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The pituitary gland plays a vital role in hormonal regulation. Pituitary lesions include tumors, cysts, and inflammatory processes that require multidisciplinary care from endocrinologists, neuro-ophthalmologists, neurosurgeons, and otolaryngologists. Treatment is typically aimed at controlling hormonal hypersecretion, decompressing the optic apparatus, and reducing tumor volume, and surgery is a common first-line approach. In this article, we provide a background on the function of the pituitary gland, common pituitary lesions, and their clinical presentations, as well as a summary of the history and physical, laboratory testing, and imaging required for the workup of a pituitary lesion.

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.

INTRODUCTION: Infratentorial tumors represent 45 to 60% of all brain tumors in children and are associated with hydrocephalus in 70 to 90% of cases. The aim of this study is to describe and analyze the surgical results and correlate them with the incidence of hydrocephalus, as well as identify predictive factors of hydrocephalus in patients underwent to a surgical treatment of posterior fossa tumors. METHODS: This is a retrospective observational study, based on demographic, clinical and radiological information of pediatric patients underwent to surgical resection of posterior fossa tumors by a single group between 2011 and 2019. RESULTS: We included 135 patients with a mean age of 7.56 years, mean follow-up of 35.7 months and overall survival of 18.8 months. Considering the histology, most tumors were pilocytic astrocytomas (34.1%), followed by medulloblastomas (27.4%) Total resection was achieved in 77.8% and tumor recurrence was observed in 16.2%. The rate of hydrocephalus was 36.3%, with most shunt procedures performed preoperatively. There was a high rate of complications associated with shunting (42.9%), mostly represented by infection (71.5%). Patients with hydrocephalus were younger (p = 0.001), showing a faster evolution between the onset of symptoms and diagnosis (p = 0.008). Tumor volume (p = 0.1) and location (p = 0.32) were not statistically significant for hydrocephalus, however, the presence of leptomeningeal disease (p = 0.001) was. The resection rate was also significant, with lesions totally resected showing the best results (p = 0.009). Regarding tumor histology, 33.3% of patients with medulloblastoma and 62.5% of patients with ependymoma were shunted. CONCLUSION: One third of children with posterior fossa tumors will require a shunt procedure. Some factors should guide the neurosurgeon during patient counseling and surgical planning to minimize the use of permanent shunts and avoid related complications.

Introduction: Spinal cord injury (SCI) is defined as an injury resulting from an insult inflicted on the spinal cord that compromises, either completely or incompletely, its major functions (motor, sensory, autonomic, and reflex). Objectives: In this chapter we aim to discuss the most important etiologies causing acute spinal cord dysfunction, its epidemiology, clinical characteristics, and treatment nuances that are essential from a neurosurgeon’s point of view. Literature Review: Acute spinal injury can be divided into traumatic and nontraumatic. Traumatic SCI is generally caused by motor vehicle accidents, assault, falls, and sports injuries. Nontraumatic SCIs have multiple etiologies, with the most frequent being degenerative spinal diseases compression, followed by extrinsic neoplastic involvement, vascular injuries, and finally inflammatory or infectious diseases. Conclusion: The correct diagnosis and management of acute spinal injury is of major importance to minimize permanent disability and its consequences.

Study design Retrospective cohort. Objective Evaluate the epidemiology of surgical patients with spinal metastases, identify the complications, and evaluate their neurological prognoses. Summary of background data The development of new oncological treatments and screening tests have increased the survival of oncologic patients, and consequently, the incidence of metastatic lesions of the spine. Methods Retrospective cohort of 40 patients surgically treated at the Hospital de Clinicas of UNICAMP for spinal metastases from January 2010 to September 2018, after diagnosis of symptomatic spinal cord compression and/or mechanical instability of the spine. Retrospectively analyzed patient charts applied the SINS score to evaluate the presence of mechanical instability. Neurological function was classified based on the Frankel index preoperative and postoperatively. To evaluate the association between variables, the Chi-square test, Fisher exact test, or Fisher-Freeman-Halton test was applied. For evaluating the improvement of neurological status between the Frankel scores before and after surgery, the McNemar test was applied for categorical and qualitative variables. In both the tests, variables with values of P > 0.05 were considered. Results Pain as the reason for the first visit presented an odds ratio (OR) = 2.44 (95% [CI]: 1.14-5.2) for instrumentation need (P = 0.024). A higher SINS score corresponded to the indication for instrumentation surgery due to the instability of the spine (P = 0.004). Within 30 days postoperative, five patients (11.1%) had complications. There was a statistically significant neurological improvement in patients who underwent surgery (P = 0.002). Conclusion Pain as the first symptom was related to mechanical instability of the spine and surgical instrumentation. Patients treated with surgery presented improvement of the neurological function in the postoperative period. Level of evidence 3.

OBJECTIVEMany repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure.METHODSThe authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography.RESULTSNo skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up.CONCLUSIONSThe KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.

Background The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use. Objective To evaluate the reliability of the new AOSpine UCCS. Methods A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed. Results Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment. Conclusion This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS.

Orientador: Andrei Fernandes Joaquim Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas Resumo: RESUMO Introdução: Aproximadamente 10% dos pacientes com câncer desenvolverão metástases espinhais ao longo de sua vida com compressão medular sintomática. O objetivo do tratamento destas lesões é a manutenção da qualidade de vida com alívio da dor, manutenção da função neurológica, estabilidade da coluna vertebral e controle local da doença. Objetivo: Analisar a associação dos fatores clínicos, oncológicos e cirúrgicos na sobrevida dos pacientes submetidos à cirurgia de coluna para tratamento de metástases sintomáticas. Método: Coorte retrospectiva de 40 pacientes tratados cirurgicamente no Hospital de Clínicas da UNICAMP por compressão medular (CM) por metástases epidurais na coluna vertebral (MECV) no período de janeiro de 2010 até dezembro de 2018. Analisamos os prontuários com dados clínicos e aplicamos as escalas de Tomita, escore de Tokuhashi modificado, ECSS e escore de SINS. O estado sistêmico do paciente foi baseado nas escalas de Karnofsky Performance Scale (KPS) e Eastern Cooperative Oncology Group (ECOG-PS). A taxa de sobrevida em meses foi estimada pela curva de Kaplan-Meier, com o óbito considerado como desfecho e teste de log-rank para identificar a existência de fatores prognósticos para melhor sobrevida. Em todos os casos, adotou-se o nível de significância de 5% (p ? 0,05). Resultados: Houve prevalência dos sítios primários: mama, pulmão e próstata (50%); as metástases eram predominantemente torácicas ou lombares (77,5%) e, na maior parte das vezes, únicas. Pacientes submetidos à instrumentação cirúrgica associada à cirurgia de descompressão tiveram uma propensão maior a iniciar o quadro com dor (p=0,024), presença de deformidade secundária à metástase (p=0,042) ou colapso de um corpo vertebral (p=0,008) antes da cirurgia. A aplicação retrospectiva do escore de SINS mostrou relação direta com a realização de instrumentação (p=0,004). Em relação ao déficit neurológico, este estudo demonstra que há melhora neurológica no pós-operatório ao se comparar com o pré-operatório (p=0,002). A média da sobrevivência foi de 8,4 meses após a cirurgia. Pacientes com KPS < 70 tiveram uma sobrevida média de 6,36 meses, enquanto os com KPS > 70 apresentaram sobrevida média de 14,48 (p=0,04), sendo que KPS < 70 representa um OR= 2,33 (IC95 1,1 ¿ 4,7) de óbito em até 6 meses (p=0,037). A sobrevida média dos pacientes classificados como ECOG 2 foi de 7,05 meses (IC95 3,4-10,7) e dos pacientes classificados como ECOG 3 e 4 foi de 1,24 meses (IC95 0,8-1,59). A sobrevida média entre os pacientes com metástases irressecáveis em outros órgãos foi de 6,3 meses (IC95 3,7-8,9) em comparação com os que não possuíam metástases, que foi de 13,8 meses (IC95 10,0 ¿ 17,68) (p=0.022). A presença de metástase visceral apresenta um OR= 2,34 (IC95 1,33-4,13) com o desfecho óbito em 1 ano (p=0,01). Conclusão: A sobrevida dos pacientes com MECV foi associada ao estado funcional do paciente no pré-operatório definido pelo KPS e escala ECOG, além da presença de metástases viscerais não ressecáveis. Os pacientes submetidos ao procedimento cirúrgico têm tendência a melhorar do déficit neurológico pré-operatório. Dor como primeiro sintoma teve relação com a presença de instabilidade mecânica da coluna evidenciada por pontuações altas no escore SINS Abstract: ABSTRACT Introduction: Approximately 10% of cancer patients will develop spinal metastases throughout their life with symptomatic spinal cord compression. The goal of the treatment of these lesions is the maintenance of the quality of life with pain relief, maintenance of the neurological function, stability of the spine and local control of the disease. Objective: To analyze the association of clinical, oncological and surgical factors in the survival of patients undergoing spinal surgery for treatment of symptomatic spinal metastases. Method: Retrospective cohort of 40 patients surgically treated at the Hospital de Clínicas da UNICAMP by spinal cord compression (SCC) for epidural spinal metastases (EM) between January 2010 and December 2018. We analyzed the medical records and applied the Tomita scales, modified Tokuhashi score, ECSS and SINS score. The patient's systemic status was evaluatedby the Karnofsky Performance Scale (KPS) and Eastern Cooperative Oncology Group (ECOG-PS) scales. The survival rate in months was estimated by the Kaplan-Meier curve, with the death considered as the outcome and log rank test to identify the existence of prognostic factors for better survival. In all cases, the level of significance was considered as 5% (p ? 0.05). Results: Prevalence of primary sites: breast, lung and prostate (50%); metastases were predominantly thoracic or lumbar (77.5%) and mostly unique. Patients submitted to surgical instrumentation associated with decompression surgery had a higher propensity to clinically present with pain (p = 0.024), presence of deformity secondary to metastasis (p = 0.042) or collapse of a vertebral body (p = 0.008) before surgery. The retrospective application of the SINS score showed a direct relationship with the performance of instrumentation (p = 0.004). In relation to the neurological deficit, this study shows that there is neurological improvement in the postoperative period compared to the preoperative period (p = 0.002). The mean survival was 8.4 months after surgery. Patients with KPS 70 had a mean survival of 14.48 (p = 0.04), with KPS

SUMMARY OBJECTIVE: To present the surgical results of patients who underwent axis screw instrumentation, discussing surgical nuances and complications of the techniques used. METHODS: Retrospective case-series evaluation of patients who underwent spinal surgery with axis instrumentation using screws. RESULTS: Sixty-five patients were included in this study. The most common cause of mechanical instability was spinal cord trauma involving the axis (36 patients – 55.4%), followed by congenital craniocervical malformation (12 patients – 18.5%). Thirty-seven (57%) patients required concomitant C1 fusion. Bilateral axis fixation was performed in almost all cases. Twenty-three patients (35.4%) underwent bilateral laminar screws fixation; pars screws were used in twenty-two patients (33.8%), and pedicular screws were used isolated in only three patients (4.6%). In fourteen patients (21.5%), we performed a hybrid construction. There was no neurological worsening nor vertebral artery injury in this series. CONCLUSION: Axis screw instrumentation proved to be a safe and efficient method for cervical stabilization. Laminar and pars screws were the most commonly used RESUMO OBJETIVO: Apresentar os resultados cirúrgicos de pacientes submetidos à instrumentação com parafusos do áxis, discutindo nuances cirúrgicas e complicações das técnicas utilizadas. MÉTODOS: Série retrospectiva de pacientes submetidos à instrumentação do áxis utilizando parafusos. RESULTADOS: Sessenta e cinco pacientes foram incluídos neste estudo. A causa mais comum de instabilidade foi trauma raquimedular envolvendo o áxis (36 pacientes – 55,4%), seguida por malformação craniocervical congênita (12 pacientes – 18,5%). Trinta e sete (57%) pacientes necessitaram concomitante fusão de C1. Fixação bilateral foi realizada em quase todos os casos. Vinte e três pacientes (35,4%) foram submetidos à fixação com parafusos de lâmina; parafusos de pars foram utilizados em 22 pacientes (33,8%) e de pedículo, isoladamente, em três (4,6%). Em 14 casos (21,5%), realizamos técnicas combinadas. Não houve piora neurológica ou lesão de artéria vertebral nesta série de casos. CONCLUSÃO: A instrumentação com parafusos do áxis foi um método seguro e eficaz para estabilização cervical. A fixação da lâmina e a da pars foram as técnicas mais utilizadas.