Clinical Research
Evaluation of temporal muscle trophism in relation to the manipulation time and infiltration of 0.5% isobaric bupivacaine through a pterional approach
Evaluación del trofismo del músculo temporal posquirúrgico en relación con el tiempo de manipulación y la infiltración transoperatoria de bupivacaína isobárica al 0,5% en pacientes sometidos a craneotomía pterional
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It was designed and popularised by Yasargil<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">1–4</span></a> and is used in approximately 10% of skull base surgeries and in 5% of aneurysm surgeries.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Disconnection of the temporal muscle (TM),<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">1–4,6</span></a> which is associated with its postoperative atrophy, is included in the steps for PA, generating functional and cosmetic defects as a result.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">6,7</span></a> Another point in the technique of this approach is the identification and appropriate dissection of the superficial temporal artery, which can be preserved without damage in up to 44% and, in up to 38% of patients, a repair may be performed with the aim of compromising the irrigation of the skin muscle flap as little as possible.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">8</span></a> All this should take into account that the percentage of post-craniotomy TM atrophy is 30% in the first month and 50 to 60% in the subsequent six months.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> The dissection and preservation of the frontal branch of the facial nerve is considered a key point in PA, since injury to this results in paralysis of the forehead muscle, the orbicularis oculi muscle, and the corrugator supercilii muscle, also impacting the functional and cosmetic outcome.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a> Specifically, TM atrophy is attributed to: (1) direct damage to the muscle fibres due to inappropriate dissection or excessive retraction,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> (2) TM ischaemia due to the interruption of a nutrient artery,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> (3) inappropriate tension when fixing the muscle<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">6</span></a> and muscle denervation due to direct or indirect damage.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Various TM dissection and reconstruction techniques have been reported in order to prevent and reduce atrophy of the muscle, such as retrograde dissection, fixation of the TM to a cuff of muscle, fixation to the bone in line with the upper temporal, cortical osteotomy, myofascial bone flap, middle skull base reconstruction, using lateral-based pericranial flaps, etc., obtaining good cosmetic and functional outcomes, but with a high level of difficulty in the surgical technique.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7,10–13</span></a> The PA technique has been compared with other techniques such as preformed titanium plates and mini-pterional craniotomy to facilitate and improve the more anatomical restoration of the temporal muscle, both with good outcomes. However, so far none of the techniques described has managed to prevent TM atrophy entirely.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Mobilisation of the TM generates an alteration in the functioning of the temporomandibular joint, which manifests with pain, limited ability to chew, problems with occlusion, mouth opening and lateral movement of the jaw.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7,16,17</span></a> It has been observed that between four to six months after a craniotomy, 48% of patients complain of pain during the dental examination and 28% of pain during normal jaw movements.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">16,18</span></a> Cases of pain after a pterional craniotomy have been associated with muscular hypertrophy with response to the application of botulinum toxin type A.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The administration of 0.75% bupivacaine into the striated muscle has a pleiotropic effect, generating hypertrophy of the muscle fibres. This effect was identified in patients who underwent cataract surgery when presenting with strabismus due to hypertrophy of the injected muscle, which has been corroborated with magnetic resonance studies.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">18,20–22</span></a> It has been observed that hypertrophy of the rectus abdominis muscle improves strabismus and diplopia on approximately day 33, and still persists on day 54, even up to 12 months with 0.5% bupivacaine.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">23–25</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Bupivacaine generates atrophy two to six weeks after application, followed by regeneration in weeks six to eight. Compared with lidocaine, the latter generates more atrophy in the muscles and less muscle regeneration.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">1.5% bupivacaine has been used in conjunction with botulin toxin in the antagonist muscle with good outcomes for the treatment of strabismus, observing an increase in the thickness and length of the antagonist muscle of 1.01<span class="elsevierStyleHsp" style=""></span>mm at 30 days after application.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">24,27</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">After the injection of local anaesthetics (bupivacaine, lidocaine, mepivacaine) on days 2–3, invasion of the muscle fibres damaged by phagocytic cells was observed. After four to five days, the damaged muscle fibres present dense concentrations of phagocytes and mononuclear myoblast cells; after seven days, the first myotubes and maturation of them is observed.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3,10,28</span></a> Several studies have reported that in the first 20 days from the application of bupivacaine, a phase of myotoxicity followed by regeneration of the histologically normal muscle fibres is observed, accompanied by hypertrophy, and this effect has not been seen with the application of bupivacaine at a concentration of less than 0.5%.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">25,29,30</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathophysiology by which bupivacaine generates alteration in the striated muscle is in the mitochondria, where a series of bioenergetic and structural alterations are presented. These are described in experimental models. The intensity of the changes observed is related to the concentration of bupivacaine and the time of exposure.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The ultrastructural and morphological changes of the neuromuscular junction during the regeneration of the muscle fibres degenerated by the application of single doses of bupivacaine resemble those that occur during the differentiation from normal muscle fibres.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">30</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The adverse effects reported with bupivacaine include hypersensitivity reactions, cardiac dysfunction and central nervous system dysfunction. The latter arise from direct injection into a blood vessel, use of excessive doses or a rapid absorption. The majority can be prevented by making an informed choice, using a rigorous technique and carrying out close monitoring.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">32</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">To date, there have been no studies or research protocols in the medical literature which evaluate the manipulation time of the TM and which make use of bupivacaine for the treatment of TM atrophy after a pterional craniotomy. The aim of this study was to describe the effects of these variables.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0065" class="elsevierStylePara elsevierViewall">An analytical, longitudinal study conducted at the Hospital Central Sur de Alta Especialidad [Central Southern Highly Specialised Hospital], PEMEX (HCSAE). Patients aged 18–80 who underwent skull surgery with PA using the temporal muscle retraction technique by Spetzler and Lee,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a> in the period from 1 March 2016 to 30 April 2017, were included. Patients with a history of prior PA, who had undergone a craniotomy, had muscle disorders and/or were allergic to bupivacaine were excluded. 0.5% bupivacaine was administered in four quadrants of the temporal muscle during the surgical repair.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The following variables were recorded in the period prior to surgery and during the subsequent 90 days:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Trophism of the temporal muscle: this was evaluated by measuring the thickness in the preoperative computed tomography of the skull and at 90 days after the surgical procedure.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Difficulty chewing: degree of force in accordance with the patient's perception.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Degree to which jaw movement is affected using the Helkimo index modified by Maglione (see appendix, additional material available in the electronic version).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Time of bone diaeresis and synthesis: time between the start and end of the craniotomy.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Time of muscle flap diaeresis and synthesis: time between the start of the temporal muscle incision until fixation.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Muscle retraction time.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Surgery time.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">For the statistical analysis, measures of central tendency, frequency and prevalence of each previously mentioned quantitative variable were obtained. The Student's <span class="elsevierStyleItalic">t</span>-test was used for independent variables in the comparison of the difference in trophism of the temporal muscle between patients who were infiltrated with 0.5% bupivacaine and those who were not infiltrated with it, and the Friedman test to compare preoperative and postoperative indices. Pearson's correlation was performed for intraoperative times with the thickness of the temporal muscle. Values of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 were established as statistically significant. The analysis was carried out using the statistical analysis program IBM SPSS 25.0.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">A total of 29 patients underwent a pterional craniotomy. Sixteen patients (55.17%) had criteria for infiltration with 0.5% bupivacaine. The mean age of presentation was 61.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.3. The female gender prevalence obtained was 88%, and the male gender prevalence was 12%. The conditions most frequently operated on using the pterional approach in our institution were cerebral aneurysm (56%), meningioma (25%), arachnoid cyst (6%) and glioma (6%).</p><p id="par0120" class="elsevierStylePara elsevierViewall">In relation with the intraoperative periods (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), an average surgical time of 4.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.15<span class="elsevierStyleHsp" style=""></span>h, a mean muscular retraction time of 2.94<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.97<span class="elsevierStyleHsp" style=""></span>h, time of bone diaeresis and synthesis 2.55<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.09<span class="elsevierStyleHsp" style=""></span>h and time of muscle flap diaeresis and synthesis 2.86<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.07<span class="elsevierStyleHsp" style=""></span>h. The correlation between intraoperative times and muscle thickness was looked for, with negative correlations being defined in all cases (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). They were not statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The dysfunction indices were evaluated in the patients infiltrated with 0.5% bupivacaine, comparing that presented in the preoperative period against that shown 90 days after the surgery (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The following information was reported:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">a.</span><p id="par0130" class="elsevierStylePara elsevierViewall">We found a moderate preoperative range of motion dysfunction in 6.3% of patients and no dysfunction in 93.8%, in contrast with 12.5% without dysfunction, 56.3% with moderate deficit and 31.3% with severe deficit in the postoperative range of motion. This difference was statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">b.</span><p id="par0135" class="elsevierStylePara elsevierViewall">In relation with the Helkimo dysfunction index, it was found that 81.3% of the population presented with a normal index, and 18.7% with a mild index in the preoperative period. In the postoperative period, a mild index was reported in 93.7% of patients, a moderate index in 6.3%, with the difference being statistically significant between both groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">c.</span><p id="par0140" class="elsevierStylePara elsevierViewall">The Fonseca index was compared, finding a statistically significant difference (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.025) between the preoperative (62.5% normal, 25% mild, 12.5% moderate) and the postoperative period at 90 days (normal 31.3%, mild 50% and moderate 18.7%).</p></li></ul></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">In patients infiltrated with 0.5% bupivacaine, a mean difference in thickness of the temporal muscle of 0.275<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.18<span class="elsevierStyleHsp" style=""></span>mm was observed by computed tomography. In those not infiltrated, the result was 2.39<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.30<span class="elsevierStyleHsp" style=""></span>mm, with a statistically significant difference being found between both groups (<span class="elsevierStyleItalic">t</span>(27)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−5.118, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Within the descriptive statistics of our sample, we found that, in conditions of the middle and anterior fossae, PA is the option to enable better exposure of the skull base.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">5,33</span></a> As it is such a conventional approach, the impact on the postoperative aesthetics and functionality of the temporal muscle has an impact on the patient's quality of life regardless of the underlying condition.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7,17</span></a> For this reason, different techniques for the dissection and reconstruction of the temporal muscle and superficial temporal artery have been developed. However, none has been effective in 100% of cases at preventing TM atrophy.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7–11</span></a> The objective of this study was to offer a proposal for an adjuvant treatment to improve these results.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The average time for the performance of a pterional craniotomy, the times of muscle flap and bone diaeresis and synthesis were found with negative, not statistically significant correlations, which were probably related to the size of the sample presented.</p><p id="par0160" class="elsevierStylePara elsevierViewall">We appreciate that the TM retraction time is what determines the higher negative correlation in the muscle thickness. We therefore infer that the greater the retraction time, the lower the postoperative muscle thickness that patients undergoing a pterional craniotomy will present, which had not previously been described. In the current literature, we can find that the direct damage to the TM fibres is generated due to inappropriate dissection or excessive retraction, ischaemia, inappropriate tension when fixing the muscle and muscle denervation.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">6–10</span></a> With the results obtained in our study, we consider that the intraoperative times do present their impact on TM trophism, probably by generating greater susceptibility of this to the damages previously mentioned.</p><p id="par0165" class="elsevierStylePara elsevierViewall">By carrying out the analysis of the different temporomandibular disorder indices (see appendix, additional material available in the electronic version), we found that for range of motion dysfunction, the Helkimo dysfunction index and the Fonseca index have a statistically significant difference when comparing the preoperative and postoperative period. This translates into the retraction of the temporal muscle having an impact on the range of motion, chewing, mouth opening<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7,16,18,34</span></a> and this results in a deterioration in the quality of life of the patient who undergoes a pterional craniotomy.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Based on the previous analyses performed in the literature, where the effect of bupivacaine on the muscle fibres was reported,<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20–30,35</span></a> we decided to administer this medicine into the temporal muscle in order to reduce the previously mentioned adverse effects and TM atrophy. We found it statistically significant that the difference in thickness of the TM in patients in whom 0.5% bupivacaine was applied is lower in comparison with patients not infiltrated with 0.5% bupivacaine. This leads us to propose the administration of this local anaesthetic as additional management for the repair of the TM.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0175" class="elsevierStylePara elsevierViewall">Manipulation of the TM during PA has a significant impact on the patient's quality of life, due to atrophy.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7,17,18,34</span></a> Our study presents that the administration of intraoperative 0.5% bupivacaine offers a reduction in the difference of TM thickness between the preoperative and postoperative period, as it has been found that this medicine prevents muscular atrophy.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20–30,35</span></a> However, the sample size is a limitation. We therefore intend to encourage the scientific and surgical community to carry out new studies with this medicine or other local anaesthetics in order to improve the quality of life of neurosurgical patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1239562" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patient and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1150385" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1239563" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1150384" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-23" "fechaAceptado" => "2019-03-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1150385" "palabras" => array:4 [ 0 => "Bupivacaine" 1 => "Temporal muscle" 2 => "Atrophy" 3 => "Pterional approach" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1150384" "palabras" => array:4 [ 0 => "Bupivacaína" 1 => "Músculo temporal" 2 => "Atrofia" 3 => "Craneotomía pterional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are different techniques for the reconstruction of the temporal muscle (TM) in the pterional approach (PA) in order to avoid and reduce atrophy, it has not been able to avoid it in its entirety.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The administration of bupivacaine generates regeneration of muscle fibres. There are no studies in the medical literature that evaluate the time of TM manipulation and the use of bupivacaine for the treatment of atrophy after pterional approach, the present investigation aim is to describe the effects of these variables.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patient and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Longitudinal study, including patients from 18-80 years old with pterional approach at 2016–2017. We evaluated the effects of the TM manipulation times and the administration of 0.5% bupivacaine on the trophism and function of TM.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Twenty-nine patients underwent a PA; 16(55.17%) count with criteria for 0.5% bupivacain infiltration.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We found a negative correlation between manipulation times and trophism, with no statistically significance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.05).</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We evaluated presurgical and postsurgical index of Helkimo and Fonseca's index, finding an increase of disfunction with statistically significance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05).</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">In patients who were infiltrated with 0.5% bupivacaine we observed a mean difference in the TM's trophism of 0.275<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.18<span class="elsevierStyleHsp" style=""></span>mm, in contrast with no infiltrated which was 2.39<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.30<span class="elsevierStyleHsp" style=""></span>mm (<span class="elsevierStyleItalic">t</span>[27]<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−5.118, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.0001).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The manipulation of the TM during a pterional approach conditioned an impact on the quality of life according to the disfunction indexes, due to atrophy. This investigation exhibits that de administration of 0.5% bupivacaine during surgery offers a decrease in the TM atrophy.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patient and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Existen diferentes técnicas para reconstrucción del músculo temporal (MT) en el abordaje pterional (AP) con el objetivo de evitar y disminuir la atrofia, hasta el momento ninguna ha logrado evitarla en su totalidad.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La administración de bupivacaína genera regeneración de fibras musculares. Aún no existe en la literatura médica estudios que evalúen el tiempo de manipulación del MT y que den uso a la bupivacaína para el tratamiento de la atrofia después de un abordaje pterional, el presente estudio pretende describir los efectos de estas variables.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio longitudinal, incluyendo pacientes de 18-80 años y sometidos a abordaje pterional en los años 2016-2017. Evaluamos los efectos de la manipulación del MT y la administración de bupivacaína al 0,5% sobre el trofismo y la función del MT.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Veintinueve pacientes fueron sometidos a AP; 16(55,17%) contaron con criterios para infiltración con bupivacina al 0,5%.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se encontró una correlación negativa entre los tiempos de manipulación y el trofismo, no estadísticamente significativo (p>0,05).</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se evalúo los índices de disfunción de Helkimo y Fonseca prequirúrgicos y posquirúrgicos encontrándose un incremento estadísticamente significativo en la disfunción (p<0,05).</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">En pacientes infiltrados con bupivacaína al 0,5% se observó una diferencia media del espesor de MT de 0,275±1,18<span class="elsevierStyleHsp" style=""></span>mm, en contraste con los no infiltrados de 2,39±1,30<span class="elsevierStyleHsp" style=""></span>mm (t[27] = -5,118, p=0,0001).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La manipulación del MT durante el abordaje pterional, condiciona un impacto sobre la calidad de vida de acuerdo con los índices de disfunción, debido a la atrofia. Esta investigación presenta que la administración de bupivacaína al 0,5% durante la cirugía ofrece una disminución en la atrofia del MT.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar1005">Valdivia-Chiñas H, Córdoba-Mosqueda ME, Cruz-Cruz EF, Ochoa-Cacique D, Medina-Carrillo Ó, García-González U. Evaluación del trofismo del músculo temporal posquirúrgico en relación con el tiempo de manipulación y la infiltración transoperatoria de bupivacaína isobárica al 0,5% en pacientes sometidos a craneotomía pterional. Neurocirugia. 2019;30:222–227.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean (hours) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Standard deviation (hours) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Muscle retraction time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time of bone diaeresis and synthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time of muscle flap diaeresis and synthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2118249.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Intraoperative periods in patients with pterional approach and infiltration of 0.5% bupivacaine.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pearson's correlation for thickness of the temporal muscle \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Muscle retraction time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.262 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time of muscle flap diaeresis and synthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.047 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time of bone diaeresis and synthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2118250.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Correlation of intraoperative times with the difference in thickness of the temporal muscle in the postoperative period at 90 days.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperative<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postoperative (90 days) <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Range of motion dysfunction</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Helkimo dysfunction index</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Fonseca index</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.025<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2118248.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 is considered a statistically significant value.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Comparison between dysfunction indices in the preoperative and postoperative period of patients with pterional approach infiltrated with 0.5% bupivacaine.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 121937 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The pterional approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.G. Vishteh" 1 => "F.F. Marciano" 2 => "C.A. David" 3 => "J.J. Baskin" 4 => "R.F. Spetzler" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Oper Tech Neurosurg" "fecha" => "1998" "volumen" => "1" "paginaInicial" => "39" "paginaFinal" => "49" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0185" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A craniotomia pterional: descrição passo a passo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F.C. Neto" 1 => "G.C. Ribas" 2 => "E. De Oliveira" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arq Neuropsiquiatr" "fecha" => "2007" "volumen" => "65" "paginaInicial" => "101" "paginaFinal" => "106" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0190" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The pterional craniotomy: tips and tricks" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.L. Dória-Netto" 1 => "E. Oliveira" 2 => "G.C. Ribas" 3 => "M.H. Faria" 4 => "J.M. Campos Filho" 5 => "F. 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