendo mepacrina, fenitoina e clorpromazina , estabilizando o quadro ate final de maio de 2002. Exames laboratoriais negativos ou normais. Pesquisa de proteina 14-3-3 no liquor foi positiva; enolase-neuronio-especifica no liquor foi normal. Estudo genetico do gen PRNP nao revelou mutacao descrita anteriormente. EEG (23/10/2001) revelou intensa atividade irritativa hemisferio cerebral esquerdo. Estudo de ressonância magnetica revelou areas de hipersinal em T2 e FLAIR em regioes temporal esquerda e bioccipital; gânglios da base normal. Imagens de DWI mostraram hipersinal nas mesmas areas.Outro EEG (15/03/2002) revelou padrao periodico de ondas trifasicas sugestivos de CJD. A paciente fez uso de mepacrina associado a clorpromazina com aparente estabilizacao do quadro, ate seu obito por complicacoes infecciosas pulmonares em abril de 2003.

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

Samii's essentials in neurosurgery

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.

Long-term facial nerve clinical evaluation following vestibular schwannoma surgery

Approaches to the Orbit: a 360 Degrees View.- Intraoperative Brain Mapping.- Functional Microsurgery of Vestibular Schwannomas.- Preservation and Restitution of Auditory Function in Neurofibromatosis Type 2.- Peripheral nerve entrapment syndromes of the lower extremity.- Hypoglossal-facial nerve anastomosis.- Pituitary Surgery Beyond the Sella.- Endoscopy and thermodiskoplasty: a minimally invasive surgical treatment for lumbar pain.- Full-endoscopic lumbar and cervical surgery for disc herniation.- Mini-open transforaminal lumbar interbody fusion for degenerative diseases.- Spinal robotics.- Sphenoid wing meningiomas.- Proliferation Behaviour in Meningiomas.- Syringomyelia and Syringobulbia.- Neural transplantation and restoration of motor behavior in Parkinsons disease.- Potential and limitations of chronic high-frequency deep-brain stimulation in parkinsons disease.- Arachnoid cysts of the posterior fossa.- Surgical reconstruction of musculocutaneous nerves in traumatic brachial plexus injuries.- Facial pain - diagnosis and therapy.- Microvascular Decompression (MVD) for Trigeminal Neuralgia (TN).- Spinal Intramedullary Tumors.- Bypass and vascular reconstruction for anterior circulation aneurysms.- Cerebral bypass and vascular reconstructions for posterior circulation aneurysms.- Facial and cochlear nerve function after surgery of cerebellopontine angle meningiomas.- Optic nerve sheath meningiomas.- Chordomas and Chondrosarcomas.- Vestibular Schwannoma: current state of the art.- Retrosigmoid approach to the posterior and middle fossae.- Endoscope-assisted Microsurgery.- Preoperative visualization of the facial nerve using diffusion tensor imaging fiber tracking in patients with large vestibular schwannomas.- Endoscopic transnasal surgery for clival chordoma.- Olfactory Groove Meningiomas: Pitfalls and surgical technique.- Malformation.- Diagnosis and treatment of adult hydrocephalus.- Petroclival Meningiomas Diagnosis, Treatment and Results.- The surgical management of trigeminal schwannomas.- Facial nerve schwannomas.- Surgery of large and giant residual/recurrent vestibular schwannomas.- Jugular foramen tumors - Diagnosis and management.- Navigated Semirobotic Pedicle Screw Placement - Experience with 250 Consecutive Cases.- Total Lumbar Facet Replacement - Indication, Technique and 3-Years Results.- The Virtual Operating Field - How Image Guidance became integral to microneurosurgery.- Primary Tethered Cord Syndrome.- Considerations on Experimental Neuromodulation Following Grafting the Spinal Cord to Skeletal Muscles for Clinical Application.- Surgery of Cerebellopontine angle Epidermoids.