Special article
Epidemiological aspects of syringomyelia in a 19-year old cohort of spinal cord injury patients
Aspectos epidemiológicos de la siringomielia en una cohorte de 19 años de pacientes con lesión de la médula espinal
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"es" => array:1 [ "titulo" => "Aspectos epidemiológicos de la siringomielia en una cohorte de 19 años de pacientes con lesión de la médula espinal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2434 "Ancho" => 2176 "Tamanyo" => 189331 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Syrinx extension (number of vertebral levels) before and after (A) adhesiolysis or syringopleural shunting and (B) surgical treatment for the entire sample.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">p-value by the Wilcoxon signed-rank test.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Spinal cord injury (SCI) is a medically complex and life-disrupting condition associated with very high mortality rates.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Post-traumatic syringomyelia (PTS) is a potentially serious complication of SCI referring to a disorder in which a cyst or cavity forms within the spinal cord caused by alterations in cerebrospinal fluid (CSF) flow after a trauma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–7</span></a> Several theories have been proposed, but the pathophysiology of syringomyelia formation is not completely understood.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Approximately 4% of persons with SCI have been reported to develop clinically symptomatic PTS.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> PTS is often the result of severe spinal cord injuries and is associated with significant spinal deformity and stenosis of the spinal canal. Surgical approaches aimed at reestablishing normal CSF flow through enlargement of the dural sac and subarachnoid space, lysis of adhesions within the subarachnoid space<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> or correction of posttraumatic kyphosis<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> may promote the regression of spinal cord cysts or improve deteriorating symptoms.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Conditions other than trauma such as Chiari malformation type 1,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> tumors, and meningitis<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> can also change the normal CSF fluid dynamics.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The most commonly reported symptoms of PTS on presentation are paresthesia in the upper limbs, the onset of neuropathic pain, and increased spasticity.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, the risk factors for the development of PTS,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> follow-up routines, optimal surgical approach, and prognosis have not been well defined. In the past, the diagnosis of PTS was made using metrizamide computed tomography (CT).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The prevalence of PTS has been found to be as high as 51% in SCI patients with the use of magnetic resonance imaging (MRI).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Krebs et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> concluded that PTS mainly occurs in patients with motor and sensory complete SCI and those aged >30 years have an increased risk of syrinx formation within five years after injury.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Over time, surgery has become the most important pillar of treatment.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> The purpose of surgery is to reduce the cystic cavity and halt the progression of clinical signs and symptoms. Numerous surgical techniques have been described in the literature for the treatment of PTS,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> of which the preferred first-line techniques are adhesiolysis with or without expansile duraplasty and shunting.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Predisposing factors, treatment, and prognosis for PTS have not been well defined in clinical practice. This study aimed to determine the prevalence, clinical and radiological risk factors, and surgical management of PTS in a 19-year cohort study of SCI patients treated at a SCI rehabilitation center.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">This is a retrospective study of an institutional database prospectively maintained through protocols developed by neurosurgery and rehabilitation service staff for evaluation and assessment of the signs and symptoms of PTS patients. Patients were treated at the Sarah Network of Rehabilitation Hospitals/SARAH Brasília, Brasília, Brazil from January 2000 to December 2018. The research was approved by the Sarah Network of Rehabilitation Hospitals Ethics Committee (90708418.8.0000.0022).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population</span><p id="par0040" class="elsevierStylePara elsevierViewall">The inclusion criteria were patients aged 18 years or older with a history of SCI in whom PTS was confirmed by MRI and whose clinical and imaging data were available. Patients with non-traumatic syringomyelia caused by Chiari malformation, tumors, or central nervous system (CNS) infections were excluded.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data collection</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Demographic and clinical data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The clinical records, imaging studies, and physical therapy findings of PTS patients prospectively recorded in the electronic health records were reviewed. The variables analyzed were prevalence, demographic data, trauma event, clinical and radiological risk factors, location and size of the syrinx, and outcome impacts of surgical technique on PTS treatment.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">SCI classification</span><p id="par0050" class="elsevierStylePara elsevierViewall">Spinal cord injury was classified according to the American Spinal Injury Association (ASIA) impairment scale (AIS<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> at the time of admission to the SCI rehabilitation program.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Radiological assessment of PTS cysts</span><p id="par0055" class="elsevierStylePara elsevierViewall">PTS cysts were measured using magnetic resonance imaging (MRI) and computed tomography (CT). CT and MRI scan reports were retrospectively reviewed by consensus opinion of two reviewers, one radiologist and one neurosurgeon, using AquariusNET Viewer 4.4 (TeraRecon Inc., Fremont, CA, USA). The radiological variables evaluated are described below.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Cyst area: determined from T2 axial MRI scans (1.5 T) in two dimensions measured in mm² using AquariusNET 4.4. Cyst area at the level of maximum distension of the syrinx was also measured postoperatively at the same level of preoperative MRI measurements.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Number of spinal segments involved: determined from T2 sagittal MRI (1.5 T) scans of the cervical spine.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Residual deformity in the sagittal plane: assessed from MRI scans and measured as the angle between the cranial and caudal margin of the vertebrae involved in the trauma.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Surgical technique</span><p id="par0075" class="elsevierStylePara elsevierViewall">Syringopleural shunting: the patient is placed in the prone position; laminectomy is then completed followed by a durotomy and small myelotomy, usually overlying the area of the largest syrinx dilation to access the syrinx cavity. The intraoperative microscope is utilized to complete the insertion of the proximal catheter (James lumbar peritoneal shunt) to prevent drainage of the cyst and reduce the syrinx cavity to accommodate the catheter. The distal catheter accesses the pleural space for proper positioning.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Adhesiolysis: the patient is placed in the prone position. In general, the entry site involves the area affected by the trauma; based on preoperative MRI, laminectomy was completed to locate the areas affected with adhesions, followed by microsurgical durotomy to reduce the adhesions around the spinal cord for recovery of the altered CSF flow, both at the upward and downward extension of the syrinx and reestablish CSF flow.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Surgical complications</span><p id="par0085" class="elsevierStylePara elsevierViewall">Any undesirable, unintended, and direct results of surgery that occurred in the immediate postoperative period until the end of data collection were recorded.</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The analyses were performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). The demographic and clinical characteristics of patients are reported as absolute frequencies (n), whereas categorical variables are reported as relative frequencies (%); continuous variables are reported as mean, standard deviation, median, and range (minimum–maximum). Data were screened for normality using the Kolmogorov-Smirnov test. Comparisons of cyst area and number of vertebral levels before and after surgery were performed using the Wilcoxon signed-ranked test. A p-value of < 0.05 was considered significant.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">Over the 19-year period, reviews of all records of 920 SCI patients revealed 85 patients who met the clinical and neuroradiological criteria for the diagnosis of PTS (9%) and who were prospectively followed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Demographic analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical and demographic characteristics of PTS patients. Motor vehicle accidents were the leading cause of spinal cord injury (68.2%), mainly involving the thoracic spine. Most patients with PTS (n = 63; 74.1%) were treated surgically for their spinal injury at the time of injury.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Neurological condition</span><p id="par0105" class="elsevierStylePara elsevierViewall">The prevalence of PTS was higher in patients with ASIA impairment scale grade A. The mean interval (± SD) between SCI and the onset of syringomyelia symptoms was 7.1 ± 6.4 years with a median of 5.5 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Surgical treatment</span><p id="par0110" class="elsevierStylePara elsevierViewall">As detailed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, the main indication for surgical treatment was paresthesia in the upper limbs (n = 27; 45%), followed by paraparesis (n = 7; 11.7%). In three patients with bulbomedullary syringomyelia, surgical treatment was indicated to prevent respiratory embarrassment. Surgical treatment was indicated in 48 patients and the operative procedures included 29 syringopleural shunts, 17 adhesiolysis, and two syringosubarachnoid shunts.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Radiological findings</span><p id="par0115" class="elsevierStylePara elsevierViewall">The results of surgical treatment of PTS (adhesiolysis and shunting) were assessed by the reduction in the size (largest area) and extension (number of vertebral levels) of the syrinx. A significant reduction in size was observed after adhesiolysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) whereas a significant reduction in extension was observed after syriogopleural shunting (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). When considering the entire sample, a significant reduction both in the number of vertebral levels involved (p = 0.05) and in the largest area of the syrinx (p = 0.001) was observed after surgical treatment.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Complication rates</span><p id="par0120" class="elsevierStylePara elsevierViewall">The persistence of the presurgical clinical condition was the main post-surgery complication factor observed, affecting 66.7% of the patients. Overdrainage and pleural effusion were also observed and were related to syringopleural shunting (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Revision rates</span><p id="par0125" class="elsevierStylePara elsevierViewall">Eight of 17 (47%) patients who underwent adhesiolysis required reoperation, 11/29 (37.9%) patients in whom the initial surgery was a syringopleural shunt required revision, and the two patients who underwent syringosubarachnoid shunting (2/2, 100%) needed another procedure, but there was no significant difference in revision rates between surgical techniques (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">There is great variability in the reported incidence of PTS, which may be related to the difference in study populations, including cadaver studies, complementary exams, and follow-up period.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Incidence</span><p id="par0135" class="elsevierStylePara elsevierViewall">The current study was conducted in a rehabilitation center in Brazil where SCI patients usually participate in an intensive rehabilitation program<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> that includes regular reviews and yearly neurological examinations and are followed up for life. Due to the unique nature of the SCI unit, we were able to analyze a large population of 85 patients with clinically diagnosed and radiologically confirmed PTS who were identified among 920 (9%) SCI patients. Another Brazilian retrospective study reported an incidence of 6% between 2004 and 2008.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Demographic analysis</span><p id="par0140" class="elsevierStylePara elsevierViewall">A British study reported an incidence of PTS of 0.02% (n = 16) with 50% of patients managed conservatively at the time of SCI.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In the current study, only 25.9% of patients were not treated surgically at the time of injury and road traffic accidents were the leading cause of SCI (68.2%), and 63.5% of patients had an ASIA impairment scale score of A. Similar results were reported by Karam et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> for the mechanism of injury (58% of motor vehicle accidents) and ASIA score (51% of ASIA A).</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Neurological condition</span><p id="par0145" class="elsevierStylePara elsevierViewall">The mean time from injury to onset of PTS was seven years, and detection of a syrinx is only possible with continuous follow-up of SCI patients.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Surgical treatment</span><p id="par0150" class="elsevierStylePara elsevierViewall">Irrespective of surgical technique (i.e., adhesiolysis or shunting), there was a reduction both in the extension and diameter of the syrinx after surgery. However, the reduction in the size of the syrinx was statistically significant only in patients who underwent adhesiolysis, but not shunting. Karam et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> retrospectively analyzed 27 patients with posttraumatic syringomyelia and reported that 11 (41%) patients underwent adhesiolysis with duraplasty and shunting was performed in 16 (39%) patients. Only three of the 11 (27%) patients in whom the initial surgery included a duraplasty required reoperation, whereas 10/16 (62.5%) patients who underwent shunting required revision surgery. In contrast, reoperation rates were higher for adhesiolysis than shunting in the current study, but there was no significant difference between the two techniques (p = 0.21).</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Radiological findings</span><p id="par0155" class="elsevierStylePara elsevierViewall">Here, we aimed to examine the radiological aspects of PTS in detail because most studies have assessed the impact of surgical treatment by the extent (number of vertebral levels) rather than the diameter of the syrinx. A more comprehensive radiological analysis is needed because, in some cases, there is a postoperative reduction in the extent of the syrinx with a paradoxical increase in its size. In the current study, magnetic resonance imaging with T2 axial scans of the spinal cord were performed pre- and postoperatively to determine the maximum area of the syrinx, which effectively revealed a reduction in the diameter of the syrinx and nerve decompression around the syrinx cavity.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Complication and reoperation rates</span><p id="par0160" class="elsevierStylePara elsevierViewall">The respiratory-related operative complications observed in our study were caused by incorrect placement of the shunt into the pleural space. Overall, the two surgical procedures exposed patients to both clinical and radiological malfunction/persistence, which was the leading cause of reoperation. Nevertheless, an additional procedure is not performed when there is a discrepancy between clinical and imaging findings such as in cases without amelioration of symptoms but with a significant reduction in the size of the syrinx cavity or in patients with clinical improvement but in whom the size of the syrinx on postoperative MRI has not changed. Aghakhani et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> investigated the complications associated with shunting and adhesiolysis for PTS. There were three cases of CSF fistula and one case of meningitis, but neither of these complications was observed in our study. In addition, the authors found that shunting exposed the patients to a higher rate of reoperation, whereas only one patient who underwent adhesiolysis required revision. In contrast, 47% and 37.9% of patients who underwent adhesiolysis and syringopleural shunting in our study, respectively, required revision.</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Study limitations</span><p id="par0165" class="elsevierStylePara elsevierViewall">There is no reliable functional outcome scale in the medical records for the pre- and postoperative assessment of patients. PTS is a rare complication, and the study cohort lacks statistical power. Finally, there are no clinical and radiological data available from the time of injury for analysis of other potential risk factors for the development of syringomyelia.</p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Conclusion</span><p id="par0170" class="elsevierStylePara elsevierViewall">The surgical treatment of post-traumatic syringomyelia resulted in a significant radiological reduction in the size of the syrinx, demonstrating a relevant anatomical modification. However, the pre-surgical clinical condition of the participants remained unchanged after the surgical approach.</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">CRediT Author contribution statement</span><p id="par0175" class="elsevierStylePara elsevierViewall">Vitor Aguiar: Conceptualization, Methodology, Data-analyzer, Writing- Original draft preparation. Giovani Batista: Methodology, Data-analyzer; Ricardo Gepp: Writing- Reviewing and Editing; Asdrubal Falavigna: Conceptualization, Methodology, Writing- Reviewing and Editing.</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Funding</span><p id="par0180" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2292609" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1905259" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1905257" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2292610" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1905258" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study population" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Data collection" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Demographic and clinical data" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "SCI classification" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Radiological assessment of PTS cysts" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Surgical technique" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Surgical complications" ] ] ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Statistical analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0060" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Demographic analysis" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Neurological condition" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Surgical treatment" ] 3 => array:2 [ "identificador" => "sec0080" "titulo" => "Radiological findings" ] 4 => array:2 [ "identificador" => "sec0085" "titulo" => "Complication rates" ] 5 => array:2 [ "identificador" => "sec0090" "titulo" => "Revision rates" ] ] ] 8 => array:3 [ "identificador" => "sec0095" "titulo" => "Discussion" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Incidence" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Demographic analysis" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Neurological condition" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Surgical treatment" ] 4 => array:2 [ "identificador" => "sec0120" "titulo" => "Radiological findings" ] 5 => array:2 [ "identificador" => "sec0125" "titulo" => "Complication and reoperation rates" ] 6 => array:2 [ "identificador" => "sec0130" "titulo" => "Study limitations" ] ] ] 9 => array:2 [ "identificador" => "sec0135" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0140" "titulo" => "CRediT Author contribution statement" ] 11 => array:2 [ "identificador" => "sec0145" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0150" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-07-24" "fechaAceptado" => "2024-09-17" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1905259" "palabras" => array:5 [ 0 => "Spinal cord injury" 1 => "Syringomyelia" 2 => "Magnetic resonance imaging" 3 => "Adhesiolysis" 4 => "Syringopleural shunting" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1905257" "palabras" => array:8 [ 0 => "AIS" 1 => "ASIA" 2 => "CNS" 3 => "CSF" 4 => "CT" 5 => "MRI" 6 => "PTS" 7 => "SCI" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1905258" "palabras" => array:5 [ 0 => "Lesión de la médula espinal" 1 => "Siringomielia" 2 => "Resonancia magnética" 3 => "Adhesiolisis" 4 => "Derivación siringopleural" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">To determine the prevalence, clinical and radiological risk factors, and surgical management of post-traumatic syringomyelia (PTS) in a 19-year cohort study of Spinal Cord Injury (SCI) patients treated at a SCI rehabilitation center.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of SCI patients in whom PTS was radiologically confirmed between January 2000 and December 2018. Protocols for assessing signs and symptoms of PTS were applied prior to PTS diagnosis and treatment and later at neurosurgical and rehabilitation reviews. The variables analyzed were prevalence, demographic data, trauma event, clinical and radiological risk factors, location and size of the syrinx, and effectiveness of the surgical procedures.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Over the 19-year period, review of 920 SCI patients revealed 85 patients who met the clinical and neuroradiological criteria for the diagnosis of PTS and who were prospectively followed. Road traffic accidents were the leading cause of injury (n = 58; 68.2%), syringomyelia was most commonly observed in the thoracic spine (n = 56; 65.9%), and upper extremity paresis was the most common indication for surgical treatment (n = 27; 45%). Surgical treatment was indicated in 48 patients and the operative procedures included 29 syringopleural shunts (60.4%), 17 adhesiolysis (35.4%), and two syringosubarachnoid shunts (4.1%). The prevalence of PTS was 9% and was higher in patients with ASIA impairment scale grade A injuries. Most patients with PTS (63/85, 74.1%) were treated surgically at the time of injury. There was a significant reduction both in the extent (p = 0.05) and largest area (p = 0.001) of the syrinx after surgical treatment. Reoperation rates were 47% and 37.9% for adhesiolysis and syringopleural shunting, respectively.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Follow-up and routine clinical examination of SCI patients is critical for the diagnosis of PTS in patients with late neurological deterioration. Surgical treatment has a positive impact in reducing the size of the syrinx as seen on postoperative MRI.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia, los factores de riesgo clínicos y radiológicos y el tratamiento quirúrgico de la siringomielia postraumática (SPT) en un estudio de cohorte de 19 años de pacientes con Lesion medular Espinal (LME) tratados en un centro de rehabilitación de LME.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de pacientes con LME en quienes se confirmó radiológicamente el SPT entre enero de 2000 y diciembre de 2018. Se aplicaron protocolos para evaluar los signos y síntomas del SPT antes del diagnóstico y tratamiento del SPT y posteriormente en las revisiones neuroquirúrgicas y de rehabilitación. Las variables analizadas fueron prevalencia, datos demográficos, evento traumático, factores de riesgo clínicos y radiológicos, ubicación y tamaño de la siringe y efectividad de los procedimientos quirúrgicos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Durante el período de 19 años, la revisión de 920 pacientes con LME reveló que 85 pacientes cumplían con los criterios clínicos y neurorradiológicos para el diagnóstico de SPT y que fueron seguidos prospectivamente. Los accidentes de tráfico fueron la principal causa de lesiones (n = 58; 68,2%), la siringomielia se observó con mayor frecuencia en la columna torácica (n = 56; 65,9%) y la paresia de las extremidades superiores fue la indicación más común de tratamiento quirúrgico (n = 27; 45%). Se indicó tratamiento quirúrgico en 48 pacientes y los procedimientos quirúrgicos incluyeron 29 derivaciones siringopleurales (60,4%), 17 adhesiolisis (35,4%) y dos derivaciones siringosubaracnoideas (4,1%). La prevalencia de SPT fue del 9% y fue mayor en pacientes con lesiones de grado A en la escala de deterioro de ASIA. La mayoría de los pacientes con SPT (63/85, 74,1%) fueron tratados quirúrgicamente en el momento de la lesión. Hubo una reducción significativa tanto en la extensión (p = 0,05) como en el área más grande (p = 0,001) de la siringe después del tratamiento quirúrgico. Las tasas de reoperación fueron del 47% y del 37,9% para adhesiolisis y derivación siringopleural, respectivamente.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">El seguimiento y el examen clínico de rutina de los pacientes con LME es fundamental para el diagnóstico de SPT en pacientes con deterioro neurológico tardío. El tratamiento quirúrgico tiene un impacto positivo en la reducción del tamaño de la siringe, como se observa en la resonancia magnética posoperatoria.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1442 "Ancho" => 2505 "Tamanyo" => 203670 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart for the selection of SCI patients diagnosed with PTS.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SCI: Spinal cord injury; PTS: Post-traumatic syringomyelia.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2464 "Ancho" => 2177 "Tamanyo" => 169316 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cyst area before and after (A) adhesiolysis or syringopleural shunting and (B) surgical treatment for the entire sample.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">p-value by the Wilcoxon signed-ranked test. SPS: syringopleural shunting.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2434 "Ancho" => 2176 "Tamanyo" => 189331 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Syrinx extension (number of vertebral levels) before and after (A) adhesiolysis or syringopleural shunting and (B) surgical treatment for the entire sample.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">p-value by the Wilcoxon signed-rank test.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">AIS: ASIA impairment scale.</p>" "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"> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients (%) \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">Male gender \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 (87.1) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of trauma</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>Motor vehicle accident \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (68.2) \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>Shallow water diving \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (10.6) \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>Falls \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (10.6) \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>Stabbing \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (4.7) \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>Gunshot wound \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.5) \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>Blunt force trauma \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2.4) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AIS on admission at rehabilitation program</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>A \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 (63.5) \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>B \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (11.8) \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>C \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (8.2) \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>D \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (14.1) \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>E \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2) \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>Cauda equina syndrome \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of injury</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>Cervical \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (31.8) \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>Thoracic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 (65.9) \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>Lumbar \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2) \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>Medullary cone \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2) \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">Surgical treatment at the time of injury \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 (74.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3715526.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical and demographic characteristics of patients with posttraumatic syringomyelia (n = 85).</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">n, absolute number of patients; %, relative frequency.</p>" "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"> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n (%) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Indication for surgery</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>Upper extremity paresis \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (45.0) \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>Pain \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (15.0) \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>Lower extremity paresis \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (11.7) \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>Hypoesthesia \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (6.7) \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>Worsening gait \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (6.7) \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>Lower extremity paresthesia \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (5.0) \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>Prophylaxis \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (5.0) \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>Ascending sensory level \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.3) \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>Worsening trunk stability \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.7) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical approach</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>Syringopleural shunting \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (60.4) \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>Adhesiolysis \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (35.4) \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>Syringosubarachnoid shunting \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3715527.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Indications for surgical treatment and surgical approach for patients with posttraumatic syringomyelia (n = 48).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">n, absolute number of patients; %, relative frequency.</p>" "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"> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n (%) \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">Pulmonary contusion \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.2%) \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">Operative wound dehiscence \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.2%) \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">Pleural effusion \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (8.3%) \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">Intradural hematoma \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.2%) \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">Overdrainage \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.2%) \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">Malfunction/Persistence \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (66.7%) \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">Worsening gait \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (8.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3715528.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Complications observed after surgical procedures in patients with posttraumatic syringomyelia.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">SPS: syringopleural shunting; SSS: syringosubarachnoid shunting. n, absolute number of patients; %, relative frequency.</p>" "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"> \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 " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgery for syringomyelia, n (%)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Total</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleItalic"><span class="elsevierStyleSup">a</span></span></a></th></tr><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"> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adhesiolysis \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SPS \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SSS \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">Reoperation \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="left" 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="left" 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="left" 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="left" 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="left" 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">No \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (52.9) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (62.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.21</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">Yes \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (47.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (37.9) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (100.0) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (43.8) \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">Total \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \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="left" 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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \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="left" 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 => "xTab3715529.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Chi-square test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Reoperation rates for PTS surgery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International perspectives on spinal cord injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. 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