Tratamiento quirúrgico de las enfermedades de transición cervicotorácica

OBJETIVO: avaliar o resultado do tratamento cirúrgico de pacientes portadores de doenças na transição cervicotorácica da coluna vertebral. MÉTODOS: foram avaliados, retrospectivamente, 20 pacientes: nove (45%) apresentavam lesões traumáticas, sete (35%) lesões neoplásicas e quatro (20%) doenças degenerativas. No grupo de pacientes com lesões traumáticas, foi realizada fixação posterior em cinco deles (55,5%), fixação anterior em um (11,1%) e abordagem combinada (anterior e posterior) em três (33,3%). Dos sete pacientes com lesões tumorais, quatro (57,1%) foram submetidos ao tratamento cirúrgico pela abordagem combinada e três (42,8%) pela abordagem posterior isolada. No grupo de pacientes com doenças degenerativas da coluna vertebral, três (75%) foram tratados pela abordagem posterior e um (25%) de forma combinada. Todos os pacientes foram avaliados por meio de parâmetros clínicos (dor e déficit neurológico), radiológicos (manutenção da redução, soltura ou quebra dos implantes) e funcionais (SF-36, escala de dor e trabalho de Denis). RESULTADOS: os 20 pacientes foram seguidos por um período que variou de seis meses a 11 anos (média de 44,6 meses ± 29,02). Dos 13 pacientes que apresentavam déficit neurológico, oito apresentaram melhora do nível na escala de Frankel (61,5%) e cinco pacientes (38,4%) permaneceram com o quadro inalterado. Como complicações um paciente (5%) apresentou soltura do implante e quatro pacientes evoluíram com infecção pós-operatória (20%). Segundo as escalas de dor e trabalho de Denis, 80% dos pacientes apresentavam pouca ou nenhuma dor (P1 e P2) e 70% dos pacientes tinham retornado ao trabalho (W1, W2 e W3). Os pacientes que não apresentavam déficit neurológico (Frankel E) obtiveram escores mais altos de qualidade de vida pelo questionário SF-36, quando comparados aos escores dos pacientes que mantinham alterações neurológicas (Frankel A-D). CONCLUSÃO: o tratamento das doenças da transição cervicotorácica da coluna vertebral apresenta detalhes adicionais aos demais segmentos da coluna vertebral. Na vigência de tratamento cirúrgico, existem pontos a serem respeitados como a anatomia relacionada ao acesso cirúrgico, as características anatômicas peculiares das vértebras e a biomecânica singular desse segmento da coluna vertebral.OBJECTIVE: to assess the results of the surgical treatment of patients with disease in the cervicothoracic junction of the spine. METHODS: twenty patients were retrospectively evaluated. Nine patients (45%) had traumatic lesions, seven (35%) neoplasic lesions and four (20%) degenerative arthropathies. In the group of patients with traumatic lesions it has been accomplished the posterior fixation in five patients (55.5%), anterior fixation in one patient (11.1%) and the combined approach (anterior and posterior) in three patients (33.3%). In the seven patients with neoplasic lesions, four (57.1%) underwent to the surgical treatment through the combined approach and 3 (42.8%) through the posterior approach. In the group of patients with spinal degenerative disease, three (75%) were treated through the posterior approach and one (25%) in a combined way. The patients were evaluated on the basis of clinical (pain and neurological deficit), radiological (reduction maintenance and implant loosening or break) and functional parameters (SF-36, Denis scale of work and pain). RESULTS: twenty patients were followed-up for a period of time ranging from six months to 11 years (44.6 months ± 29.02). From 13 patients which presented neurological deficit, eight patients presented improvement in Frankel scale level (61.5%) and five patients (38.5%) remained with the same level. As complications, one patient (5%) presented implant loosening and four patients presented postoperative infection (20%). In pain and work assessment, 80% of the patients presented few or no pain (P1 and P2) through Denis scale of pain, and 70% of the patients had returned to work (W1, W2 and W3) through Denis scale of work. The patients without neurological deficit (Frankel E) presented higher scores of life quality through the SF-36 questionnaire compared to the patients who had neurological deficit (Frankel A-D). CONCLUSION: the treatment of the diseases of the cervicothoracic junction of the spine presents additional details compared to the others segments of the spine. The surgical treatment has aspects to be respected as the anatomy related to the surgical access, the peculiar anatomic characteristics of the vertebrae and the unique biomechanics of this spinal segment.OBJETIVO: evaluar el resultado del tratamiento quirúrgico de pacientes portadores de enfermedades de transición cervicotorácica de la columna vertebral. MÉTODOS: fueron retrospectivamente evaluados veinte pacientes. Nueve pacientes (45%) presentaron lesiones traumáticas, 7 (35%) lesiones neoplásicas y 4 enfermedades degenerativas (20%). En el grupo de pacientes con lesiones traumáticas fue realizada una fijación posterior en 5 pacientes (55.5%), una fijación anterior en 1 paciente (11,1%) y abordaje combinado (anterior y posterior) en 3 pacientes (33.3%). De los 7 pacientes con lesiones tumorales, cuatro (57.1%) fueron sometidos al tratamiento quirúrgico por abordaje combinado y 3 (42.8%) por abordaje posterior aislado. En el grupo de pacientes con enfermedades degenerativas de la columna vertebral, tres (75%) fueron tratados por abordaje posterior y uno de forma combinada (25%). Todos los pacientes fueron evaluados por medio de parámetros clínicos (dolor y déficit neurológico), radiológicos (mantenimiento de la reducción, soltura o quiebra de los implantes) y funcionales (SF-36, escala de dolor y trabajo de Denis). RESULTADOS: los veinte pacientes fueron seguidos por um periodo que varió de 6 meses a 11 años (promedio de 44.6 meses ± 29.02). De los 13 pacientes que presentaron déficit neurológico, ocho presentaron una mejora en el nivel de la escala de Frankel (61.5%) y cinco pacientes (38.4%) permanecieron con un cuadro inalterado. Como complicaciones un paciente (5%) presentó soltura del implante y cuatro pacientes evolucionaron con infección postoperatoria (20%). Según las escalas de dolor y el trabajo de Denis, el 80% de los pacientes presentaron poco o nada de dolor (P1 y P2) y el 70% de los pacientes regresaron al trabajo (W1, W2 y W3). Los pacientes que no presentaron déficit neurológico (Frankel E) tuvieron escores mas altos de calidad de vida por el cuestionario SF-36, cuando comparados con los pacientes con alteraciones neurológicas (Frankel A-D). CONCLUSIÓN: el tratamiento de las enfermedades de la transición cervicotorácica de la columna vertebral presenta detalles adicionales a los demás segmentos de la columna vertebral. En la vigencia al acceso quirúrgico existen puntos a ser respetados como la anatomía relacionada al acceso quirúrgico, las características anatómicas peculiares de las vértebras y biomecánica singular de ese segmento de la columna vertebral

Traumatic atlanto-occipital dislocation: a case report

A luxação traumática atlanto-occipital é lesão rara, de incidência desconhecida e está associada a elevada taxa de mortalidade. Os autores relatam o diagnóstico, tratamento e seguimento de dois anos de uma paciente de 25 anos de idade, vítima de acidente automobilístico e luxação atlanto-occipital traumática confirmada por exames de imagem.Traumatic atlanto-occipital dislocation is a rare lesion whose incidence is not know, and which is associated to a high rate of mortality. The authors report the diagnosis, treatment, and two-year follow-up of a 25 year-old patient who had had an automobile accident with imaging-confirmed traumatic atlanto-occipital dislocation

Functional and radiographic comparison of anterior and posterior instrumentation for the correction of adolescent thoracic idiopathic scoliosis

OBJETIVO: Estudo retrospectivo comparando resultados da IA e da IP em pacientes operados com o diagnóstico de EIA (tipo 1 de Lenke). MÉTODOS: Os resultados de 24 pacientes com idade de 11 a 18 anos com EIA tipo Lenke I e submetidos a tratamento cirúrgico por meio da abordagem anterior (12 pacientes) ou posterior (12 pacientes) foram comparados. Todos os pacientes foram operados pelo mesmo cirurgião e seguidos por um período mínimo de cinco anos. As variáveis de comparação incluíram: correção sagital e coronal, distância da vértebra apical a linha média, rotação da vértebra apical, número de vértebras instrumentadas e variáveis funcionais por meio do questionário SRS-22. Os dados obtidos foram analisados com a versão 9 do programa SAS. Os dois grupos foram comparados com o teste t de Student com um nível de significância de 5% (0,05). RESULTADOS: A correção da curva no plano frontal no pós-operatório imediato (p = 0,031), tardio (p = 0,043) e também a rotação da vértebra apical no pós-operatório imediato (p = 0,002) e tardio (p = 0,021) no grupo de pacientes submetidos à correção por meio da abordagem anterior. O número de vértebras instrumentadas foi 7,69 ± 1,38 no grupo de pacientes submetidos a IA e 11,38 ± 2,92 na IP (p = 0,021). A avaliação funcional (SRS-22) não demonstrou diferença significativa (p > 0,05) entre os grupos. CONCLUSÃO: O grupo de pacientes submetidos à correção da escoliose por instrumentação anterior apresentou maior correção no plano frontal, maior derrotação da vértebra apical e menor número de vértebras artrodesadas.OBJECTIVE: To evaluate and compare the results of AI and PI in patients diagnosed with Lenke type I curves who were treated surgically. METHODS: The results of 24 patients aged 11 to 18 years with Lenke type I idiopathic scoliosis who underwent surgery with anterior (12 patients) or posterior (12 patients) instrumentation were compared. All patients were operated by the same surgeon and were followed up for a minimum period of five years. Variables for comparison include: coronal and sagittal correction, distance from apical vertebra to midline, apical vertebral rotation, number of instrumented vertebrae and functional variables by means of the SRS-22 questionnaire. The data obtained were analyzed with the SAS program, version 9. The two groups were compared with a 2-tailed Student's t-test with a level of significance set at 5% (0.05). RESULTS: The correction of the curve on the frontal plane was higher at immediate (p=0.031) and late postoperative (p=0.043) as well the apical vertebral rotation during immediate (p=0.002) and late (p=0.019) evaluation in the anterior spinal fusion group. The number of instrumented vertebrae was 7.69±1.38 in the anterior spinal fusion patients and 11.38±2.92 in the posterior spine fusion patients (p=0.021). Functional assessment (SRS-22) showed no significant difference (p>0.05) between groups. CONCLUSION: Anterior spine fusion patients presented greater scoliosis correction on frontal plane, greater derotation of apical vertebrae and smaller number of fused vertebrae

Tornillos pediculares: las estructuras anatómicas en riesgo en el tratamiento de escoliosis idiopática

OBJETIVO: Avaliar a posição das estruturas anatômicas em risco durante a inserção de parafusos pediculares na coluna torácica e sua relação com a variação do ângulo de Cobb. MÉTODOS: Os parâmetros estudados foram: a medida do ângulo de Cobb nas radiografias e a posição da medula espinhal, da cavidade pleural e aorta na ressonância nuclear magnética em relação a uma linha de 40mm criada para simular o parafuso pedicular nas cinco vértebras apicais. RESULTADOS: A distância da aorta ao corpo vertebral e o ângulo de segurança do lado convexo apresentaram diferença estatística quando relacionados com a variação do ângulo de Cobb medido. CONCLUSÃO: Os resultados apresentados sugerem maior risco de lesão da artéria aorta com o aumento do ângulo de Cobb e aumento do risco na inserção de parafusos pediculares no lado convexo da curvatura, quando se considera o ângulo de segurança

Community Care Administration of Spinal Deformities in the Brazilian Public Health System

OBJECTIVE: Underfunding of the surgical treatment of complex spinal deformities has been an important reason for the steadily growing waiting lists in publicly funded healthcare systems. The aim of this study is to characterize the management of the treatment of spinal deformities in the public healthcare system. METHODS: A cross-sectional study of 60 patients with complex pediatric spinal deformities waiting for treatment in December 2013 was performed. The evaluated parameters were place of origin, waiting time until first assessment at a specialized spine care center, waiting time for the surgical treatment, and need for implants not reimbursed by the healthcare system. RESULTS: Ninety-one percent of the patients lived in São Paulo State (33% from Ribeirão Preto - DRS XIII). Patients waited for 0.5 to 48.0 months for referral, and the waiting times for surgery ranged from 2 to 117 months. Forty-five percent of the patients required implants for the surgical procedure that were not available. CONCLUSION: The current management of patients with spinal deformities in the public healthcare system does not provide adequate treatment for these patients in our region. They experience long waiting periods for referral and prolonged waiting times to receive surgical treatment; additionally, many of the necessary procedures are not reimbursed by the public healthcare system

Raízes nervosas redundantes da cauda equina: revisão da literatura

In imaging diagnosis, redundant nerve roots of the cauda equina are characterized by the presence of elongated, enlarged and tortuous nerve roots in close relationship with a high-grade lumbar spinal canal stenosis. This is not an independent entity, but it is believed to be a consequence of the chronic compression at the level of the lumbar canal stenosis and thus may be part of the natural history of lumbar spinal stenosis. The present paper is aimed at reviewing the histopathological, electrophysiological and imaging findings, particularly at magnetic resonance imaging, as well as the clinical meaning of this entity. As the current assessment of canal stenosis and root compression is preferably performed by means of magnetic resonance imaging, this is the imaging method by which the condition is identified. The recognition of redundant nerve roots at magnetic resonance imaging is important, particularly to avoid misdiagnosing other conditions such as intradural arteriovenous malformations. The literature approaching the clinical relevance of the presence of redundant nerve roots is controversial. There are articles suggesting that the pathological changes of the nerve roots are irreversible at the moment of diagnosis and therefore neurological symptoms are less likely to improve with surgical decompression, but such concept is not a consensus

EARLY COMPLICATIONS OF SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

ABSTRACT Objective: To evaluate the early postoperative complications associated with the surgical approach of the cervical spine of patients with cervical spondylotic myelopathy (CSM), comparing the anterior surgical, the posterior surgical, and the combined approaches. Methods: This is a retrospective study based on a database with 169 patients. Demographic data, such as gender and age, and surgical data, such as surgical approach, number of segments with arthrodesis, surgical time, and complications, were evaluated. Complications were divided into major (deep surgical wound infection, intercurrence with the implant, early new compression, and heart failure) and minor (dysphagia, superficial infection, pain, urinary intercurrence, neuropraxia of the C5 root, acute confusional state, and surgical wound hematoma). Results: This included 169 patients, 57 women (33.7%) and 112 men (66.2%). Age ranged from 21 to 87 years, with a mean of 56.48 (± 11) years. Of these, 52 (30.8%) underwent the anterior approach; 111 (65.7%), the posterior approach; and 6 (3.5%), the combined approach. Conclusion: As in the literature, we evinced dysphagia, pain, and superficial infection of the surgical wound as the most frequent postoperative complications. However, it was impossible to establish a statistical relationship between the incidence of complications and surgical time, access route, and number of fixed segments. Level of Evidence III, Retrospective Comparative Study

Evaluation of terminal vertebral plate on cervical spine at different age groups and its correlation with intervertebral disc thickness

OBJETIVO: Avaliar por meio de histomorfometria, a espessura da placa vertebral terminal, a espessura do disco intervertebral e a sua correlação nas diferentes faixas etárias, tentando identificar a sua correlação. MÉTODOS: Foram avaliados os segmentos cervicais C4-C5 e C5-C6 de 50 cadáveres humanos , de ambos os sexos, divididos em 5 grupos com intervalo de faixa etária de 10 anos, a partir dos 21 anos de idade. A avaliação da espessura da PVT e do disco intervertebral foi realizada por meio de avaliação histomorfométrica dos cortes histológicos corados pela hematoxilina e eosina. A espessura da PVT inferior de C4, PVT superior de C5, PVT inferior de C5 e PVT superior de C6 foram comparadas entre si e também com a espessura do disco intervertebral interposto entre as respectivas PVT. RESULTADOS: A espessura das placas vertebrais terminais adjacentes ao mesmo DI não apresentou diferença estatística. No entanto, a comparação da espessura das placas vertebrais superior e inferior da mesma vértebra cervical (C5), apresentou diferença estatística em todas as faixas etárias avaliadas. Foi observado coeficiente de correlação estatística, maior que 80%, entre a espessura daplaca vertebral terminal e o disco intervertebral adjacente, com proporcional redução de espessura de ambas estruturas, nos diferentes níveis cervicais avaliados, e também nas diferentes faixas etárias avaliadas. CONCLUSÃO: A placa vertebral terminal apresenta correlação morfológica com o disco intervertebral ao qual entra em contato, e não apresenta correlação com a placa vertebral terminal da mesma vértebra.OBJECTIVE: To evaluate, by means of histomorphometry, terminal vertebral plate thickness, intervertebral disc thickness and its correlation on different age groups, seeking to identify its correlation. METHODS: C4-C5 and C5-C6 cervical segments removed from human cadavers of both genders were assessed and divided into five groups of 10-year age intervals, from 21 years old. TVP and intervertebral disc thickness evaluation was made by means of histomorphometry of histological slides stained with hematoxylin and eosyn. Lower C4 TVP, upper C5 TVP, and upper C6 TVP de were compared between each other and to the interposed intervertebral disc thickness between relevant TVP. RESULTS: The thickness of terminal vertebral plates adjacent to the same ID did not show statistic differences. However, the comparison of upper and lower vertebral plates thickness on the same cervical vertebra (C5), showed statistical difference on all age groups studied. We found a statistical correlation coefficient above 80% between terminal vertebral plate and adjacent intervertebral disc, witha proportional thickness reduction of both structures on the different cervical levels studied, and also on the different age groups assessed. CONCLUSION: Terminal vertebral plate shows a morphologic correlation with the intervertebral disc next to it, and does not show correlation with the terminal vertebral plate on the same vertebra

AGREEMENT ON MRI DIAGNOSIS IN COMPRESSIVE MALIGNANT VERTEBRAL FRACTURES

ABSTRACT Objective: Verify interobserver and intraobserver agreement of malignant compressive vertebral fractures (MCVF) diagnosis using magnetic resonance imaging (MRI). Methods: We retrospectively included a lumbar spine MRI of 63 patients with non-traumatic compressive vertebral fracture diagnoses. Each lumbar vertebra was classified as: without fracture, with fracture of benign characteristics, or with fracture of malignant characteristics. Two medical residents in radiology, one musculoskeletal radiologist fellow, one musculoskeletal radiologist, and two spine surgeons evaluated MRI exams, independently and blindly. Each observer performed two readings, with a 15-day interval between evaluations. A simple Kappa coefficient was used to calculate the intra and interobserver agreement. The reference standard classification was based on bone biopsy or clinical, and imaging follow-up of at least two years, for diagnostic performance analysis. Diagnostic performance was assessed by calculating sensitivity, specificity, accuracy, and positive and negative predictive values with a 95% confidence interval (CI). Results: We observed substantial to perfect intraobserver agreement (kappa: 0.80 to 1.00) and substantial interobserver agreement (kappa 0.64 to 0.77). In general, the sensitivity for the detection of MCVF was moderate, except for the second-year radiology resident that achieved a lower sensitivity. The specificity, accuracy, and negative predictive value were high for all observers. Conclusion: MCVF diagnosis using MRI showed substantial interobserver agreement. The second-year medical resident achieved lower sensitivity but high specificity for MCVF. Regarding the seniors, there was no statistical significance between spine surgeons and the musculoskeletal radiologist. Level of Evidence III; Diagnostic

Parafusos pediculares: estruturas anatômicas em risco no tratamento da escoliose idiopática Tornillos pediculares: las estructuras anatómicas en riesgo en el tratamiento de escoliosis idiopática Pedicle screws: anatomic structures at risk in idiopathic scoliosis treatment

OBJETIVO: Avaliar a posição das estruturas anatômicas em risco durante a inserção de parafusos pediculares na coluna torácica e sua relação com a variação do ângulo de Cobb. MÉTODOS: Os parâmetros estudados foram: a medida do ângulo de Cobb nas radiografias e a posição da medula espinhal, da cavidade pleural e aorta na ressonância nuclear magnética em relação a uma linha de 40mm criada para simular o parafuso pedicular nas cinco vértebras apicais. RESULTADOS: A distância da aorta ao corpo vertebral e o ângulo de segurança do lado convexo apresentaram diferença estatística quando relacionados com a variação do ângulo de Cobb medido. CONCLUSÃO: Os resultados apresentados sugerem maior risco de lesão da artéria aorta com o aumento do ângulo de Cobb e aumento do risco na inserção de parafusos pediculares no lado convexo da curvatura, quando se considera o ângulo de segurança.OBJETIVO: Evaluar la posición de las estructuras anatómicas en situación de riesgo durante la inserción de tornillos pediculares en la columna torácica y su relación con la variación del ángulo de Cobb. MÉTODOS: Los parámetros estudiados fueron: la medida del ángulo de Cobb en las radiografías y la posición de la médula espinal, la cavidad pleural y la aorta en la RM en relación con una línea de 40mm, diseñada para simular el tornillo pedicular en el plano de las cinco vértebras apicales. RESULTADOS: La distancia desde la aorta hacia el cuerpo vertebral y el ángulo de seguridad en el lado convexo mostraron diferencia estadística relacionada con la variación del ángulo de Cobb medido. CONCLUSIÓN: Los resultados sugieren un mayor riesgo de daño a la aorta con el aumento del ángulo de Cobb e incremento del riesgo en la inserción de tornillos pediculares en el lado convexo cuando se considera el ángulo de seguridad.OBJECTIVE: To evaluate the position of anatomical structures at risk during insertion of pedicle screws in the thoracic spine and its relation to the variation of Cobb angle. METHODS: The parameters studied were: the degree of Cobb angle on radiographs and the position of the spinal cord, the pleural cavity and aorta on MRI in relation to a line of 40mm created to simulate the pedicle screw in the five apical vertebrae. RESULTS: The distance from the aorta to the vertebral body and the angle of security of the convex side showed statistical difference when related to variation of Cobb angle measured. CONCLUSION: The results suggest a greater risk of injury to the aorta with increasing Cobb angle and increased risk in the insertion of pedicle screws on the convex side of curvature when considering the safety angle