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Objective To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. Material and methods We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients’ positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as > 50% attenuation in amplitude or > 10% increase in latency of SEP, or abolishment or 50–80% attenuation of MEP. Results Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n = 6) or partial (n = 4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. Conclusion Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

Assessment of scientific bibliographic production is a complex issue, mainly based on the impact factor (IF) of the journals and the h index, that quantifies the number of cites an author receives. In order to estimate the bibliographic production and the influence of co-authorship among Spanish neurosurgeons, we performed a PubMed search aimed to identify all papers published by a sample of neurosurgeons.Cross-sectional observational and regional study. We identified a sample of 183 neurosurgeons from Madrid and Castilla y León Autonomous Communities. The bibliometric information was gathered in March 2022 via PubMed free access website. For each author we registered the type of journal, total number of articles, order of appearance in the authors' list, total IF, the proportion of articles signed as first or second author (Personal Authorship Quotient [PAQ]) and the percentage of IF attributable to those articles (Personal Impact Quotient [PIQ]).A total of 3,592 articles from 183 authors were published in 412 different journals, of which only 9.9% were pure neurosurgical journals. Only 17 neurosurgeons (9,3%) had published at least one article as unique author. The average number of articles per neurosurgeon was 20 (median 9) of which 57.7% were published in neurosurgical journals, and 22,2% in Neurocirugía (official publication of the SENEC). The average PAQ was 0.367 (median 0.364) and the average PIQ was 0.317 (median 0.251). Both proportions tended to decrease as the number of publications increased.On average, Spanish neurosurgeons publish half of their articles in neurosurgical journals, appear as first or second author in one third of the cases, and the IF attributable to these papers comprise 25% of the total IF. The PAQ and PIQ provide bibliometric information that minimizes the enlarging effect on curriculum of massive co-authorship and allow comparisons among authors and different scientific fields.

Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients.

Aim To determinate molecular changes in the downstream epidermal growth factor receptor signaling pathway using serial liquid biopsies in patients with metastatic colorectal tumors (mCRC) under anti-angiogenic treatment. Patients and methods Determination of RAS mutation in primary tissue samples from colorectal tumors was performed in the 23 patients included in the study at diagnosis using quantitative-polymerase chain reaction. Sequential mutations were studied in circulating tumor (ct) DNA obtained from plasma samples. Results Twenty-three patients with RAS-mutated primary tumors were included. In the first ctDNA determination, 17 of these patients were found to have wild-type RAS status. Remarkably, three out of these 17 wild-type cases changed to RAS-mutated in subsequent ctDNA assays. Conclusion Serial liquid biopsies in patients with mCRC might be a useful tool for identifying changes in the RAS mutation status in patients who had undergone previous anti-angiogenic therapy. The understanding of these changes might help to better define the landscape of mCRC and be the path to future randomized studies.

Introduction It is common practice to prescribe prophylactic antiepileptic drugs (AED) to high-grade glioma (HGG) patients without a history of seizures, yet with limited evidence supporting its use. Ideally, the effectiveness of prophylactic anticonvulsants must outweigh the occurrence of adverse effects and interactions related to AED. The authors conducted a systematic review and metanalysis of longitudinal studies regarding the effectiveness of prophylactic AED in seizure-naive HGG patients. Materials and methods PubMed/MEDLINE, Cochrane Central Register of Controlled trials, Embase and clinicaltrials.gov databases were systematically searched. Of the initial 1773 studies identified, 15 were finally selected for data extraction and analysis. Heterogeneity among studies, pooled hazard ratios, publication bias and sensitivity analyses were performed separately for a 15-study group (HGG patients within larger series of brain tumors) and a 6-study group (exclusively HGG patients). Results AED prophylaxis did not significantly reduce the incidence of postoperative seizures compared with controls, both in the 15-study group (Mantel-Haenszel random-effects pooled OR 1.08, 95% CI 0.82–1.43, 2123 patients) and in the 6-study group (pooled OR 1.22, 95% CI 0.77–1.92, 540 patients). However, some issues (paucity of prospective trials, overall moderate-risk of bias, and few studies addressing HGG patients exclusively) preclude firm conclusions against routine prophylactic AED prescription. Reported adverse effects attributable to AED were acceptable in the majority of studies. Conclusions Within the limitations of this review, the results of this metanalysis do not support the routine administration of prophylactic AED to HGG patients without a history of seizures.

The systematic adoption of the histopathologic criteria provided by the 2016 update of the WHO classification of brain tumors has markedly increased the relative proportion of atypical and anaplastic meningiomas. These tumors exhibit a much greater recurrence rate compared to benign meningiomas, which negatively impacts survival. In recent years, the publication of numerous retrospective case series, yet no randomized controlled trials, on the impact of radiation therapy in non-benign meningioma, has yielded conflicting evidence. At present, maximum safe resection, including the dural attachment, is the preferred primary treatment modality for all types of meningiomas. Adjuvant radiotherapy is currently recommended for subtotally resected grade II and for all grade III meningiomas. However, in grade II meningiomas achieving complete resection, close radiologic and clinical observation is a feasible option. Despite the great amount of non-benign meningiomas available and eligible for trials, there is a striking lack of prospective studies testing adjuvant therapies against observation for this subset of patients. An updated and systematic literature review is provided on the effectiveness and indications of radiotherapy on grade II and III meningiomas.

The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2–3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies.

Resumen El objetivo principal del tratamiento en las metastasis espinales es el control local de la enfermedad, el alivio del dolor y el mantenimiento de la deambulacion. Clasicamente, se ha recomendado una reseccion quirurgica del tumor lo mas amplia posible seguida de radioterapia o quimioterapia adyuvante. En la actualidad, la radioterapia estereotaxica corporal (SBRT) en dosis unica o hipofraccionada proporciona tasas globales de control local al ano superiores al 95% con minima morbilidad, incluso en histologias que suelen considerarse radiorresistentes. Por otro lado, mediante cirugia de descompresion circunferencial posterolateral y estabilizacion de la columna es factible crear un espacio de 2-3 mm entre el borde tumoral y la duramadre (separation surgery) suficiente para permitir administrar de forma segura SBRT a dosis ablativas. Dado que con frecuencia se trata de pacientes fragiles, dicha cirugia puede realizarse mediante tecnicas minimamente invasivas, que reducen la agresividad quirurgica y ayudan a minimizar el retraso de eventuales tratamientos sistemicos.

The molecular biology of human glioma is a complex and fast-growing field in which basic research needs to meet clinical expectations in terms of anti-tumor efficacy. Although much effort is being done in molecular biology research, significant contribution to the quality of life and overall survival still lacks. The vastness of molecular biology literature makes it virtually impossible for clinicians to keep up to date in the field. This paper reviews some practical concepts regarding glioma tumorigenesis from the clinician's perspective. Five main aspects are discussed: major intracellular signaling pathways involved in glioma formation; genomic, epigenetic and transcriptomic relevant features of glioma; the prognostic and predictive values of molecular markers according to the new WHO classification of glial tumors; the importance of molecular and cellular heterogeneity in glioblastoma, responsible for its therapy resistance; and the interaction between glioma and the immune system, in view of the novel and promising targeted therapies.

Resumen Objetivo Evaluar la efectividad y seguridad del polvo de vancomicina topico como profilaxis de infeccion de herida quirurgica (IHQ) en cirugia de columna electiva por abordaje posterior. Material y metodos Estudio unicentrico cuasiexperimental de comparacion pre- y postintervencion. El grupo postintervencion recibio profilaxis antibiotica estandar preoperatoria junto a 1 g de polvo de vancomicina en el lecho quirurgico antes del cierre de la herida. El grupo preintervencion solo recibio la profilaxis intravenosa. Resultados Participaron 150 pacientes en cada grupo. Ocurrieron 12 infecciones (7 superficiales, 5 profundas) en el grupo postintervencion y 16 infecciones (7 superficiales, 9 profundas) en el grupo preintervencion. El riesgo de IHQ profunda se redujo del 6% al 3,3% (OR 0,54; IC 95% 0,17-1,65; p = 0,411) con el tratamiento. El porcentaje de IHQ profunda por gramnegativos-positivos fue del 80-20% en el grupo tratado con vancomicina y del 33-67% en los no tratados (p = 0,265). No se produjeron efectos adversos locales ni sistemicos por el tratamiento. Conclusion La profilaxis con polvo de vancomicina en cirugia electiva de columna por abordaje posterior no redujo de forma significativa la incidencia de IHQ superficial o profunda. Se constato una tendencia al aumento de IHQ profunda por microorganismos gramnegativos en los tratados con vancomicina.

Objective To assess the effectiveness and safety of vancomycin powder as surgical siteinfection (SSI) prophylaxis in posterior bilateral elective spinal surgery. Materials and methods Single-center quasi-experimental pre and postintervention compa-rative cohort study. The post-intervention group received standard intravenous antibioticprophylaxis plus 1 g of vancomycin powder into the surgical field before wound closure, andthe pre-intervention group only the intravenous prophylaxis. Results 150 patients were included in each group. Twelve SSI (7 superficial and 5 deep)occurred in the post-intervention group and 16 SSI (7 superficial and 9 deep) in the pre-intervention group. The risk of deep SSI decreased from 6.0% to 3.3% (OR 0,54, 95%CI 0.17-1.65, p = 0.411) with vancomycin powder. The percentage of deep SSI due to gramnegative-positive germs were 80%-20% and 33%–67% for the post- and pre-interventiongroups, respectively (p = 0.265). No local or systemic adverse effects occurred attributableto vancomycin powder. Conclusion In posterior elective spinal surgery, prophylaxis with vancomycin powder didnot result in a significantly reduced incidence of superficial and deep SSI. There was a trendtowards a higher incidence of deep SSI caused by gram negative microorganisms amongthose treated with vancomycin.

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned.

Cauda equina syndrome (CES) caused by lumbar disk extrusion is classically considered an indication of urgent surgery. CES can be subdivided into CESI (incomplete CES) and CESR (complete CES with urinary retention and incontinence). This paper evaluates the long-term functional outcome of a CES cohort operated on due to disk herniation.Single-center retrospective observational study. CES patients due to disk herniation that underwent surgery between 2000 and 2016 were included in the study. Demographic data, time intervals to diagnosis and surgery, preoperative neurologic status and outcome at the end of follow up were recorded.Twenty-two patients were included (median age 44 years). Eight patients were CESR and 14 CESI. Median time from symptom onset to diagnosis was 78h (range, 12-720h), and from diagnosis to surgery 24h (range, 5-120h). Median follow up was 75 months (range, 20-195 months). At the end of follow up, in the CESR group (median time from diagnosis to surgery, 23h) only pain significantly improved after surgery (p=0.007). In the CESI group (median time from diagnosis to surgery 23h) low back pain, sciatica and urinary sphincter function significantly improved (p0.001). There were no significant differences between early (48h) operation (n=4) and late (n=18) in terms of sphincter recovery (Fisher's Exact Test, p=0.076).Pain associated to CES improved both in the CESI and CESR groups. However, urinary sphincter impairment significantly improved only in the CESI group. No significant differences were found regarding long-term functional outcome between early and late surgery.

The increasing age and complexity of in-hospital neurosurgery patients have raised the number of consultations with Internal Medicine. This type of collaboration is discretional and lacks temporal continuity. The full-time appointment of an internal medicine practitioner to a Neurosurgery Department, with complete care attributions except for strict surgical work, is a feasible organizational option. This method minimizes the need for medical consultation, improves the perceived quality of care, allows neurosurgeons to focus on purely surgical tasks, provides an integral vision of the patient's condition, enriches the group with specialized non-neurosurgical knowledge, and raises the scientific level of the team. In our Neurosurgery Department, an internal medicine practitioner has been working as part of the staff for 14 years. We describe her medical activity duties, the advantages our department gains from her daily work, and the professional and working implications derived.

Resumen La cirugia de columna lumbar degenerativa, aunque efectiva, produce resultados suboptimos y cierto grado de discapacidad en un porcentaje relevante de pacientes. El tratamiento rehabilitador postoperatorio no ha demostrado utilidad a medio y a largo plazo. La denominada «prehabilitacion» (tratamientos fisioterapicos y/o cognitivo-conductuales) busca aumentar las capacidades funcionales del paciente antes de la intervencion mejorando el estado fisico y la percepcion del dolor, de la experiencia quirurgica o de sus consecuencias. Diversos estudios sugieren que la prehabilitacion mejora la funcionalidad postoperatoria, acorta la estancia hospitalaria y podria ahorrar costes frente a la rehabilitacion postoperatoria clasica. Sin embargo, su efecto real parece influenciarse de variables como la obesidad, comorbilidades y, especialmente, una erronea percepcion de la historia natural de estas enfermedades, en forma de catastrofismo y cinesifobia. En este trabajo se describe el concepto de prehabilitacion, se revisa la literatura al respecto y se discute el papel de diversos condicionantes clinicos involucrados.

Meningioma is a common slow-growing intra-cranial neoplasm affecting 2-3% of the population, with the potential for irreversible brain damage. The widespread availability of modern neuroimaging allows early detection of small asymptomatic meningiomas. Given that morbidity and mortality rates associated to treatment of small asymptomatic meningiomas is remarkably lower than that of symptomatic, it can be hypothesized whether active search for meningiomas in the general population is warranted. In this paper we explore the justifications and rationale of an eventual screening program for the detection of small asymptomatic meningiomas and discuss its feasibility. Cost-effectiveness, applicability, and ethical issues are also analyzed. Screening for meningiomas would secondarily identify other incidental findings (brain aneurysms, pituitary adenomas, and many others) that would also benefit from surveillance and/or treatment. A broad screening protocol, based on magnetic resonance, with specific calculations for a regional area in Spain, is also provided. Meningiomas are prevalent lesions with a prolonged pre-symptomatic period in which early detection is possible. Magnetic resonance is simple, accurate, innocuous, and serves as screening and confirmatory test. Although screening for asymptomatic meningiomas seems to be clinically well-substantiated and no ethical issues a priori preclude its implementation, its cost-effectiveness needs to be further studied and confirmed.Los meningiomas son neoplasias intracraneales de lento crecimiento, que afectan a del 2-3% de la población, y que potencialmente pueden provocar lesiones cerebrales irreversibles. La creciente disponibilidad de pruebas de neuroimagen permite la detección incidental y precoz de meningiomas asintomáticos de pequeño tamaño. Dado que la morbimortalidad asociada al tratamiento de los meningiomas asintomáticos es marcadamente menor que la de los sintomáticos, se plantea la posibilidad de realizar una búsqueda activa de meningiomas en la población general. En este trabajo exploramos las razones que podrían sustentar la puesta en marcha de un programa de cribado de meningiomas intracraneales y discutimos su factibilidad. Así mismo, analizamos cuestiones relativas a su aplicabilidad, coste-efectividad y problemas éticos. Un cribado dirigido a meningiomas identificaría secundariamente otros hallazgos incidentales (aneurismas, adenomas hipofisarios, etc.) que también podrían beneficiarse de un eventual seguimiento y/o tratamiento. Además, proponemos un protocolo general de cribado, basado en resonancia magnética, con cálculos preliminares específicos, y dirigido a un área sanitaria española. Los meningiomas son lesiones prevalentes con un período presintomático muy largo en el que es factible su detección precoz. La resonancia magnética es un método de cribado sencillo, preciso, inocuo y sirve como test confirmatorio. Aunque un eventual programa de cribado de meningiomas podría estar bien sustentado desde el punto de vista clínico, y no parecen existir a priori impedimentos éticos, su coste-efectividad precisa confirmación en estudios futuros.

Meningioma is a common intracranial neoplasm currently classified in 15 histologic subtypes across 3 grades of malignancy. First-choice therapy for meningioma is maximum safe resection for grade I tumors, and surgery plus optional and mandatory adjuvant radiotherapy for grade II and III, respectively, given the increased rate of recurrence even in the event of complete resection. The WHO 2016 histopathologic grading of meningioma has been questioned due to subjectivity and its controversial predictive power for recurrence. Novel DNA methylation profiling has simplified classification into six classes that seem to improve prognostic accuracy. We review five main topics of molecular biology research regarding tumorigenesis and natural history of meningioma from the clinician’s perspective: the histopathologic diagnostic features and pitfalls of the current tumor classification; the molecular integrated diagnosis supported by identification of genetic alterations and DNA methylation profiling; the general landscape of the various signaling pathways involved in meningioma formation; the pathogenic theories of the peri-tumoral edema present in meningioma and its therapy implications; and a summarized review on the current treatments and plausible targeted therapies directed to meningioma. It seems likely that molecular assessment will be introduced within the next update of the WHO classification of meningiomas, acknowledging the promising value of DNA methylation profiling. This integrated diagnostic protocol will simplify tumor subtype categorization and provide improved accuracy in predicting recurrence and outcome. Although much effort is being done in identifying key gene mutations, and elucidating specific intracellular signaling pathways involved in meningioma tumorigenesis, effective targeted therapies for recurrent meningiomas are still lacking.

Background Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism. Case Description We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures. Conclusions Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.

Resumen Objetivo Describir pros y contras de diversas medidas de proteccion radiologica y sus implicaciones en el diseno de un quirofano de neurocirugia. Material y metodos Se realizo una reforma estructural del quirofano de neurocirugia a proposito de la adquisicion y uso de un O-arm. Se ampliaron las medidas y blindajes del quirofano, y se instalo una mampara blindada y abatible en su interior. Se midieron dosis de radiacion delante y detras de la mampara. Resultados La mampara proporciona una radioproteccion integral para todo el personal de quirofano (dosis Conclusiones El blindaje de paredes, techos y suelos, la forma rectangular y la superficie lo mas amplia posible, la presencia de una mampara plomada y abatible, y los sistemas de seguridad que impiden una irrupcion inesperada en el quirofano mientras se esta irradiando son cuestiones relevantes a tener en cuenta en el diseno del quirofano de neurocirugia.

Objective To describe pros and cons of some radiation protection measures and the implications on the design of a neurosurgery operating room. Material and methods Concurring with the acquisition and use of an O-arm device, a structural remodelling of our neurosurgery operating room was carried out. The theatre was enlarged, the shielding was reinforced and a foldable leaded screen was installed inside the operating room. Radiation doses were measured in front of and behind the screen. Results The screen provides whole-body radiation protection for all the personnel inside the theatre (effective dose μSv at 2.5 m from the gantry per O-arm exploration; 0.0 μSv received behind the screen per O-arm exploration; and undetectable cumulative annual radiation dose behind the screen), obviates the need for leaded aprons and personal dosimeters, and minimises the circulation of personnel. Enlarging the size of the operating room allows storing the equipment inside and minimises the risk of collision and contamination. Rectangular rooms provide greater distance from the source of radiation. Conclusion Floor, ceiling and walls shielding, a rectangular-shaped and large enough theatre, the presence of a foldable leaded screen, and the security systems precluding an unexpected irruption into the operating room during irradiation are relevant issues to consider when designing a neurosurgery operating theatre.

At least 50% of surgically resected non-functioning pituitary adenomas (NFPA) recur. Either early or late adjuvant radiotherapy is highly efficacious in controlling recurrent NFPA but associates potentially burdensome complications like hypopituitarism, vascular complications or secondary neoplasm. Reoperation is indicated in bulky tumor rests compressing the optic pathway. To date, no standardized medical therapy is available for recurrent NFPA although cabergoline and temozolomide show promising results. Guidelines on the management of recurrent NFPAs are now available. The new 2017 WHO pituitary tumor classification, based on immunohistochemistry and transcription factor assessment, identifies a group of aggressive NFPA variants that may benefit from earlier adjuvant therapy. Nevertheless, NFPA patients exhibit a reduced overall life expectancy largely due to hypopituitarism and treatment-related morbidity. The management of recurrent NFPA benefits from a multidisciplinary teamwork of surgeons, endocrinologists, radiation oncologists, ophthalmologists, pathologists and neuro-radiologists in order to provide individualized therapy and anticipate deterioration.

Resumen La obesidad (IMC > 30 kg/m2) es una pandemia con graves implicaciones medicas y economicas. Existe una creciente evidencia que relaciona procesos relacionados con el metabolismo del tejido adiposo, preferentemente abdominal, con un estado inflamatorio cronico de baja intensidad mediado por adipocinas y otras sustancias que favorecen la lesion discal y el dolor lumbar cronico. La obesidad condiciona en gran medida la evaluacion preoperatoria y la tecnica quirurgica en cirugia de columna. Diversos metaanalisis confirman un aumento de complicaciones tras cirugia lumbar en el paciente obeso (especialmente infecciones y trombosis venosas). Sin embargo, los resultados funcionales de estas intervenciones son favorables aunque inferiores a los de la poblacion no obesa, teniendo en cuenta que parten de valores basales inferiores y el pronostico de los obesos tratados conservadoramente es mucho peor. El impacto de una reduccion de peso preoperatoria no se ha estudiado de forma prospectiva en este tipo de pacientes.

Resumen Objetivo Describir y discutir el papel del tratamiento quirurgico en la espondilodiscitis espontanea. Pacientes y metodos Analisis retrospectivo de resultados y complicaciones de una cohorte de pacientes intervenidos por espondilodiscitis espontanea (no posquirurgica) de cualquier nivel espinal y etiologia. Resultados En el periodo 1995-2014 se trataron 83 pacientes (45% mujeres, edad mediana 66 anos) con diagnostico de espondilodiscitis (confirmacion microbiologica en el 67,4%). Existio deficit neurologico preoperatorio en el 44,5%. El nivel mas frecuentemente afectado fue el dorsal (54,2%). Los principales germenes aislados fueron Mycobacterium tuberculosis (22,9%), Staphylococcus aureus (20,5%) y SARM (7,2%). Se intervinieron 81 pacientes mediante: laminectomia simple y/o biopsia (22,2%), laminectomia, desbridamiento y artrodesis posterior (43,2%), y desbridamiento y fijacion anterior (34,5%). El 86,7% de los pacientes intervenidos obtuvieron buena evolucion postoperatoria (mejoria sintomatica o del deficit). Se estabilizaron 7 pacientes y empeoraron 2. Aparecieron complicaciones en 35 pacientes, fundamentalmente derrame pleural (9), anemia (7) y necesidad de reintervencion y desbridamiento (7). La mediana de estancia postoperatoria fue de 14 dias. Tras un seguimiento medio de 8,5 meses se consideraron curados 46 pacientes, 10 presentaron secuelas, se perdieron 22 pacientes y 5 fallecieron. La cirugia no motivo reingresos. Conclusiones Aunque la antibioterapia especifica y prolongada es el tratamiento estandar, la cirugia permite obtener muestra para estudio microbiologico e histopatologico, desbridar el foco infeccioso y estabilizar la columna. En nuestra experiencia la utilizacion de material metalico de fijacion acelera la recuperacion y no predispone a ulteriores infecciones o a cronificacion de las mismas.

The assessment of response to therapy in glioblastoma remains a challenge, because the surrogate measures of survival are subject to radiographic misinterpretation. A solid and reliable definition of progression is needed for both clinical decision-making and for evaluating response within the clinical trials. Historically, assessment criteria have used radiologic and clinical features aimed to correctly classify patients into progressive or non-progressive disease. The widely used RANO criteria are a valuable tool in disease evaluation, both in the clinical setting and in the clinical trials. However, assessment criteria have certain limitations that emerging image techniques have tried to overcome. Differentiating true progression from treatment-related changes (like pseudoprogression or pseudoresponse) is crucial in order not to prematurely discontinue adjuvant chemotherapy or redirect the patient to second-line options. This fact underscores the need for advanced radiologic techniques, like specific diffusion and perfusion MRI sequences, MR spectroscopy and PET, which seem to play a role in distinguishing these phenomena.

Objectives To describe the rationale, pros and cons, and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable (TLICS > 4) thoracolumbar fractures. Patients and methods Clinical and radiological data and outcomes from a cohort treated surgically via said approach were retrospectively reviewed. All patients were operated on exclusively by 5 neurosurgeons trained in spine surgery. Results Between June 1999 and December 2015, 86 patients underwent surgery (median age 42 years, most common level: L1). Approximately 32.5% presented with a preoperative neurological defect. After surgery (mean duration: 275 min), 75.6% presented with no neurological sequelae and only one-third required blood transfusion. Median postoperative stay was 7 days. Correction of kyphosis was considered adequate and suboptimal but acceptable in 91% and 9% of the patients, respectively. Complications occurred in 36 patients, the majority being transient. We observed failure of the construct in 2 cases (collapse of an expandable cage and extrusion of a locking screw). No infections, vascular or visceral lesions, permanent neurological worsening or mortality occurred during hospitalisation. One patient ultimately needed additional posterior fixation due to persistence of pain. Median follow-up was 252 days (27.9% was lost to follow-up). Conclusions The extrapleural extraperitoneal approach provides solid anterior reconstruction, allows wide decompression of the spinal canal, and permits adequate and long-lasting correction of kyphosis. The rates of infection, construct failure, need for reoperation and vascular or visceral lesions are minimal.

Resumen Objetivos Describir los fundamentos, las ventajas, los inconvenientes y las complicaciones del abordaje anterolateral extrapleural-extraperitoneal en fracturas toracolumbares inestables (TLICSS > 4). Pacientes y metodos Se evaluan retrospectivamente datos clinicos y radiologicos, resultados y complicaciones de una cohorte intervenida mediante dicho abordaje. Todos los pacientes fueron intervenidos exclusivamente por 5 neurocirujanos entrenados en cirugia de columna. Resultados Un total de 86 pacientes fueron intervenidos entre junio de 1999 y diciembre de 2015 (mediana de edad 42 anos y nivel mas frecuente L1). El 32,5% presentaban defecto neurologico preoperatorio. Tras la intervencion (duracion media: 275 min), el 75,6% quedaron sin secuelas neurologicas y solo un tercio de pacientes preciso transfusion. La estancia media postoperatoria fue de 7 dias. La correccion de la cifosis se considero correcta y suboptima pero aceptable en el 91 y el 9% de los casos, respectivamente. Ocurrieron complicaciones en 36 pacientes, la gran mayoria transitorias. Se constataron 2 fallos de material (colapso de caja expansible y extrusion de tornillo de bloqueo). No ocurrieron infecciones, lesiones vasculares, lesiones viscerales, empeoramiento neurologico permanente ni mortalidad durante el ingreso. Un paciente preciso estabilizacion posterior tardia por persistencia del dolor. El seguimiento mediano fue de 252 dias (27,9% perdidas). Conclusiones El abordaje extrapleural-extraperitoneal proporciona una estabilizacion anterior solida, permite una amplia descompresion del canal y una correccion adecuada y duradera de la cifosis. Las tasas de infeccion, fallo del material, necesidad de reoperacion y lesiones vasculares o viscerales son minimas.

Resumen Introduccion La cirugia de la hernia discal lumbar (HDL) es una de las intervenciones con mayor variabilidad geografica en su indicacion. Desarrollo Se realiza una revision bibliografica sobre la historia natural, el papel de la exploracion neurologica, el timing de la cirugia, el tratamiento basado en la evidencia y el conflicto de intereses relativos a la HDL. La cirugia acorta significativamente el tiempo de dolor respecto al tratamiento conservador, aunque este efecto se diluye a partir del ano. No parece existir una modalidad terapeutica superior al resto respecto del control del dolor o de la recuperacion neurologica, ni una tecnica quirurgica claramente superior a la discectomia simple. La gran variabilidad geografica puede deberse a una ausencia de criterios cientificos solidos en la indicacion. Conclusiones La historia natural de la HDL es favorable y debe respetarse un minimo de 6 semanas antes de indicar pruebas de imagen o considerar la cirugia. Es preciso concretar y respetar la indicacion quirurgica, evitando los conflictos de intereses.

The management of diffuse supratentorial WHO grade II glioma remains a challenge because of the infiltrative nature of the tumor, which precludes curative therapy after total or even supratotal resection. When possible, functional-guided resection is the preferred initial treatment. Total and subtotal resections correlate with increased overall survival. High-risk patients (age >40, partial resection), especially IDH-mutated and 1p19q-codeleted oligodendroglial lesions, benefit from surgery plus adjuvant chemoradiation. Under the new 2016 WHO brain tumor classification, which now incorporates molecular parameters, all diffusely infiltrating gliomas are grouped together since they share specific genetic mutations and prognostic factors. Although low-grade gliomas cannot be regarded as benign tumors, large observational studies have shown that median survival can actually be doubled if an early, aggressive, multi-stage and personalized therapy is applied, as compared to prior wait-and-see policy series. Patients need an honest long-term therapeutic strategy that should ideally anticipate neurological, cognitive and histopathologic worsening.

OBJECTIVES: Since the introduction of endovascular treatment for cerebral aneurysms, hospitals in which subarachnoid hemorrhage is treated show different availability and/or preferences towards both treatment modalities. The main aim is to evaluate the clinical and angiographic results according to the hospital's treatment preferences applied. METHODS: This study was conducted based on use of the subarachnoid hemorrhage database of the Vascular Pathology Group of the Spanish Neurosurgery Society. Centers were classified into 3 subtypes according to an index in the relationship between endovascular and surgical treatment as: endovascular preference, high endovascular preference, and elevated surgical preference. The clinical results and angiographic results were evaluated among the 3 treatment strategies. RESULTS: From November 2004 to December 2017, 4282 subarachnoid hemorrhage patients were selected for the study: 630 (14.7%) patients from centers with surgical preference, 2766 (64.6%) from centers with endovascular preference, and 886 (20.7%) from centers with high endovascular preference. The surgical preference group obtained the best angiographic results associated with a greater complete exclusion (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). The surgical preference subgroup obtained the best outcome at discharge (65.45%), followed by the high endovascular preference group (61.5%) and the endovascular preference group (57.8%) (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). CONCLUSIONS: In Spain, there is significant variability in aneurysm exclusion treatment in aneurysmal subarachnoid hemorrhage. Surgical centers offer better results for both surgical and endovascular patients. A multidisciplinary approach and the maintenance of an elevated quality of surgical competence could be responsible for these results.

Resumen Objetivos Valorar el impacto de la introduccion del tratamiento endovascular en pacientes con hemorragia subaracnoidea espontanea aneurismatica (HSAa) en un centro de medio-bajo volumen. Material y metodos Estudio observacional retrospectivo donde se comparan los resultados clinicos de pacientes con HSAa en 2 periodos, antes y despues de disponer de tratamiento embolizador. Las variables estudiadas mas relevantes fueron: modalidad de tratamiento, mortalidad intrahospitalaria y diferida, complicaciones intraprocedimiento, tasas de resangrado y vasoespasmo, y resultados al final del seguimiento medidos mediante la escala de resultado de Glasgow (GOS). Resultados Se trato en total a 71 pacientes en 2 periodos: 2010-2011 (32 pacientes; 19 clipajes, 6 embolizaciones,7 no tratados) y 2012-2013 (39 pacientes; 3 clipajes, 34 embolizaciones, 2 no tratados). Ambas cohortes no presentaron diferencias significativas en cuanto a edad, sexo, grado clinico al ingreso, tipo y localizacion de los aneurismas y puntuacion de Fisher, asi como en mortalidad intrahospitalaria (28,1% vs. 25,6%, p = 0,35), resultado clinico valorado segun la puntuacion de GOS (salvo en GOS 5: 43,37% vs. 53,8%, p = 0,045), tasa de hidrocefalia e incidencia de vasoespasmo sintomatico. La segunda cohorte obtuvo mejores resultados agregados respecto a la primera para GOS 1 + 2 + 3 (36,3% vs. 43,75%, p = 0,034) y para GOS 4 + 5 (61,5% vs. 56,25%, p = 0,078). El porcentaje de pacientes que no fueron tratados fue significativamente inferior en el segundo periodo (5,1% vs. 21,8%, p Conclusiones El tratamiento endovascular permitio tratar un porcentaje mayor de pacientes con HSAa con una disminucion en la tasa de resangrados. Este hecho se tradujo en una modesta reduccion en la morbimortalidad.

Ependymoma is an uncommon neuroepithelial tumor that may arise anywhere within the neuroaxis, both in children and in adults. It has been classically graded upon histopathological features, yet with limited clinical utility. Recently, DNA methylation profiling has provided a novel classification of ependymoma in nine molecular subgroups. This stratification method harbors prognostic value with supratentorial RELA-fusion and posterior fossa group A tumors showing a significantly shorter survival compared to the rest. Currently, the treatment of choice involves maximal safe resection and, in cases of residual disease, adjuvant conformal radiotherapy. Second-look surgery is also a feasible and recommended option for incompletely resected tumors. The role of chemotherapy is not yet established and can be considered in infants and children with relapsing disease or prior to re-intervention. Although targeted agents do not seem to play a role as adjuvant therapy, they are currently being tested for recurrent disease.

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned.

The increasing age and complexity of in-hospital neurosurgery patients have raised the number of consultations with Internal Medicine. This type of collaboration is discretional and lacks temporal continuity. The full-time appointment of an internal medicine practitioner to a Neurosurgery Department, with complete care attributions except for strict surgical work, is a feasible organizational option. This method minimizes the need for medical consultation, improves the perceived quality of care, allows neurosurgeons to focus on purely surgical tasks, provides an integral vision of the patient's condition, enriches the group with specialized non-neurosurgical knowledge, and raises the scientific level of the team. In our Neurosurgery Department, an internal medicine practitioner has been working as part of the staff for 14 years. We describe her medical activity duties, the advantages our department gains from her daily work, and the professional and working implications derived.

Surgery for lumbar degenerative pathology, although effective, results in suboptimal outcome and degrees of disability in a relevant proportion of patients. Postoperative rehabilitation has failed to demonstrate efficacy in the mid and long term. So-called "prehabilitation" (physiotherapy and/or cognitive-behavioral therapy) focuses in augmenting patients' functional capacities before surgery by improving their physical condition and their perception of pain, surgical experience or its consequences. Several studies suggest that prehabilitation improves postoperative outcome, shortens hospital stay and may reduce costs compared to classic postoperative rehabilitation. However, its true effect seems to be influenced by factors like obesity, co-morbidity and, especially, by a wrong perception of the natural history of this pathology in terms of catastrophising and kinesiphobia. In this paper we describe the concept of prehabilitation, review the literature, and discuss the role of some clinical conditionings involved.

In the last decade, electronic media has irrupted physician's clinical practice. Patients increasingly use Internet and social media to obtain enormous amounts of unsupervised data about cancer. Blogs, social networking sites, online support groups and forums are useful channels for medical education and experience sharing but also perfect environments for misinformation, quackery, violation of privacy and lack of professionalism. The widespread availability of such electronic resources allows some followers of the alternative oncology to spread useless irrational and controversial remedies for cancer, like false medicaments, miraculous diets, electronic devices, and even psychic therapies, as did charlatans in the past, providing false expectations about cancer treatments. Moreover, so-called predatory journals have introduced confusion and malpractice within the academic biomedical publishing system. This is a rising editorial phenomenon affecting all fields of biomedicine, including oncology that jeopardizes the quality of scientific contribution and damages the image of open access publication.

So-called predatory publishing is a new and rising phenomenon presenting as an intellectual fraud that jeopardises the quality of scientific contribution, compromises the activity of authors, reviewers and editors of legitimate journals, damages the image of open access publications and is a very profitable business. In this paper, we review the concept and relevance of predatory journals and the characteristics that differentiate them from legitimate publications. Neurosurgical and general neuroscience journals are not immune to this problem. Academic institutions and ethics committees have a duty to raise awareness of this phenomenon and provide information and support to authors and the whole scientific community to avoid its propagation and potential control of biomedical publishing.

Objective To describe and discuss the role of surgery in the management of spontaneous spondylodiscitis. Patients and methods Retrospective review on the outcome and complications of a cohort of patients undergoing surgery for spontaneous (non-postoperative) spondylodiscitis of any spinal level or aetiology. Results From 1995 to 2014, 83 patients (45% females, median age 66) with spondylodiscitis were treated. Microbiological confirmation was obtained in 67.4%. Forty-four percent of patients presented with neurological defect. The most common affected level was thoracic (54.2%). The most frequent isolations were Mycobacterium tuberculosis (229%), Staphylococcus aureus (20.5%) and MRSA (7.2%). Eighty-one patients underwent surgery: simple laminectomy and/or biopsy (22.2%), debridement and posterior fixation (43.2%) and debridement and anterior fixation (34.5%). Improvement of pain or neurological defect was achieved in 86.7% of the patients; 7 patients stabilised and 2 worsened. Complications occurred in 35 patients, mainly pleural effusion (9), anaemia (7) and need for re-debridement (7). Median postoperative stay was 14 days. After a median follow up of 8.5 months, 46 patients were considered completely cured, 10 presented sequelae, 22 patients were lost and 5 patients died. No readmissions occurred because of the infectious episode. Conclusions Although prolonged and specific antibiotic therapy remains the mainstay of treatment in spontaneous spondylodiscitis, surgery provides samples for microbiological confirmation and histopathologic study, allows debridement of the infectious foci and stabilises the spine. In our experience, the use of internal metallic fixation material accelerates recovery and does not predispose to chronic infection.

Obesity (BMI>30Kg/m2) is a pandemic with severe medical and financial implications. There is growing evidence that relates certain metabolic processes within the adipose tissue, preferentially abdominal fat, with a low-intensity chronic inflammatory state mediated by adipokines and other substances that favor disk disease and chronic low back pain. Obesity greatly conditions both the preoperative evaluation and the spinal surgical technique itself. Some meta-analyses have confirmed an increase of complications following lumbar spine surgery (mainly infections and venous thrombosis) in obese subjects. However, functional outcomes after lumbar spine surgery are favorable although inferior to the non-obese population, acknowledging that obese patients present with worse baseline function levels and the prognosis of conservatively treated obese cohorts is much worse. The impact of preoperative weight loss in spine surgery has not been prospectively studied in these patients.

Background Central nervous system nocardial infection is a rarely reported disease that usually affects patients with predisposing and debilitating conditions but also the immunocompetent population. The most common variant affecting the brain is Nocardia farcinica . Management of brain nocardiosis is troublesome and requires consideration of the severity of the underlying systemic disease, the difficulties in identifying the bacterium, and the frequent delay in initiating adequate therapy. Case Description We present 3 cases of N. farcinica brain abscess (single, multiloculated, and multifocal) diagnosed in 3 patients with predisposing factors that could be successfully cured. The patients underwent craniotomy, evacuation of the purulent collection, and partial resection of the abscesses' walls. Confirmation of N. farcinica species was achieved using specific polymerase chain reaction sequencing of the 16S ribosome RNA gene. Antibiotic therapy was selected on susceptibility tests and was maintained for 10 months (1 case) and 12 months (2 cases). Conclusions Brain nocardiosis needs to be suspected primarily (though not exclusively) in immunocompromised patients presenting with neurologic deficit and harboring intracerebral lesions resembling brain tumors. Early identification of the specific species is paramount in order to initiate long-term antibiotic therapy, acknowledging the inherent resistance of N. farcinica to third-generation cefalosporins and its susceptibility to trimethoprim-sulphamethoxazole. According to the literature, surgical excision or aspiration of the brain abscess seems to provide good chances of eradication of the disease. In our experience, successful outcome was achieved with subtotal resection and prolonged and adequate antibiotic therapy.

Idiopathic spinal cord herniation (ISCH) is a relatively rare and frequently misdiagnosed condition. It preferentially affects women and causes progressive thoracic myelopathy that presents as a Brown-Séquard syndrome or as spastic paraparesis. Although its etiology and pathogenesis are controversial, ISCH is characterized by the presence of an anterior dural defect that allows the incarceration of a segment of the cord. Typically, a C-shaped ventral displacement and kinking of the cord are visible on sagittal MRI. Surgery aimed at stopping or reversing myelopathic symptoms is usually recommended for symptomatic patients. Surgical options include reduction of the hernia and direct suturing, or enlargement of the dural defect, with or without patching. Suturing under the cord in a very tight space can be troublesome and may lead to neurological deterioration. The authors present the case of a symptomatic ISCH in which nonpenetrating titanium microstaples were used to close the dural defect after cord reduction. The patient experienced a good outcome, and the follow-up MRI study showed adequate cord repositioning and stability of the suture. The use of microstaples, which allows for an easier and faster dural closure than conventional suturing, is a novel technical adjunct that has not been previously reported for this condition. In addition, microstaples produce minimal metallic artifact that does not hinder the quality of follow-up MR images.