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Abstract Focal cortical dysplasia (FCD) is a brain malformation that causes medically refractory epilepsy. FCD is classified into three categories based on structural and cellular abnormalities, with FCD type II being the most common and characterized by disrupted organization of the cortex and abnormal neuronal development. In this study, we employed cell-type deconvolution and single-cell signatures to analyze bulk RNA-seq from multiple transcriptomic studies, aiming to characterize the cellular composition of brain lesions in patients with FCD IIa and IIb subtypes. Our deconvolution analyses revealed specific cellular changes in FCD IIb, including neuronal loss and an increase in reactive astrocytes (astrogliosis) when compared to FCD IIa. Astrogliosis in FCD IIb was further supported by a gene signature analysis and histologically confirmed by glial fibrillary acidic protein (GFAP) immunostaining. Overall, our findings demonstrate that FCD II subtypes exhibit differential neuronal and glial compositions, with astrogliosis emerging as a hallmark of FCD IIb. These observations, validated in independent patient cohorts and confirmed using immunohistochemistry, offer novel insights into the involvement of glial cells in FCD type II pathophysiology and may contribute to the development of targeted therapies for this condition.

IntroductionFocal cortical dysplasia (FCD) is a common cause of pharmacoresistant epilepsy. According to the 2022 International League Against Epilepsy classification, FCD type II is characterized by dysmorphic neurons (IIa and IIb) and may be associated with balloon cells (IIb). We present a multicentric study to evaluate the transcriptomes of the gray and white matters of surgical FCD type II specimens. We aimed to contribute to pathophysiology and tissue characterization.MethodsWe investigated FCD II (a and b) and control samples by performing RNA-sequencing followed by immunohistochemical validation employing digital analyses.ResultsWe found 342 and 399 transcripts differentially expressed in the gray matter of IIa and IIb lesions compared to controls, respectively. Cholesterol biosynthesis was among the main enriched cellular pathways in both IIa and IIb gray matter. Particularly, the genes HMGCS1, HMGCR, and SQLE were upregulated in both type II groups. We also found 12 differentially expressed genes when comparing transcriptomes of IIa and IIb lesions. Only 1 transcript (MTRNR2L12) was significantly upregulated in FCD IIa. The white matter in IIa and IIb lesions showed 2 and 24 transcripts differentially expressed, respectively, compared to controls. No enriched cellular pathways were detected. GPNMB, not previously described in FCD samples, was upregulated in IIb compared to IIa and control groups. Upregulations of cholesterol biosynthesis enzymes and GPNMB genes in FCD groups were immunohistochemically validated. Such enzymes were mainly detected in both dysmorphic and normal neurons, whereas GPNMB was observed only in balloon cells.DiscussionOverall, our study contributed to identifying cortical enrichment of cholesterol biosynthesis in FCD type II, which may correspond to a neuroprotective response to seizures. Moreover, specific analyses in either the gray or the white matter revealed upregulations of MTRNR2L12 and GPNMB, which might be potential neuropathological biomarkers of a cortex chronically exposed to seizures and of balloon cells, respectively.

Abstract Objectives We compared the proteomic signatures of the hippocampal lesion induced in three different animal models of mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE+HS): the systemic pilocarpine model (PILO), the intracerebroventricular kainic acid model (KA), and the perforant pathway stimulation model (PPS). Methods We used shotgun proteomics to analyze the proteomes and find enriched biological pathways of the dorsal and ventral dentate gyrus (DG) isolated from the hippocampi of the three animal models. We also compared the proteomes obtained in the animal models to that from the DG of patients with pharmacoresistant MTLE+HS. Results We found that each animal model presents specific profiles of proteomic changes. The PILO model showed responses predominantly related to neuronal excitatory imbalance. The KA model revealed alterations mainly in synaptic activity. The PPS model displayed abnormalities in metabolism and oxidative stress. We also identified common biological pathways enriched in all three models, such as inflammation and immune response, which were also observed in tissue from patients. However, none of the models could recapitulate the profile of molecular changes observed in tissue from patients. Significance Our results indicate that each model has its own set of biological responses leading to epilepsy. Thus, it seems that only using a combination of the three models may one replicate more closely the mechanisms underlying MTLE+HS as seen in patients.

Traumatic atlanto-occipital dislocation (TAOD) are uncommon injuries associated with high immediate mortality rate and occurs more than twice in children than adults, due to biomechanical properties and immaturity of children's cervical spine. We report a pediatric patient with TAOD, who underwent occipitocervical stabilization and also developed a late hydrocephalus requiring a shunt procedure. A six-year-old boy was admitted to the emergency department after a car accident with refractory cervical pain. A cervical computed tomography (CT) scan showed an anterior C1–C2 level hematoma, and a dynamic CT scan demonstrated an increasing basion-dens interval on extension. Cervical magnetic resonance imaging (MRI) showed discontinuity of the tectorial membrane and diffused hyperintense signal on the left alar ligament. These findings were attributed to TAOD, and an occipitocervical fusion was performed. The pain and neurological status improved after surgery, but after 3 months he returned with persistent vomiting, headache, and a CT scan showing hydrocephalus. Then, a ventriculoperitoneal shunt was performed, improving the symptoms. One year after the injury, the patient remained asymptomatic, and a later radiography demonstrated satisfactory bone fusion. In conclusion, the decision-making process regarding treatment should consider several clinical and radiographic findings. Occipitocervical fusion is the treatment of choice, while hydrocephalus is not an unusual complication in children.

Apert syndrome is an uncommon autosomal dominant condition with a varied clinical spectrum which includes premature cranial and facial suture fusion and complex upper and lower limb syndactilies. In this manuscript, we share our posterior vault distraction osteogenesis (PVDO) experience regarding Apert syndrome patients so that a larger patient population may benefit. In addition, we aimed to determine an onset of elevated intracranial pressure in the long term follow up. A retrospective study was performed on consecutive patients with syndromic craniosynostosis who were diagnosed with Apert syndrome, underwent PVDO between 2012 and 2019, and received at least 2 years of follow-up care. Demographic data, diagnosis, surgery related data, and outcome data (perioperative and mid-term complications and need for additional surgery), were verified by means of medical records, clinical photographs, radiographic images, and interviews with all included patients and/or their parents. The present study included 14 patients who were diagnosed respectively with Apert syndrome (n = 14). The average posterior advancement distance achieved was 19.37 ± 3.0 mm. Two patients included in this study presented major complications, but neither experienced permanent sequelae or a lethal course. Two Apert patients presented cerebral spinal fluid (CSF) leakage (Clavien–Dindo type II). One patient presented a onset of elevated intracranial pressure at 4 years of follow up. PVDO is an effective procedure at alleviating intracranial pressure and present a low complication rate.

This is a surgical technique video of a right peri-insular hemispherotomy in a child with Rasmussen’s encephalitis. The patient is a 5-year-old boy with focal onset impaired awareness seizures started 6 months before surgery, developing different subtypes of focal seizures and evolving to drug-resistant epilepsy. In neurological examination, he already had a left-sided hemiparesis with pyramidal signs. Magnetic resonance imaging showed right-sided cortical atrophy and fronto-insular subcortical hyperintensity signal areas. The preoperative electroencephalogram revealed frequent right-sided central mid temporal spikes. The history and complementary exams raised a hypothesis of Rasmussen’s encephalitis, a rare neurological condition, characterized by unilateral chronic inflammation of the cerebral cortex, causing drug-resistant epilepsy, and evolving to progressive neurological decline1. The hemispherotomy is an effective procedure aimed to isolate the entire hemisphere functionally with minimal removal of brain tissue, and remains the only cure for seizures caused by Rasmussen’s encephalitis2,3. Long-term seizure freedom may be achieved in around 80% of patients and improves quality of life4. It’s already accepted that briefer duration of epilepsy preceding the surgery is associated to better adaptive functioning postoperatively due to the high neuroplasticity of young patients4. Three years after surgery, the patient remains seizure free, walking without help.

An 8-month-old boy was referred to our department with a protruding soft mass in the lumbosacral region since birth, with intact overlying skin. The patient had clubfoot, and congenital scoliosis. On neurological examination, he had preserved muscle strength, but evolved with distal weakness and increasing in the lumbar mass volume. MRI confirmed the diagnosis of terminal myelocystocele by the typical finding of a trumpet-like flaring meningocele. Terminal myelocystocele classically presents as a large lumbosacral mass with skin cover, containing fat, cerebrospinal fluid, and neural tissue1,2. The spinal cord herniates through the dysraphic spine and terminates at a neural placode, whereas the central canal opens into a CSF-filled, ependyma-lined cavity3. We present a 2D operative video comprising microsurgical repair of the defect, resection of the nonfunctional caudal cyst wall, reconstruction of the proximal neural placode, and duroplasty.

Background: Despite the various treatment protocols available, survival evaluation is a fundamental criterion for the definition of surgical management; there are still many inconsistencies in the literature on this topic, especially in terms of the value of surgery and its morbidity in patients with very short survival. Objective: The objective was to analyze the association of clinical, oncological, and surgical factors in the survival of patients undergoing spinal surgery for spinal metastases (SM). Materials and Methods: A retrospective cohort of forty patients who were surgically treated at our institution for SM between 2010 and 2018 were included in the study. We applied the prognostic scales of Tomita and Tokuhashi in each patient and evaluated the systemic status using Karnofsky Performance Scale (KPS) and Eastern Cooperative Oncology Group Performance Scale. Survival rate in months was estimated using the Kaplan–Meier curve, with death considered as primary outcome and, for the evaluation of the association between the variables, the Chi-square test, Fisher's exact test, or Fisher–Freeman–Halton test was applied for better survival. The level of statistical significance was considered as 5% (P ≤≤ 0.05). Results: The mean survival was 8.4 months. Patients with KPS 70 had a mean survival of 14.48 months (P = 0.04). The mean survival of patients classified as ECOG 2 was 7.05 months (95% confidence interval [CI]: 3.4–10.7), and that of patients classified as ECOG 3 and 4 was 1.24 months (95% CI: 0.8–1.59). The mean survival rate among the patients with unresectable metastases in other organs was 6.3 months (95% CI: 3.9–8.9), while the survival rate of those who did not have metastases was 13.8 months (95% CI: 10.0–17.68; P = 0.022). Conclusion: Survival was associated with the preoperative functional status defined by the KPS and ECOG scales and with the presence of nonresectable visceral metastases.

Hippocampal sclerosis (HS) is a common cause of pharmacoresistant focal epilepsy. Here, we (1) performed a histological approach to the anterior temporal pole of patients with HS to evaluate cortical and white matter (WM) cell populations, alteration of myelin integrity and markers of neuronal activity, and (2) correlated microscopic data with magnetic resonance imaging (MRI) findings. Our aim was to contribute with the understanding of neuroimaging and pathophysiological mechanisms of temporal lobe epilepsy (TLE) associated with HS. We examined MRIs and surgical specimens from the anterior temporal pole from TLE-HS patients (n = 9) and compared them with 10 autopsy controls. MRIs from healthy volunteers (n = 13) were used as neuroimaging controls. Histological techniques were performed to assess oligodendrocytes, heterotopic neurons, cellular proliferative index, and myeloarchitecture integrity of the WM, as well as markers of acute (c-fos) and chronic (ΔFosB) activities of neocortical neurons. Microscopic data were compared with neuroimaging findings, including T2-weighted/FLAIR MRI temporopolar blurring and values of fractional anisotropy (FA) from diffusion-weighed imaging (DWI). We found a significant increase in WM oligodendrocyte number, both in hematoxylin and eosin, and in Olig2-stained sections. The frequencies of oligodendrocytes in perivascular spaces and around heterotopic neurons were significantly higher in patients with TLE–HS compared with controls. The percentage of 2',3'-cyclic-nucleotide 3'-phosphodiesterase (CNPase; a marker of myeloarchitecture integrity) immunopositive area in the WM was significantly higher in TLE-HS, as well as the numbers of c-fos- and ΔFosB-immunostained neocortical neurons. Additionally, we demonstrated a decrease in axonal bundle integrity on neuroimaging, with a significant reduction in the FA in the anterior temporal pole. No differences were detected between individuals with and without temporopolar blurring on visual MRI analysis, considering the number of oligodendroglial cells and percentage of WM CNPase-positive areas. Also, there was no relationship between T2 relaxometry and oligodendrocyte count. In conclusion, our histopathological data support the following: (1) the hypothesis that repetitive neocortical neuronal activity could induce changes in the WM cellular constitution and myelin remodeling in the anterior temporal pole from patients with TLE-HS, (2) that oligodendroglial hyperplasia is not related to temporal blurring or T2 signal intensity on MRI, and (3) that reduced FA is a marker of increase in Olig2-immunopositive cells in superficial temporopolar WM from patients with TLE-HS.

Introduction: Plastic surgery requires diverse skills, knowledge, and competencies, and its scope is broad and challenging. Thus, all plastic surgeons go through extensive education/training, which begins during residency and continues throughout their lives. This study aims to outline a formal training program in 2-dimensional standardized photographic documentation ("photodocumentation") to complement surgical and scientific training during residency in Plastic Surgery. Methods: The components (strategies, topics covered, skills acquisition, and feedback processes) of training in photodocumentation during residency in Plastic Surgery were detailed. Results: Topics in the photodocumentation training program included resident activities, interactions among residents, professional photographers, and surgeons/preceptors, studio settings, cameras, lenses, principles (exposure, aperture, speed, ISO, and depth of field), lighting, preparation and positioning of patients and the camera, photoshoot conditions, photo views, photo database, image formats, computerized photogrammetry, and ethical and medical-legal issues. Conclusion: Training in photodocumentation complements the arsenal of skills needed by residents in Plastic Surgery for continuing education, in order to better prepare them for future careers.

Introduction: The objectives of this study were as follows: (1) to outline a scientific research skills training program, (2) to evaluate the profile of participation of plastic surgery residents in articles, and (3) to analyze the impact of the implementation of the training program on quantitative bibliometric indexes. Methods: This was a bibliometric analysis of the participation of plastic surgery residents of a single institution in articles published in peer-reviewed journals between 2006 and 2014. The data collected were the number of authors, position of residents among authors, article titles, indexing databases and impact factor of the journals, study design, and levels of evidence. Two periods (January 2006 to January 2010 [A] and February 2010 to February 2014 [B]) were created to study the evolutionary profile of the impact of the implementation of the training program outlined in this study. Results: A significant predominance (p < 0.05) was observed among articles published in national journals in the Portuguese language and in the SciELO and LILACS databases, and articles without residents as corresponding author, without impact factor, without assumptions, and with a level of evidence III (retrospective studies). The inter-period comparative analysis revealed a significant increase (p < 0.05) in the numbers of published articles and residents with publications at the end of their residency, in the involvement of one or more residents, and in the articles published in English (period A < period B). Conclusion: The implementation of a scientific research skills training program led to an increase in research activity of (peer-reviewed articles) during the residency.

A female newborn patient presents with meningitis and hydrocephalus after lumbosacral myelomeningocele repair and skin closure. An external ventricular drain was used during the meningitis treatment. Patient had a late onset multiloculated hydrocephalus and isolated fourth ventricle on CT scan follow-up. We performed combined approach with a craniotomy, dissection of intraparietal sulcus entering in the atrium of left lateral ventricle and used endoscopic assistance to fenestrate intraventricular septations and to put a ventricular catheter through tentorium to drain both supra and infratentorial ventricles. The patient improved clinically and radiologically.

A male 3-year-old child was referred to our service due to increasing head size and mild headache. On physical examination, head circumference was 55 cm (bigger than 97th percentile), the child was conscious, alert and oriented to person, place, time and event, his pupils were isochoric, the light reflex was bilaterally positive, eye movements showed a slight palsy on the abduction of the left eye, and a partial vision loss on the left eye was detected. Gait was also impaired. MRI presented a cystic lesion in the suprasellar region suggesting arachnoid cyst, associated with hydrocephalus. An endoscopic ventricular approach was performed through a straight incision over Kocher’s point. The cyst was easily identified, coagulated with cautery and incised with endoscopic scissors. A ball-valve mechanism was well visualized. Prepontine cistern was also sharply opened and the whole cyst wall was coagulated. The patient was discharged on the second postoperative day showing a clinical improvement. Late head CT presented also a radiologic improvement.

Background:. Pfeiffer syndrome (PS) is a very rare condition with a wide clinical spectrum. There are only a few studies that address the classification and treatment of PS and take into account the most commonly presented clinical features. Thus, the objectives of this study are to propose an algorithm for PS management based on a modified severity scale and correlate PS severity with tracheostomy placement. Methods:. An observational retrospective study was performed on consecutive patients with PS (n = 12), who underwent surgery between 2008 and 2018. Clinical features and findings of all included patients with PS were classified as types A, B, and C, which guided treatment workflow. The Fisher test was used to correlate the severity of patients with PS with tracheostomy placement. Results:. There were 12 patients, classified as type A (n = 3), type B (n = 6), and type C (n = 3). All patients who received tracheostomies (n = 6) were stratified into the severe category (n = 9; types B and C) (P < 0.05). There were 4 minor complications, and 1 major complication according to a modified Clavien–Dindo surgical complication scale. Conclusion:. A treatment algorithm based on the 3 different Pfeiffer types was proposed. Severity of PS statistically correlates to tracheostomy placement.

Introduction Spinal cord injury (SCI) is common in polytrauma patients. The standard exam for the initial evaluation is computed tomography (CT), due to its higher sensitivity and specificity when compared with plain radiographs. However, CT is insufficient for the management of some cases, especially to evaluate ligamentous and spinal cord injuries. The objective of the present study is to describe clinical scenarios in which the CT scan was insufficient to guide the treatment of SCIs. Methods We present the cases of four polytrauma patients with normal CT scans at admission and with unstable or surgically-treated lesions. Discussion The cases reported evidence the need for ongoing neurological surveillance with serial physical examination and magnetic resonance imaging (MRI) in cases of neurological injury not explained by CT or occult instability. Conclusion Computed tomography is not always sufficient to determine the management of SCIs. A comprehensive evaluation of the clinical data, CT findings and, occasionally, MRI findings is crucial in order to choose the best conduct.

Abstract Neurofibromatosis type II (NF2) is a rare autosomal dominant inherited disease caused by a mutation in chromosome 22q12 and associated with multiple central nervous system tumors. In this paper, we describe a rare case of cervicomedullary junction ependymoma associated with NF2 in a 25-year-old man who underwent surgical treatment with total resection and had a good clinical outcome. We discussed the nuances of the surgical resection and the literature concerning this rare form of presentation of NF2.

Introduction: Upper cervical injuries (UCI) have a wide range of radiological and clinical presentation due to the unique complex bony, ligamentous and vascular anatomy. We recently proposed a rational approach in an attempt to unify prior classification system and guide treatment. In this paper, we evaluate the clinical results of our algorithm for UCI treatment. Materials and Methods: A prospective cohort series of patients with UCI was performed. The primary outcome was the AIS. Surgical treatment was proposed based on our protocol: Ligamentous injuries (abnormal misalignment, facet perched or locked, increase atlanto-dens interval) were treated surgically. Bone fractures without ligamentous injuries were treated with a rigid cervical orthosis, with exception of fractures in the dens base with risk factors for non-union. Results: Twenty-three patients treated initially conservatively had some follow-up (mean of 171 days, range from 60 to 436 days). All of them were neurologically intact. None of the patients developed a new neurological deficit. Fifteen patients were initially surgically treated (mean of 140 days of follow-up, ranging from 60 to 270 days). In the surgical group, preoperatively, 11 (73.3%) patients were AIS E, 2 (13.3%) AIS C and 2 (13.3%) AIS D. At the final follow-up, the American Spine Injury Association (ASIA) score was: 13 (86.6%) AIS E and 2 (13.3%) AIS D. None of the patients had neurological worsening during the follow-up. Conclusions: This prospective cohort suggested that our UCI treatment algorithm can be safely used. Further prospective studies with longer follow-up are necessary to further establish its clinical validity and safety.

AimsTo assess the validity of an online method to quantitatively evaluate cerebral hypometabolism in patients with pharmacoresistant focal epilepsy as a complement to the visual analysis of the 18F-FDG positron emission tomography (PET)/CT exam.MethodsA total of 39 patients with pharmacoresistant epilepsy and probable focal cortical dysplasia [22 patients with frontal lobe epilepsy (FLE) and 17 with temporal lobe epilepsy (TLE)] underwent a presurgical evaluation including EEG, video-EEG, MRI, and 18F-FDG PET/CT. We conducted the automated quantification of their 18F-FDG PET/CT data and compared the results with those of the visual-PET analysis conducted by experienced nuclear medicine physicians. For each patient group, we calculated Cohen’s Kappa coefficient for the visual and quantitative analyses, as well as each method’s sensitivity, specificity, and positive and negative predictive values.ResultsFor the TLE group, both the visual and quantitative analyses showed high agreement. Thus, although the quantitative analysis could be used as a complement, the visual analysis on its own was consistent and precise. For the FLE group, on the other hand, the visual analysis categorized almost half of the cases as normal, revealing very low agreement. For those patients, the quantitative analysis proved critical to identify the focal hypometabolism characteristic of the epileptogenic zone. Our results suggest that the quantitative analysis of 18F-FDG PET/CT data is critical for patients with extratemporal epilepsies, and especially those with subtle MRI findings. Furthermore, it can easily be used during the routine clinical evaluation of 18F-FDG PET/CT exams.SignificanceOur results show that quantification of 18F-FDG PET is an informative complementary method that can be added to the routine visual evaluation of patients with subtle lesions, particularly those in the frontal lobes.

A retrospective case-control study based on craniometrical evaluation was performed to evaluate the incidence of basilar invagination (BI). Patients with symptomatic tonsillar herniation treated surgically had craniometrical parameters evaluated based on CT scan reconstructions before surgery. BI was diagnosed when the tip of the odontoid trespassed the Chamberlain’s line in three different thresholds found in the literature: 2, 5 or 6.6 mm. In the surgical group (SU), the mean distance of the tip of the odontoid process above the Chamberlain’s line was 12 mm versus 1.2 mm in the control (CO) group (p

Intramedullary lipomas correspond to about 1% of the intramedullary tumors. These lesions are commonly associated with spinal dysraphisms and midline defects. Non-dysraphic lipomas are quite rare lesions, potentially located at any site of the spinal cord. Here we present the case history of an intramedullary non-dysraphic cervical spine lipoma.

Introduction: Basilar invagination (BI) is a congenital craniocervical junction (CCJ) anomaly represented by a prolapsed spine into the skull-base that can result in severe neurological impairment. Materials and Methods: In this paper, we retrospective evaluate the surgical treatment of 26 patients surgically treated for symptomatic BI. BI was classified according to instability and neural abnormalities findings. Clinical outcome was evaluated using the Nόrick grade system. Results: A total of 26 patients were included in this paper. Their age ranged from 15 to 67 years old (mean 38). Of which, 10 patients were male (38%) and 16 (62%) were female. All patients had some degree of tonsillar herniation, with 25 patients treated with foramen magnum decompression. Nine patients required a craniocervical fixation. Six patients had undergone prior surgery and required a new surgical procedure for progression of neurological symptoms associated with new compression or instability. Most of patients with neurological symptoms secondary to brainstem compression had some improvement during the follow-up. There was mortality in this series, 1 month after surgery, associated with a late removal of the tracheal cannula. Conclusions: Management of BI requires can provide improvements in neurological outcomes, but requires analysis of the neural and bony anatomy of the CCJ, as well as occult instability. The complexity and heterogeneous presentation requires attention to occult instability on examination and attention to airway problems secondary to concomitant facial malformations.

OBJECTIVE: Evaluate the surgical results of axis screw instrumentation. METHODS: Retrospective evaluation of the clinical and radiological data of patients submitted to axis fixation using screws. RESULTS: Seventeen patients were surgically treated. The mean age was 41.8 years (range: 12-73). Spinal cord trauma was the most common cause of instability (8 patients - 47%). Bilateral axis fixation was performed in all cases, except one, with laminar screw (total of 33 axis screws). Seven patients (41.1%) underwent bilateral pars screws; laminar screws were used in six cases and pedicular screws were used in two. In two cases, we performed a hybrid construction (laminar + pars and pedicle + pars). There was no neurological worsening or death, nor complications directly related to use axis screws. CONCLUSION: Axis instrumentation was effective and safe, regardless of the technique used for stabilization. Based on our learnt experience, we proposed an algorithm to choose the best technique for axis screw fixation.

OBJETIVO: descrever técnica minimamente invasiva para abordagem das hérnias discais com material de baixo custo. MÉTODOS: estudo prospectivo da avaliação dos resultados cirúrgicos de dez pacientes submetidos à microdiscectomia lombar tubular com uso de seringas descartáveis de diâmetros progressivos. RESULTADOS: utilizando os critérios de MacNab modificados, 60% dos pacientes apresentaram resultados considerados excelentes, 30% bons e 10% razoáveis. O tempo médio de cirurgia foi de 70 minutos e o de permanência hospitalar, de 14 horas. CONCLUSÃO: o uso de seringas descartáveis para microdiscectomia tubular foi seguro, de baixo custo e com resultados preliminares semelhantes aos da literatura para o tratamento minimamente invasivo da hérnia discal lombar.OBJETIVO: describir una técnica mínimamente invasiva para el abordaje de las hernias discales con material de bajo costo y de fácil acceso. MÉTODOS: estudio prospectivo de la evaluación de los resultados quirúrgicos de diez pacientes sometidos a una microdiscectomía lumbar utilizando jeringas desechables de diámetros progresivos. RESULTADOS: utilizando los criterios de MacNab cambiados, un 60% de los pacientes tuvieron resultados considerados como excelentes, el 30% buenos y el 10% razonables. El tiempo medio de cirugía fue 70 minutos y de permanencia en el hospital fue de 14 horas. CONCLUSIÓN: los resultados del estudio indican que la técnica es viable, de bajo costo y con resultados similares a los reportados en la literatura para el tratamiento mínimamente invasivo de la hernia discal lumbar.OBJECTIVE: to describe a minimally invasive technique to treat lumbar disc herniation with low-cost material. METHODS: this is a prospective evaluation of ten patients submitted to a tubular lumbar microdiscectomy with disposable syringes for herniated disc. The modified MacNab criteria were used to evaluate the surgical results. RESULTS: according to the modified MacNab criteria, surgical results were divided in: excellent in 60%, good in 30% and reasonable in 10%. The mean surgical time was 70 minutes and the mean hospital stay was 14 hours. CONCLUSION: the minimal invasive tubular microdiscectomy with disposable syringes is a feasible technique which obtains good results at a low cost, and the surgical results were similar to the recent literature about the treatment of herniated lumbar disc disease.

Eleven patients with jugular foramen lesions with or without extradural extension were operated at University Hospital of Campinas (UNICAMP), in Campinas, Brazil, between 1998 and 2001. Neck dissection, mastoidectomy without transposition of the facial nerve and myofascial flap reconstruction of the cranial base with an especially developed technique were carried out in 7 patients. Four patients were operated using retrosigmoid craniectomy. Total excision was accomplished in 9 cases. All patients did not show evidence of disease progression at least after 2 years follow-up. There was no mortality. New lower cranial nerve deficits occurred in 5 patients. Nine maintain or improved their preoperative status based on Karnofsky and Glasgow Outcome Scale. A complex anatomy of this region demand wide exposures for treat those tumors. For this reason, an adequate approach for curative resection of most lesions and an efficient skull base reconstruction decreasing postoperative morbidity are essential.Onze pacientes com lesões expansivas do forame jugular associadas ou não a componente extradural foram submetidos a ressecção cirúrgica no Hospital das Clínicas da Universidade Estadual de Campinas (UNICAMP) entre 1998 e 2001. Foi utilizada cirurgia combinada com dissecção do pescoço, mastoidectomia sem transposição do nervo facial e técnica de reconstrução miofascial da base do crânio desenvolvida por um dos autores. Quatro pacientes foram operados via craniectomia retrosigmoidea. Ressecção total foi feita em 9 pacientes, subtotal em um e parcial em outro. Nenhum dos 11 pacientes teve progressão da doença em 2 anos de acompanhamento. Não houve mortalidade. Cinco pacientes tiveram déficits adicionais de nervos cranianos baixos. Nove pacientes mantiveram ou melhoraram suas pontuações de acordo com a escala de Karnofsky. Para adequada abordagem do paciente com tumor de forame jugular, são necessários bom conhecimento anatômico da região, exposição cirúrgica ampla, e técnica de reconstrução eficiente para obter cura com baixas taxas de complicações pós-operatórias.

OBJETIVO: Apresentar os resultados cirúrgicos de uma série de casos de estabilização da coluna cervical superior com o uso de parafusos de massa lateral do atlas. MÉTODOS: Avaliação retrospectiva dos resultados cirúrgicos de pacientes submetidos à estabilização da coluna cervical superior com o uso de parafusos de massa lateral do atlas. RESULTADOS: Seis pacientes foram operados durante o período de janeiro de 2009 a abril de 2010, quatro homens e duas mulheres. Não houve morbidade permanente ou morbidade nessa série de casos. A principal causa de instabilidade atlanto-axial foi trauma e houve apenas um caso de fratura patológica do odontoide por metástase de próstata. A fixação do áxis foi obtida com o uso de três diferentes técnicas de parafusos (pars, pedicular e de lâmina), com igual distribuição entre os pacientes. CONCLUSÃO: O uso de parafusos na massa lateral do atlas é uma importante técnica para se obter estabilidade e fusão na coluna cervical superior, e com o conhecimento da anatomia e da técnica cirúrgica, bons resultados podem ser atingidos.OBJETIVOS: presentar los resultados quirúrgicos de una serie de casos de estabilización con el uso de tornillos de masa lateral del atlas. MÉTODOS: evaluación retrospectiva de los resultados quirúrgicos de los pacientes sometidos a estabilización de la columna cervical superior con el uso de tornillos de masa lateral del atlas. RESULTADOS: Seis pacientes operados entre enero 2009 y abril 2010, siendo cuatro hombres y dos mujeres. No hubo mortalidad o morbilidad grave en esta serie. La principal causa de inestabilidad atlantoaxial fue traumática con apenas un caso de fractura patológica del odontoide por una metástasis de tumor de próstata. Fijación del axis fue alcanzada con el uso de tres diferentes técnicas (pars, pedicular, laminar), con dos casos cada una. Conclusión: el uso de tornillos de masa lateral en el atlas es una importante técnica para alcanzar la fusión y la estabilidad de la columna cervical, y con el conocimiento de la anatomía y de la técnica quirúrgica es posible obtenerse excelentes resultados.OBJECTIVE: To present the surgical results of a case series of upper cervical spine stabilization with the use of lateral mass screws of the atlas. METHODS: Retrospective review of the surgical results of patients submitted to upper cervical spine stabilization with the use of lateral mass screws of the atlas. RESULTS: Six patients were operated in the period between January 2009 to April 2010, four men and two women. There was no permanent morbidity or mortality in the presented series. The main cause of atlanto-axial instability was trauma and there was just one case of odontoid pathologic fracture from a prostate metastasis. Axis fixation was achieved with the use of three different screw techniques (pars, pedicle and laminar), with equal distribution among the patients. CONCLUSIONS: The use of lateral mass screws of the atlas is an important technique to achieve fusion and stability of the upper cervical spine and with the knowledge of the anatomy and of the surgical technique good results can be achieved.

The posterior fossa decompression is a form of treatment suggested for patients with basilar invagination (BI) secondary to hypoplasia symptomatic of the clivus and atlantoaxial alignment preserved. Based on the fact that the worsening of cranial-cervical kyphosis (decrease of clivus-canal angle to less than 150o) can result in anterior brainstem compression, we propose that some patients may benefit from the cranio-cervical fixation. We present a case report of a patient with BI secondary to clivus hypoplasia who underwent cranio-cervical fixation in extension, with a reduction in clivus-canal angle and improvement of symptoms without posterior fossa decompression.

Relatamos nota técnica de posicionamento do paciente para melhor visualização radiológica intraoperatória em cirurgias da região cervicotorácica.Relatamos nota técnica sobre el posicionamiento quirúrgico para mejor visualización radiológica intraoperatoria en las cirugías de la región cervicotorácica.We report a technical note on patient positioning to obtain a better intraoperative radiological view in cervicothoracic region surgeries.

RESUMO Objetivo: apresentar nossa experiência no tratamento cirúrgico do hiperteleorbitismo na displasia craniofrontonasal. Métodos: análise retrospectiva dos pacientes com displasia craniofrontonasal operados por orbital box osteotomy ou por bipartição facial entre os anos de 1997 e 2015. Informações sobre as intervenções cirúrgicas foram obtidas dos prontuários médicos, exames complementares, fotografias e entrevistas clínicas. Os resultados cirúrgicos foram classificados com base na necessidade de cirurgia adicional, e a recidiva orbital foi calculada. Resultados: sete pacientes do sexo feminino foram incluídas, três submetidas à orbital box osteotomy (42,86%) e quatro (57,14%) à bipartição facial. Houve uma recidiva orbital média de 3,71±3,73mm. A média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi de 2,43±0,53. Conclusão: a abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal deve ser individualizada, respeitando, sempre que possível, a idade e as preferências dos pacientes, seus familiares e cirurgiões.

A reunião de revista "Telemedicina Baseada em Evidência - Cirurgia do Trauma e Emergência" (TBE-CiTE) realizou uma revisão crítica da literatura e selecionou os três artigos mais relevantes e atuais sobre a indicação de tomografia de crânio em pacientes pediátricos com trauma craniencefálico leve (TCE). O primeiro trabalho identificou pacientes vítimas de TCE leve com fatores de alto e baixo risco de apresentarem lesões intracranianas vistas à tomografia computadorizada (TC) de crânio e com necessidade de intervenção neurocirúrgica. O segundo trabalho avaliou o uso das recomendações do "National Institute of Clinical Excellence" em pacientes pediátricos com TCE, e utilizou como variáveis de desfecho a realização de TC ou internação hospitalar. O último artigo analisou e identificou os pacientes onde a TC de crânio seria desnecessária e, portanto, não deve ser feita rotineiramente. Baseado nessa revisão crítica da literatura e a discussão com especialistas, o TBE-CiTE concluiu que é importante evitar a exposição desnecessária de crianças com TCE leve à radiação ionizante da TC de crânio. O grupo favoreceu a utilização do guideline do PECARN onde ECG de 14, alteração do nível de consciência ou fratura do crânio palpável são indicações de TC de crânio, ou quando a experiência do médico, achados múltiplos ou piora dos sintomas ocorrerem.

OBJECTIVE: The spine is the most common location for bone metastases. Since cure is not possible, local control and relief of symptoms is the basis for treatment, which is grounded on the use of conventional radiotherapy. Recently, spinal radiosurgery has been proposed for the local control of spinal metastases, whether as primary or salvage treatment. Consequently, we carried out a literature review in order to analyze the indications, efficacy, and safety of radiosurgery in the treatment of spinal metastases. METHODS: We havereviewed the literature using the PubMed gateway with data from the MEDLINE library on studies related to the use of radiosurgery in treatment of bone metastases in spine. The studies were reviewed by all the authors and classified as to level of evidence, using the criterion defined by Wright. RESULTS: The indications found for radiosurgery were primary control of epidural metastases (evidence level II), myeloma (level III), and metastases known to be poor responders to conventional radiotherapy - melanoma and renal cell carcinoma (level III). Spinal radiosurgery was also proposed for salvage treatment after conventional radiotherapy (level II). There is also some evidence as to the safety and efficacy of radiosurgery in cases of extramedullar and intramedullar intradural metastatic tumors (level III) and after spinal decompression and stabilization surgery. CONCLUSION: Radiosurgery can be used in primary or salvage treatment of spinal metastases, improving local disease control and patient symptoms. It should also be considered as initial treatment for radioresistant tumors, such as melanoma and renal cell carcinoma.

Paraplegia is a well-defined state of complete motor deficit in lower limbs, regardless of sensory involvement. The cause of paraplegia usually guides treatment, however, some controversies remain about the time and benefits for spinal cord decompression in nontraumatic paraplegic patients, especially after 48 hours of the onset of paraplegia. The objective of this study was to evaluate the benefits of spinal cord decompression in such patients. We describe three patients with paraplegia secondary to non-traumatic spinal cord compression without sensory deficits, and who were surgically treated after more than 48 hours of the onset of symptoms. All patients, even those with paraplegia during more than 48 hours, had benefits from spinal cord decompression like recovery of gait ability. The duration of paraplegia, which influences prognosis, is not a contra-indication for surgery. The preservation of sensitivity in this group of patients should be considered as a positive prognostic factor when surgery is taken into account.

Abstract Objective: To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions. Data source: The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review. Data synthesis: We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center. Conclusions: Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

ABSTRACT Objective: To report the epidemiological profile of patients operated for treatment of spinal trauma in the UNICAMP Hospital das Clínicas. Methods: Patients older than 14 years with spinal trauma operated in the service from 2012 to 2017 with complete radiological and clinical data were evaluated. Results: A total of 143 patients were included, 120 men and 23 women, with a mean age of 37.8 years. Falls from height (32%), motorcycle (26%) and car accidents (24%) were the most common trauma mechanisms. The most affected vertebral level was C6 (11%) and most patients (55%) had some neurological deficits. The overall postoperative complication rate was 23%. Conclusions: Spinal trauma has a high socioeconomic impact due to its high morbidity and mortality, and it is necessary to study its epidemiology for the development of public policies for prevention and treatment financing. Level of Evidence: III. Type of study: Retrospective study.

Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular malformations with unspecific clinical manifestations, which often lead to misdiagnosis and delay in the establishment of effective therapies. Since the neurological prognosis depends on symptom duration and pretreatment neurological status, rapid identification and obliteration of the fistula are key to provide patients with a better quality of life. We herein describe an illustrative case of an elderly patient presenting with progressive myelopathy, with a definitive diagnosis of SDAVF after 18 months of the initial symptoms. We also review the core concepts regarding this condition and discuss strategies to prevent misdiagnosis and worsening of the neurological outcome.