The intervertebral disc disease (IDD) is one of the most common muscle-skeletal disorders, causing both high work disability and elevated healthcare costs. There are two specific origins of disk ...disease that should be kept in mind: degenerative (DDD) and traumatic (TDD). Concerning the TDD, nowadays it has not been determined which patients could gradually improve and which ones will require surgery. Some studies indicate that about 85% of lumbar and 90% cervical acute disc herniation will get better in an average of 6 weeks.
We conducted an observational, prospective study, over a group of 858 patients, with the following inclusion criteria: 1. MRI imaging indicating TDD, 2. No signs or symptoms requiring urgent surgical treatment (cauda equina syndrome, progressive or serious motor deficit or unbearable pain) and 3. Development of progressively spontaneous symptoms remission. All of the patients included in our study were treated in our Department of Neurosurgery from 2006 to 2007. Patients were tested for disc herniation regression with a second MRI study.
A spontaneous regression of their hernia was appreciated as follow: 33 cases of lumbar hernia (29 male, 4 female), 3 cervical hernia (1 male, 2 female) and 1 dorsal hernia (male).
Research about other reported series was done, and the different factors that could take place in disc spontaneous regression were analyzed: a) lodgement of the herniated disc back into the intervertebral space; b) disappearance of the herniated fragment due to dehydration and retraction mechanisms; c) gradual resorption of the herniated tissue by phagocytosis and enzymatic degradation induced by an inflammatory reaction that appeared as the disc (acting the extrusion itself as an foreign body) and, d) pulsion of cephaloarchidian liquid against the herniated portion.
Disc herniation can regress, or even disappear, in a number of patients, rendering the radiological findings not to be taken as the only surgical indication criterium. We consider that the best treatment is the one relying on a good doctor-patient relationship, suspended in a balance between conservative and surgical treatment. According to clinical data, the first one (conservative) should not exceed the estimated time beyond which the surgical result would be unsatisfactory. The second one (operative), excepting "need-to operate" situations (such as cauda equina compression, progressive or serious motor déficit, or unbearable pain), should be prudently supedited to MRI regresión control, in particular in patients in which a clinical improvement is observed. Thus, the disc herniation conservative healing, both clinical as radiological, do exist, being a concept to widespread among clinicians and patients also.
INTRODUCTION. Ganglioneuromas or gangliomas are tumours of the sympathetic ganglia that contain cells of the neural crest, so they can appear in all body localizations. They are generally benign, ...more frequent between 10 and 40 years, may secrete hormones and, sometimes, Neurofibromatosis type I and other genetic disorders can be associated. OBJECTIVE. To review the scientific literature related to the topic and to present a case treated in our service. DISCUSSION. The symptoms depend on location and vasoactive secreted hormones. In spite of that, they are generally benign tumours, although sometimes they can spread out. Since laboratory and image test are of limited usefulness, the conclusive diagnosis is anatomopathologic. In symptomatic patients the best procedure is surgical removing. CONCLUSION. Ganglioneuroma and disk herniation association constitute an exceptional disorder. Its treatment implies surgery resection.
Vertebroplasty and kyphoplasty are minimally invasive percutaneous techniques indicated in the treatment of some somatic vertebral fractures. Both are based on the introduction of a substance, called ...cement, inside the vertebral body. We can choose acrylic or biological cement. These techniques are not risk-free, cement extravasation being the main complication. Due to the short experience in the use of the biological cements, nowadays there are a lot of unresolved doubts about the long-term behaviour of these materials, especially in the case of leakage.
We report a case of biologic cement extravasation into the spinal canal during a kyphoplasty in a 23 year old man and its long-term follow-up (3 years), performing a review of the scientific literature related to the topic.
Most of the papers in the literature discuss the behaviour of the reinforcement material inside a bony environment, but they do not refer to the evolution of the cement outside the vertebral space. We have appreciated in our case that the leaked cement is not being substituted for bone but it suffers a process of progressive resorption. The extravasation of the vertebral reinforcement material is an important and potentially serious complication of the vertebral augmentation techniques. To avoid this, a very precise chirurgical technique is necessary, under radiological guidance. Biocompatibility, biodegradability and osteoconductivity are the main advantages of biological cements. We base the choice of the cement on the balloon/trabeculae interaction.
We present a series of patients with acute thoraco-lumbar fractures in whom we performed balloon vertebroplasty (kyphoplasty), either alone (percutaneous) or combined to posterior transpedicular ...fusion (open kyphoplasty). We emphasize the possibility of extending the use of kyphoplasty to non-osteoporotic vertebral fractures, and combining this method with traditional posterior fusion procedures.
Between 2003 and 2005, 138 patients suffering from thoraco-lumbar acute fractures, were treated in our Department. 87 corresponded to one vertebral level fractures; 34 to two levels, and the remaining 17 patients had more than two vertebrae affected. 65 patients (47%) received conservative therapy (rest in bed, physiotherapy, and subsequent progressive mobilization with cast). The remaining ones (73 cases; 43%) were treated invasively, performing balloon vertebroplasty alone (n=25), or kyphoplasty associated to posterior fusion in 15 cases (11%). Different kinds of screw posterior fusions were performed in the remaining patients (n=33; 24%). The latter group was not included in the present study. In the conservatively treated group (CTG), seven patients (11%) had a bad outcome, showing a persistency of hyperintensity in MRI-T2 sequences of the vertebral body, suggesting local edema. Mean hospitalization rate was 29 days in CTG. None of the 40 patients treated with kyphoplasty alone or combined with fusion showed abnormalities in neurological examination. They were classified in two groups: "Group a": Kyphoplasty alone (n=25). Mean of sagittal index in this group was 11 degrees (range: 6 degrees -15 degrees). In 9 patients, vertebral body collapse exceeded 25%. Mean hospitalization rate was 14 days. "Group b": Kyphoplasty and posterior fusion techniques (n=15): Mean sagittal index was 23 degrees (range: 13 degrees - 40 degrees). All the patients presented with a vertebral body collapse superior to 25%. All of them had posterior body wall involvement. This group was treated by surgery (decompression and fusion) and open vertebral body kyphoplasty. Mean hospitalization rate was 35 days. Clinical results of these 40 patients were measured by means of work status, restriction of physical activities and analgesic drug intake. Except for four patients of "Group b", 36 returned to their work. In 11 cases a slight reduction of physical activity was registered. Average "Group a" follow-up was 47 months (range: 10-72 months). A mean kyphosis correction of 5,3 degrees (sagittal index) was reached in this group. Average "Group b" follow-up was 26 months (range: 9-54). Mean kyphosis correction was 10,3 degrees . As for complications, we registered three balloon disruptions and five leakages into the disc.
Kyphoplasty could constitute an alternative and/or complementary treatment of traditional spinal stabilization-fusion procedures in non osteoporotic vertebral fractures. Therefore, it should be offered, when indicated, as a substantial possible part of the treatment, to the patients suffering from vertebral fractures. Additional advantages of combining kyphoplasty and posterior fusion are the possibility of reducing the number of fused levels (shorter instrumentations), and to perform a 360 degree stabilization-remodeling through a single posterior approach.
El presente trabajo revisa las líneas seguidas en casos de autopsia por sospecha de mala praxis. Se revisan las indicaciones, propósitos generales, técnicas de disección, exámenes complementarios, ...junto con los problemas éticos, de acuerdo con la experiencia del autor y la literatura. Un grado significativo de entrenamiento y experiencia tanto clínica como patológica es requerido en estos casos. Esta necesidad puede contrastar con la relativa falta de expertizatión de los médicos forenses en España, y con las limitaciones de la autopsia médico-legal. Algunas guías para solucionar este problema, como consulta con especialistas independientes, o con los comités de las especialidades médicas, son consideradas. Existen importantes problemas éticos en estos fallecimientos. En consecuencia, hay una necesidad de enfoque correcto de estos problemas. Se consideran algunas orientaciones en este sentido.
La Bioética implica hoy en día a toda la actividad médica, habiéndose convertido en un factor crucial a la hora de orientar la acción en muchas situaciones clínicas y evaluar materias médicas tales ...como publicaciones, artículos y conferencias.
Sin embargo, hasta el momento, la Bioética ha prestado poca atención a la actividad pericial médica. Ello a pesar de los importantes problemas que surgen en los peritajes ante los Tribunales. Factores como la cualificación del perito, sesgo, error, confidencialidad, conflictos entre actividad asistencial y pericial, están entre las principales materias potenciales de discusión ética.
En España, en particular, hay una falta de regulación de estos aspectos, causando importantes consecuencias sobre todo en casos de litigación por cuestiones de responsabilidad médica.
El presente trabajo intenta revisar la situación en España, comparada con las posiciones en el extranjero, y enfatizar la necesidad de una regulación legal, profesional pero sobre todo ética de la actividad pericial médica ante los Tribunales.
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