Impact of the covid-19 pandemic on spine surgery in a tertiary health care institution / Impacto da pandemia de covid-19 nas cirurgias de coluna em uma instituição terciária de saúde

ABSTRACT Objectives: To assess postoperative complications, including COVID-19 infection, among patients undergoing surgeries at a tertiary institution during the pandemic, and to develop a local epidemiological profile of spine surgery patients. Methods: Retrospective descriptive study of all patients who underwent spine surgery between March 2020 and 14 January 2021 in a tertiary institution in Latin America. All patients who underwent spine surgery were included, without age restrictions. The main outcomes were postoperative complications, including COVID-19 infection. Results: 74 patients were included in the study, 43 males and 31 females. The average age was 49.6 years. The mean duration of hospitalization was 11.5 days. Urgent surgeries were performed in 60.81% of cases. During hospitalization, only 5 of 74 patients were diagnosed with COVID-19, and only 1 patient had pulmonary involvement estimated to be greater than 50%. On average, 1.9 surgical debridements were required after postoperative surgical site infection. Conclusions: During the hospitalization period, only 6.7% of patients were diagnosed with COVID-19 infection. The COVID-19 infection death rate was 1 in 5 cases. The postoperative surgical site infection rate was 10.8%, similar to the level before the pandemic. Level of Evidence IV; Observational retrospective descriptive study .

RESUMO Objetivos: Avaliar complicações pós-cirúrgicas, incluindo infecções por COVID-19, entre pacientes cirúrgicos numa instituição terciária de saúde durante a pandemia, e desenvolver um perfil epidemiológico local de pacientes de cirurgias da coluna. Métodos: estudo descritivo e retrospectivo de todos os pacientes que passaram por cirurgias da coluna entre março de 2020 e 14 de janeiro de 2021, numa instituição terciária na América Latina. Todos os pacientes que passaram por cirurgias na coluna foram incluídos, sem restrição de idade. Os principais resultados foram complicações pós-cirúrgicas, incluindo a infecção por COVID-19. Resultados: 74 pacientes foram incluídos no estudo, 43 do sexo masculino e 31 do feminino. A média de idade foi de 49.6 anos. A duração média da hospitalização foi de 11.5 dias. Cirurgias urgentes foram realizadas em 60.81% dos casos. Durante a hospitalização, apenas 5 dos 74 pacientes foram diagnosticados com COVID-19, e apenas 1 deles teve envolvimento pulmonar estimado em mais que 50%. Em média, 1,9 desbridamentos cirúrgicos foram necessários após infecção do sítio cirúrgico. Conclusões: Durante o período de hospitalização, apenas 6,37% dos pacientes foram diagnosticados com infeção por COVID-19. A taxa de mortes devido à infecção por COVID-19 foi de 1 em 5. Infecções do sítio cirúrgico atingiram uma taxa de 10.8%, nível similar àquele prévio à pandemia. Nível de evidência IV ; Estudo observacional retrospectivo descritivo .

Tomographic analysis of c7, t1 and t2 vertebrae anatomy in children / Estudo tomográfico das vértebras c7, t1 e t2 em crianças

ABSTRACT Objective: To evaluate and compare anatomical measurements of C7, T1 and T2 vertebrae in children from 3 to 12 years of age to provide useful epidemiological data for determining the safe anatomical margin for transpedicular and translaminar fixation with screws in this population. Methods: This observational retrospective cross-sectional study evaluated 76 computed tomography scans obtained over 6 months, analyzing the following parameters: the angle of attack, length, thickness and diameter of the pedicle; and the angle of attack, length and thickness of the lamina. Results: The lamina length and thickness, as well as pedicle length varied in size according to age. Although the angle of attack was similar across different ages, age-dependent variation occurred in the T1 vertebra. Conclusion: Screws with a 3.5 mm diameter are safe to use in the C7 and T2 pedicles, while the T1 pedicle allows the introduction of larger screws ranging from 3.5-4.5 mm in diameter. In the lamina, 3.5 mm screws are safe for use only in children older than 7 years. However, each case should be analyzed individually, with the present study not aiming to replace the preoperative use of CT. Level of Evidence III, Retrospective comparative study.

RESUMO Objetivo: Avaliar e comparar as medidas anatômicas das vértebras C7, T1 e T2 em crianças de 3 a 12 anos de modo a determinar margens seguras para fixação transpedicular e translaminar com parafusos nessa população. Métodos: Estudo transversal retrospectivo observacional. Um total de 76 tomografias computadorizadas foram analisadas em um período de 6 meses. Os seguintes parâmetros foram analisados: ângulo de ataque, comprimento, espessura e diâmetro do pedículo, comprimento e espessura da lâmina. Resultados: O comprimento e espessura da lâmina bem como o comprimento do pedículo aumenta em tamanho conforme a idade. Enquanto o ângulo de ataque permanece estável conforme variação de idade; variação dependente da idade ocorre somente na vértebra T1. Conclusão: Parafusos com diâmetro de 3.5mm podem ser inseridos de maneira segura nos pedículos de C7 e T2. Já no pedículo de T1 pode-se inserir parafusos com medidas de 3.5 a 4.5mm de diâmetro de maneira segura. Na lâmina, parafusos de 3.5mm podem ser usados de maneira segura somente em crianças maiores de 7 anos. No entanto, cada caso deve ser analisado de maneira individualizada, e o presente estudo não objetivo substituir o uso de tomografia computadorizada no pré-operatório. Nível de Evidência III, Estudo Comparativo Retrospectivo.

Comparative tomographic study of the iliac screw and the S2-alar-iliac screw in children

OBJECTIVES: The recent advancements in spine fixation aid in the treatment of complex spinal pathologies. Both the iliac screw (IS) and the S2-alar-iliac (S2AI) screw provide adequate stability in the fixation of complex lumbosacral spine pathologies, leading to a significant increased rate of using these techniques in the daily practice of the spine surgeons. This study aims to analyze, describe, and compare the insertion and positioning parameters of the S2AI screw and IS techniques in children without spinal deformities. METHODS: An observational retrospective study was conducted at a university hospital in 2018, with 25 computed tomography (CT) images selected continuously. Mann-Whitney-Shapiro-Wilk tests were performed. The reliability of the data was assessed using the intraclass correlation. The data were stratified by age group only for Pearson's correlation analysis. RESULTS: The mean age was 11.7 years (4.5 SD). The mean IS length was 106.63 mm (4.59 SD). The mean length of the S2AI screw was 104.13 mm (4.22 SD). The mean skin distance from the IS entry point was 28.13 mm (4.27 SD) and that for the S2AI screw was 39.96 mm (4.54 SD). CONCLUSIONS: Through CT, the S2AI screw trajectory was observed to have a greater bone thickness and skin distance than the IS. There was a linear correlation between age and screw length for both techniques. A similar relationship was observed between skin distance and age for the S2AI screw technique. In children, the S2AI screw technique presents advantages such as greater cutaneous coverage and implant thickness than the IS technique.

Rotation assessment in adolescent idiopathic scoliosis with rod derotation / Avaliação da rotação na escoliose idiopática do adolescente com derrotação da haste

ABSTRACT Objective: Adolescent idiopathic scoliosis (AIS) is characterized by rotational and lateral deformity of the spine. The measurement of vertebral rotation is important for prognosis and treatment. Our objective was to evaluate whether the Nash-Moe method can be used to measure axial deformity correction with surgical treatment using the rod derotation maneuver at both the apex and extremities of the deformity in patients with AIS. Methods: Rotation was assessed using the Nash and Moe criteria, on preoperative and postoperative radiographs. We also evaluated the severity on the coronal plane using the Cobb method, ratio of correction achieved, screw density, and number of vertebrae involved in the instrumentation. Results: The Cobb method correction average was 54.8%. When we disregarded vertebrae that presented preoperative Nash-Moe grade 0, the average measurable correction was 54.5% in the first non-instrumented vertebra above, 69.2% in the first instrumented vertebra, 32.2% in the apical vertebra, 36.8% in the last instrumented vertebra, and 30% in the first non-instrumented vertebra below. In our study, 32.14% of the patients presented a measurable correction in the apical vertebra. Conclusion: On the axial plane, correction can be satisfactorily evaluated using the Nash-Moe method. Level of Evidence VI. Case Series.

RESUMO Objetivo: A escoliose idiopática do adolescente é caracterizada por deformidade rotacional e lateral da coluna vertebral. A medição da rotação vertebral é importante para o prognóstico e tratamento. Nosso objetivo foi avaliar se o método de Nash-Moe pode ser usado para medir a correção da deformidade axial com o tratamento cirúrgico usando a manobra de derotação em ambos os ápices e extremidades da deformidade em pacientes com EIA. Métodos: A rotação foi avaliada usando os critérios de Nash e Moe em radiografias pré e pós-operatórias. Também avaliamos a severidade no plano coronal pelo método de Cobb, a razão de correção alcançada, a densidade do parafuso e o número de vértebras envolvidas na instrumentação. Resultados: A correção do método de Cobb foi de 54,8%. Quando desconsideramos vértebras que apresentavam grau 0 no pré-operatório de Nash-Moe, encontramos, em média, 54,5% de correção mensurável na primeira vértebra não instrumentada acima, 69,2% na primeira vértebra instrumentada, 32,2% na vértebra apical, 36,8% na última vértebra instrumentada e 30% na primeira vértebra não instrumentada abaixo. Em nosso estudo, ٣٢,١٤٪ dos pacientes apresentaram uma correção mensurável na vértebra apical. Conclusão: No plano axial, a correção pode ser avaliada satisfatoriamente pelo método de Nash-Moe. Nível de Evidência VI. Série de casos.

Evaluation of alternative halo ring positions in children using tomography

OBJECTIVES: The halo ring can be applied in children, through skeletal traction or a halo vest device, to treat many cervical spine pathologies, including traumatic injuries and pathologies related to deformities. However, the procedure is associated with various complications, such as infection, pin loosening, and respiratory and neurological problems. Although widely studied in adults, the best pin insertion site in children and the correlations of pin insertion sites with outcomes and complications have not been completely elucidated. This study aimed to determine alternative pin placement sites based on a morphological analysis of the infant skull by computerized tomography (CT). METHODS: An analytical-descriptive study was performed using 50 CT scans from children. The Wilcoxon and Friedman tests were used. RESULTS: A linear and directly proportional relation was found between cranial thickness and patient age. The average thicknesses of the anterior points across all ages analyzed ranged from 4.16 mm to 4.98 mm. The thicknesses of the posterior points varied from 3.94 mm to 4.27 mm. Within each age range, points 1 cm above the standard insertion sites had thicknesses similar to those of the standard sites, and points 2 cm above the standard insertion sites had thicknesses greater than those of the standard sites. CONCLUSIONS: The cranial thickness at all points increases linearly with age. Points 1 and 2 cm above the standard insertion sites are viable alternatives for the placement of halo pins. Preoperative CT can aid in choosing the best positioning sites for pins in the skull.

Epidemiology of cauda equina syndrome. What changed until 2015 / Epidemiologia da síndrome da cauda equina. O que mudou até 2015

ABSTRACT Objective: The primary objective of this study was to analyze the characteristics and outcomes of cases admitted to hospital with cauda equina syndrome (CES) at the Institute of Orthopedics and Traumatology (IOT) from 2005 to 2015. Secondly, this article is a continuation of the epidemiological work of the same base published in 2013, and will be important for other comparative studies to a greater understanding of the disease and its epidemiology. Methods: This was a retrospective study of the medical records of admissions due to CES at IOT in the period 2005-2015 with diagnosis of CES and neuropathic bladder. The following variables were analyzed: gender, age, etiology of the disease, topographic level of the injury, time interval between injury and diagnosis, presence of neurogenic bladder, time interval between diagnosis of the CES and surgery, and reversal of the deficit or of the neurogenic bladder. Results: Since this is a rare disease, with a low global incidence, it was not possible, just with the current study to establish statistically significant correlations between the variables and outcomes of the disease. However, this study demonstrates the shortcomings of the Brazilian public health system, both with the initial management of these patients and the need for urgent surgical treatment. Conclusion: The study shows that despite well-defined basis for the conduct of CES, a higher number of sequelae caused by the pathology is observed in Brazil. The delay in diagnosis and, therefore, for definitive treatment, remains as the major cause for the high number of sequelae. Level of evidence: 4, case series.

RESUMO Objetivo: Analisar as características e os desfechos dos casos internados por síndrome da cauda equina (SCE) no Instituto de Ortopedia e Traumatologia (IOT) da Faculdade de Medicina da Universidade de São Paulo de 2005-2015. Secundariamente, este artigo é a continuação do trabalho epidemiológico de mesma base publicado em 2013 e servirá de base para outros estudos comparativos com vistas a um entendimento maior da doença e de sua epidemiologia. Métodos: Estudo retrospectivo dos prontuários das internações por SCE no IOT de 2005 a 2015 com diagnósticos de SCE e bexiga neuropática. As seguintes variáveis foram analisadas: sexo, idade, etiologia da doença, nível topográfico da lesão, tempo de história da lesão até o diagnóstico, presença de bexiga neurogênica, tempo entre o diagnóstico da SCE e a cirurgia e reversão do déficit ou da bexiga neurogênica. Resultados: Por se tratar de uma doença rara, com uma incidência global baixa, não foi possível, somente com o estudo atual, estabelecer correlações estatisticamente significativas entre as variáveis analisadas e os desfechos da doença. Porém, este estudo continua a evidenciar as deficiências do sistema público de saúde brasileiro, tanto no manejo inicial desses pacientes quanto na necessidade de tratamento cirúrgico de urgência. Conclusão: O trabalho mostra que, apesar de bem definidas as bases para conduta da SCE, observa-se no Brasil um número maior de sequelas causadas pela patologia. O atraso no diagnóstico e, a partir desse, no tratamento definitivo mantém-se como a causa para o alto número de sequelas. Nível de evidência: 4, série de casos.

A Comparative Study of Sagittal Balance in Patients with Neuromuscular Scoliosis

OBJECTIVES: Spinopelvic alignment has been associated with improved quality of life in patients with vertebral deformities, and it helps to compensate for imbalances in gait. Although surgical treatment of scoliosis in patients with neuromuscular spinal deformities promotes correction of coronal scoliotic deformities, it remains poorly established whether this results in large changes in sagittal balance parameters in this specific population. The objective of this study is to compare these parameters before and after the current procedure under the hypothesis is that there is no significant modification. METHODS: Sampling included all records of patients with neuromuscular scoliosis with adequate radiographic records treated at Institute of Orthopedics and Traumatology of Clinics Hospital of University of São Paulo (IOT-HCFMUSP) from January 2009 to December 2013. Parameters analyzed were incidence, sacral inclination, pelvic tilt, lumbar lordosis, thoracic kyphosis, spinosacral angle, spinal inclination and spinopelvic inclination obtained using the iSite-Philips digital display system with Surgimap and a validated method for digital measurements of scoliosis radiographs. Comparison between the pre- and post-operative conditions involved means and standard deviations and the t-test. RESULTS: Based on 101 medical records only, 16 patients met the inclusion criteria for this study, including 7 males and 9 females, with an age range of 9-20 and a mean age of 12.9±3.06; 14 were diagnosed with cerebral palsy. No significant differences were found between pre and postoperative parameters. CONCLUSIONS: Despite correction of coronal scoliotic deformity in patients with neuromuscular deformities, there were no changes in spinopelvic alignment parameters in the group studied.

Anatomical and radiological characteristics in adolescent idiopathic scoliosis with surgical indication / Características anatomorradiológicas na escoliose idiopática do adolescente com indicação cirúrgica

ABSTRACT OBJECTIVE: This study aims to analyze the anatomical and radiological characteristics of adolescent idiopathic scoliosis patients with surgical indication. METHODS: Retrospective, descriptive study of 100 medical records pertaining to patients included in the group of scoliosis with surgical indication from the years 2008 to 2015. Descriptive statistics were used for statistical analysis. RESULTS: 28 patients met the inclusion and exclusion criteria, and were selected for the study. The average age was 15.4 (SD ± 1.2 years); in the selected sample, the female/male ratio was 6:1; the kyphosis measured in degrees by Cobb angle between T5-T12 had an average 32.10 (SD ± 13.37); according to the Lenke classification, the most prevalent type was type 2, representing 28.6% of cases. CONCLUSION: The mean patient age in the present study was 15.4 (SD ± 1.2 years); the most prevalent type was type 2 in the Lenke classification. There is a need for new anatomical and radiological studies to elucidate the morphological characteristics common in adolescent idiopathic scoliosis patients.

RESUMO OBJETIVO: Avaliar as características anatomorradiológicas em pacientes com escoliose idiopática do adolescente com indicação cirúrgica. MÉTODOS: Estudo descritivo retrospectivo de 100 prontuários de pacientes do grupo de escoliose com indicação cirúrgica de 2008 a 2015. A análise usada foi a estatística descritiva. RESULTADOS: Preencheram os critérios de inclusão e exclusão 28 pacientes e foram selecionados para o estudo. A média foi de 15,4 ± 1,2 anos DP; na amostra selecionada, a proporção menina:menino foi de 6:1; a cifose foi medida em graus pelo ângulo de Cobb entre T5-T12 e teve como média 32,10° ± 13,37° DP; segundo a classificação de Lenke, o mais prevalente foi o tipo 2, observado em 28,6% dos casos. CONCLUSÃO: A idade média dos pacientes no presente estudo foi de 15,4 anos; o mais prevalente foi o tipo 2 da classificação de Lenke. Novos trabalhos anatomorradiológicos são necessários para elucidar características morfológicas comuns nos pacientes com escoliose idiopática do adolescente.

The influence of body image on surgical decisions in adolescent idiopathic scoliosis patients

OBJECTIVES: The objective of this study was to evaluate whether the severity of deformities in patients with adolescent idiopathic scoliosis contributes to patients’ decision regarding whether to undergo an operation. METHODS: We evaluated body image factors in adolescent idiopathic scoliosis patients. We evaluated the magnitude of the main scoliotic curve, gibbosity (magnitude and location), shoulder height asymmetry and patient’s age. We analyzed the correlation of these data with the number of years the patient was willing to trade for surgery, as measured by the time-trade-off method. RESULTS: A total of 52 patients were studied. We did not find a correlation between any of the parameters that were studied and the number of years that the patient would trade for the surgery. CONCLUSIONS: The magnitude of body deformities in patients with adolescent idiopathic scoliosis does not interfere with the decision to undertake surgical treatment.

Correlation between the degree of correction of neuromuscular scoliosis and patient quality of life

OBJECTIVE: There are few data on patient satisfaction with surgery for the correction of neuromuscular scoliosis or on the correlation between patient satisfaction and the degree of curve correction achieved by surgery. Our aim was to determine the correlations between both patient satisfaction and perception of quality of life and the degree of curve correction. METHODS: We interviewed 18 patients and administered a questionnaire that collected social and economic data and information about functional ability, comorbidities and satisfaction. Statistical analysis was performed using chi-square tests, Pearson correlation and paired t-tests. RESULTS: The mean correction achieved was 42.8%, i.e., 34.17 degrees. Early and late complication rates were low (11.1% each). Almost all of the patients (94.4%) were satisfied with the surgery, and expectations were met for 61.1% of them. Quality of life and aesthetics were improved in 83.4% and 94.4% of cases, respectively. No correlation was found between satisfaction and degree of correction. CONCLUSION: Our surgical results are similar to those of other studies with respect to the degree of correction and patient satisfaction. The disparity between satisfaction and fulfillment of expectations may be due to unrealistic initial expectations or misunderstanding of the objective of surgery. Our findings corroborate the hypothesis that satisfaction is multifactorial and not restricted to a quantitative goal. The satisfaction of patients who undergo operation for neuromuscular scoliosis does not depend directly on the degree of deformity correction. The relationship between satisfaction and the success of the correction procedure is complex and multifactorial.

TOMOGRAPHIC MORPHOLOGICAL STUDY OF THE CRANIUM AND ITS CORRELATION WITH CRANIAL HALO USE IN ADULTS / ESTUDO MORFOLÓGICO TOMOGRÁFICO DO CRÂNIO E SUA CORRELAÇÃO COM O EMPREGO DO HALO CRANIANO EM ADULTOS

ABSTRACT Objective: To evaluate using tomographic study the thickness of the cranial board at the insertions points of the cranial halo pins in adults Methods: This is a retrospective, cross-sectional, descriptive analysis of Computed Tomography (CT) scans of adult patients' crania. The study included adults between 20 and 50 years without cranial abnormalities. We excluded any exam with cranial abnormalities Results: We analyzed 50 CT scans, including 27 men and 23 women, at the original insertion points and alternative points (1 and 2 cm above the frontal and parietal bones). The average values were 7.4333 mm in the frontal bone and 6.0290 mm in the parietal bone Conclusion: There was no statistically significant difference between the classical and alternative points, making room for alternative fixings and safer introduction of the pins, if necessary. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Avaliar, através de estudo tomográfico, a espessura da tábua craniana nos pontos de inserção dos pinos do halo craniano em adultos. Métodos: Trata-se de estudo retrospectivo de corte transversal de análise de exames de tomografia computadorizada de crânios de pacientes adultos. Foram incluídos adultos entre 20 e 50 anos sem anormalidades cranianas. Excluiu-se qualquer anormalidade craniana. Resultados: Analisamos 50 tomografias de 27 homens e 23 mulheres nos pontos originais de inserção e em pontos alternativos, 1 e 2 cm acima, nos ossos frontal e parietal. Os valores médios encontrados foram de 7,4333 mm no osso frontal e 6,0290 mm no osso parietal. Conclusão: Não constatamos diferença estatisticamente significativa entre os pontos clássicos e os alternativos, abrindo espaço para fixações alternativas e introdução mais segura dos pinos, em caso de necessidade. Nível de Evidência II, Estudo Retrospectivo.

Tomographic analysis of subaxial cervical vertebrae in children between 0 and 12 years / Análise tomográfica das vértebras cervicais subaxiais em crianças de 0 a 12 anos / Análisis tomográfica de vertebras cervicales subaxiales en niños de 0 a 12 años

ABSTRACT Objective: Tomographic and anatomic analysis of cervical vertebrae in children from 0 to 12 years of age to verify the possibility of utilization of lateral mass screws. Methods: Twenty-five cervical spine tomographies of children between 0 and 12 years of age, admitted to the emergency room of Hospital das Clínicas of São Paulo were retrospectively analyzed. The following distances were measured: width and length of the lateral masses in the axial section; width and height in the coronal section; height, length and diagonal diameter in the sagittal section. The variables studied were correlated with age and sex and submitted to statistical analysis. Results: The analysis of tomographic measurements of 20 patients showed a correlation between age and dimensions of the lateral mass, which were higher after 6 years of age. In relation to sex, greater measures were observed in males in all axes. With regard to the passage of the screws, we only had 22 masses (11%) that prevented their use. However, when stratified by age, we noticed that no patients had restrictions on the use of the lateral mass screw after the age of 6. Conclusion: This study analyzed the measurements of 200 lateral masses, making it possible to infer that there is an increase of dimensions with age and in males. Through the data, it was possible to affirm that in this sample, considering the implants available in the market, the lateral mass screws could be used in 89% of the lateral masses.

RESUMO Objetivo: Análise tomográfica e anatômica das vértebras cervicais em crianças de zero a doze anos de idade para verificar a possibilidade de passagem de parafuso de massa lateral. Métodos: Foram analisadas retrospectivamente 25 tomografias de coluna cervical de crianças entre 0 e 12 anos de idade, admitidas no pronto socorro do Hospital das Clínicas de São Paulo. Foram aferidas as seguintes medidas: largura e comprimento das massas laterais no corte axial; largura e altura no corte coronal; altura, comprimento e diâmetro diagonal no corte sagital. As variáveis estudadas foram correlacionadas com a idade e o sexo dos indivíduos e submetidas a análise estatística. Resultados: Por meio da análise de medidas tomográficas de 20 pacientes, foi verificada a correlação entre idade e dimensões das massas laterais, sendo estas maiores a partir dos 6 anos. Já em relação ao sexo, foram verificadas medidas maiores no sexo masculino em todos os eixos. Com relação à passagem dos parafusos, tivemos apenas 22 massas (11%) com impossibilidade de uso. Porém, quando estratificados pela idade, notamos não haver pacientes com impedimento para uso do parafuso de massa lateral após os 6 anos. Conclusão: O estudo analisou as medidas de 200 massas laterais, possibilitando inferir que existe aumento das suas dimensões com a idade e no sexo masculino. Através dos dados, foi possível afirmar que nesta amostra, considerando-se os implantes disponíveis no mercado, o parafuso de massa lateral poderia ser utilizado em 89% das massas laterais.

RESUMEN Objetivo: Análisis tomográfico y anatómico de las vértebras cervicales en niños de hasta doce años de edad, para comprobar la posibilidad de pasaje de tornillos de masa lateral. Métodos: Se analizaron retrospectivamente 25 tomografías computarizadas de la columna cervical de niños entre 0 y 12 años de edad, ingresados en el servicio de urgencias del Hospital das Clínicas de São Paulo. Se tomaron las siguientes medidas: anchura y longitud de las masas laterales en corte axial; anchura y altura del corte coronal; altura, longitud y diámetro diagonal en el corte sagital. Las variables se correlacionaron con la edad y el sexo de los individuos y se sometieron a análisis estadístico. Resultados: Mediante el análisis de las mediciones tomográficas de 20 pacientes, se observó la correlación entre la edad y las dimensiones de las masas laterales, que son más grandes a partir de los 6 años de edad. En relación con el sexo, se observaron medidas más altas en los hombres en todos los ejes. En cuanto al paso de los tornillos, encontramos sólo 22 masas (11%) que impidieron su uso. Sin embargo, cuando se estratificó por edad, observamos que no había ningún impedimento para el uso de tornillo de masa lateral después de 6 años de edad. Conclusión: El estudio examinó las medidas de 200 masas laterales, por lo que es posible inferir que hay un aumento de tamaño con la edad y en el sexo masculino. De estos datos, fue posible afirmar que en esta muestra, teniendo en cuenta los implantes disponibles en el mercado, el tornillo de masa lateral podría ser utilizado en el 89% de las masas laterales.

Changes in the sagittal balance in congenital scoliosis correction surgery / Alterações do equilíbrio sagital na cirurgia de correção de escoliose congênita / Cambios en el equilibrio sagital en la cirugía de corrección de la escoliosis congénita

ABSTRACT Objective: This study aimed to determine whether surgery leads to changes in sagittal balance in patients with congenital scoliosis. Methods: We retrospectively reviewed all cases of scoliosis operated in a tertiary hospital between January 2009 and January 2013. In all cases the deformity in the coronal and sagittal planes, kyphosis, and lordosis were measured, using the Cobb method, and spinopelvic parameters: pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT). Results A hundred and eleven medical records were analyzed, but the sample resulted in 10 patients, six of whom were females (60%). The average age was 13.4 years. In the comparative analysis between pre and postoperative, only the coronal deformity (12.37; CI 95% [7.88-16.86]; p<0.001), the sagittal deformity (12.71; CI 95% [4.21-21.22]; p=0.011), and the lumbar lordosis (9.9; CI 95% [0.38-19.42]; p=0.043) showed significant change. Conclusion: There was no change in the spinopelvic parameters of patients with congenital scoliosis undergoing surgery at IOF-FMUSP between 2009 and 2013; however, it was observed decrease in lumbar lordosis, and deformity angle in the sagittal and coronal planes.

RESUMO Objetivos: Este estudo tem como objetivo esclarecer se existe alteração do equilíbrio sagital provocada pela intervenção cirúrgica nos pacientes com escoliose congênita. Métodos: Foram analisados retrospectivamente todos os casos de escoliose operados em um hospital terciário entre janeiro de 2009 e janeiro de 2013. Em todos os casos foram mensuradas a deformidade no plano coronal e sagital, a cifose e lordose, utilizando-se o método de Cobb, e também os parâmetros espinopélvicos: incidência pélvica (PI), inclinação sacral (SS), inclinação pélvica (PT). Resultados: Foram analisados 111 prontuários, porém a amostra resultou em 10 pacientes, dos quais seis eram do sexo feminino (60%). A média de idade foi de 13,4 anos. Na análise comparativa entre pré e pós-operatório, apenas a deformidade coronal (12,37; IC 95% [7,88-16,86]; p < 0,001), a deformidade sagital (12,71; IC 95% [4,21-21,22]; p = 0,011) e a lordose lombar (9,9; IC 95% [0,38-19,42]; p = 0,043) apresentaram alteração significativa. Conclusão: Não foi encontrada alteração nos parâmetros espinopélvicos dos pacientes com escoliose congênita submetidos à intervenção cirúrgica no IOT-FMUSP entre 2009 e 2013, contudo, foi observada diminuição da lordose lombar, do ângulo da deformidade no plano sagital e no plano coronal.

RESUMEN Objetivo: Este estudio tiene por objetivo aclarar si hay cambio de equilibrio sagital causado por la cirugía en pacientes con escoliosis congénita. Métodos: Se revisaron retrospectivamente todos los casos de cirugía de escoliosis en un hospital terciario entre enero de 2009 y enero de 2013. En todos los casos se midieron la deformidad en el plan coronal y sagital, la cifosis y lordosis, utilizando el método de Cobb, y también los parámetros espinopélvicos: incidencia pélvica (IP), pendiente sacra (PS), inclinación pélvica (IP). Resultados: Se analizaron 111 registros médicos, pero la muestra resultó en 10 pacientes, de los cuales 6 eran del sexo femenino (60%). La edad promedio fue de 13,4 años. En el análisis comparativo entre el pre y postoperatorio, solamente la deformidad coronal (12,37; IC 95% [7,88-16,86]; p < 0,001), la deformidad sagital (12,71; IC 95% [4,21-21,22]; p = 0,011) y la lordosis lumbar (9,9; IC 95% [0,38-19,42]; p = 0,043) mostraron cambios significativos. Conclusión: No hubo cambios en los parámetros espinopélvicos de los pacientes con escoliosis congénita sometidos a cirugía en IOT-FMUSP entre 2009 y 2013, sin embargo se observó disminución de la lordosis lumbar y del ángulo de deformidad en el plano sagital y plano coronal.

Computed tomography morphometric analysis of the vertebrae C7 and T1 / Análise morfométrica por tomografia computadorizada das vértebras C7 e T1 / Análisis morfométrico mediante tomografía computarizada de las vértebras C7 y T1

ABSTRACT Objective: The anatomical study of the vertebrae C7 and T1 of the cervicothoracic junction aimed to evaluate quantitatively, by axial computerized tomography (CT), the linear and angular dimensions of the anatomical laminae of the vertebrae of the cervicothoracic junction C7 and T1 in adults over 18 years. Methods: We retrospectively analyzed 49 CT of the cervical and thoracic spine (C7 and T1) of individuals over 18 years, of both sexes. We also evaluated the length and thickness of the laminae, as well as spinolaminar angle in axial sections of C7 and T1 at the point of least thickness between the inner cortical layers. The variables were correlated with age groups and sex of the individuals. Statistical analysis was performed using the t test and the results were considered significant when p<0.05. Results: After analyzing tomographic measurements of 49 patients, it was found that men had greater laminae thickness than women, both in C7 and T1, with 71% of C7 laminae and 92% of T1 laminae thicker than 5mm, and 97% of C7 laminae and 100% of T1 thicker than 4mm. The mean spinolaminar angle was 56.40 degrees in C7 and 57.31 degrees in T1. Conclusion: This study brings important anatomical information about the cervicothoracic junction C7 and T1 in the Brazilian population, showing that fixation of C7 and T1 with intralaminar screws is anatomically possible.

RESUMO Objetivo: O estudo anatômico das vértebras da transição cervicotorácica C7 e T1 teve como objetivo avaliar quantitativamente, por tomografia computadorizada axial (TC), as dimensões anatômicas lineares e angulares de lâminas das vértebras da transição cervicotorácica C7 e T1 em indivíduos adultos maiores de 18 anos. Métodos: Foram analisadas retrospectivamente 49 TC da coluna cervical e torácica (C7 e T1) de indivíduos maiores de 18 anos, de ambos os sexos. Avaliaram-se o comprimento e a espessura das lâminas, bem como o ângulo espinolaminar, em cortes axiais de C7 e T1, no ponto de menor espessura entre as camadas corticais internas. As variáveis estudadas foram correlacionadas com os grupos etários e o sexo dos indivíduos. A análise estatística foi feita pelo teste t e os resultados foram considerados significativos quando p < 0,05. Resultados: Após análise de medidas tomográficas de 49 pacientes, foi verificado que os homens apresentaram espessura de lâmina maior que as mulheres tanto em C7, quanto em T1, sendo que 71% das lâminas de C7 e 92% das lâminas de T1 apresentavam espessura maior que 5 mm e 97% das lâminas de C7 e 100% de T1, espessura maior que 4 mm. O ângulo espinolaminar apresentou média de 56,40 graus em C7 e 57,31 graus em T1. Conclusão: O estudo traz informações anatômicas importantes sobre a região da transição cervicotorácica C7 e T1 na população brasileira, mostrando ser possível anatomicamente, fixação de C7 e T1 com parafuso intralaminar.

RESUMEN Objetivo: El estudio anatómico de las vértebras de la unión cervicotorácica C7 y T1 tuvo el objetivo de evaluar cuantitativamente mediante tomografía axial computarizada (TAC), las dimensiones anatómicas lineales y angulares de láminas de las vértebras de la unión cervicotorácica C7 y T1 en adultos mayores de 18 años. Métodos: Se analizaron retrospectivamente 49 TAC de la columna cervical y torácica (C7 y T1) de pacientes mayores de 18 años de ambos sexos. Se evaluaron la longitud y el espesor de las láminas, así como el ángulo espinolaminar en secciones axiales de C7 y T1 en el punto de menor espesor entre las capas corticales internas. Las variables se correlacionaron con los grupos de edad y sexo de los individuos. El análisis estadístico se realizó mediante la prueba t y los resultados se consideraron significativos cuando p < 0,05. Resultados: Después del análisis de las mediciones tomográficas de 49 pacientes, se encontró que los hombres tenían espesor de la lámina mayor que las mujeres, tanto en C7, como en T1, con el 71% de las láminas C7 y el 92% de las láminas T1 con espesor mayor que 5 mm, 97% de C7 y 100% de T1, mayor que 4 mm de espesor. El ángulo espinolaminar promedio fue 56,40 grados en C7 y 57,31 grados en T1. Conclusión: Este estudio contiene información anatómica importante sobre la región de la unión cervicotorácica C7 y T1 en la población brasileña, mostrando que es anatómicamente posible la fijación de C7 y T1 con tornillos intralaminares.

Tomographic analysis of T-1 vertebra to insert laminar screws in children from 0 to 12 years / Análise tomográfica da vértebra T-1 para passagem de parafusos laminares em crianças de 0 a 12 anos / Análisis tomográfico de la vértebra T-1 para pasar tornillos laminares en niños de 0 a 12 años

Objective : Tomographic analysis of the T1 vertebra in children from 0 to 12 years of age, in order to obtain anatomical parameters that assist intralaminar fixation in this pediatric population. Methods : Retrospectively analysis of the spine with CT (cervical and thoracic) of individuals aged between 0 and 12 years old, of both sexes, without anatomical deformities. The CT scans were evaluated separately, on each side, for length and thickness of the laminas as well as spinolaminar angle. The morphometric analysis was performed with iSite PACS Philips Healthcare Informatics(r) program and the values were expressed in millimeters (mm). The variables were correlated with age groups and sex of individuals. Statistical analysis was performed using t test and the results were considered significant when p<0.05. Results : By means of tomographic analysis of 24 patients it was found that age has no correlation with the angle of attack for intralaminar screws T1. However, the length and thickness of the T1 lamina increase proportionally with age. The total average length of the laminas was 28.62 ± 4.42 mm. The total average thickness was 4.75 ± 0.95 mm (3.2 to 6.5). Conclusion : This study shows relevant data on the use of Tran laminar screws currently commercially available with a minimum thickness of 3.5 mm. It is thus possible to say in this sample, they can be used in 87.5% of all laminas, being applicable in all lamina in patients older than 44 months of age.

Objetivo : Análise tomográfica da vértebra T1 em crianças de zero a doze anos de idade, obtendo parâmetros anatômicos que auxiliarão a fixação intralaminar nessa população infantil. Métodos : Análise retrospectiva da coluna por TC (cervical e torácica) de indivíduos entre 0 e 12 anos de idade, de ambos os sexos, sem deformidades anatômicas. Foram avaliados, separadamente, em cada lado, o comprimento e a espessura das lâminas, bem como o ângulo espino-laminar. A análise morfométrica foi realizada com o programa iSite PACS Philips Healthcare Informatics(r) e os valores obtidos foram expressos em milímetros (mm). As variáveis estudadas foram correlacionadas com os grupos etários e o sexo dos indivíduos. A análise estatística foi feita pelo teste t e os resultados foram considerados significativos quando p < 0,05. Resultados : Por meio de análises tomográficas de 24 pacientes, verificou-se que a idade não tem correlação com o ângulo de ataque para parafusos intralaminares de T1. Já o comprimento e a espessura da lâmina de T1 aumentam proporcionalmente com a idade. O comprimento médio total das lâminas foi de 28,62 ± 4,42 mm. A média total da espessura 4,75 ± 0,95 mm (3,2 a 6,5). Conclusão : O presente estudo mostra dados relevantes sobre a utilização de parafusos translaminares, que atualmente são disponíveis comercialmente com espessura mínima de 3,5 mm. É possível, assim, afirmar que, nesta amostra, pode ser utilizado em 87,5% do total de lâminas, sendo aplicável em todas as lâminas nos pacientes acima de 44 meses de idade.

Objetivo : Análisis tomográfico de la vértebra T1 en niños de cero a doce años de edad, para obtener parámetros anatómicos que ayudarán la fijación con tornillos intralaminares en esta población infantil. Métodos : Análisis retrospectivo de la columna por TAC (cervical y torácica) de individuos entre 0 y 12 años de edad, de ambos sexos, sin deformidades anatómicas. Se evaluaron por separado, en cada lado, la longitud y el grosor de las láminas, así como el ángulo espinolaminar. El análisis morfométrico se realizó con el programa iSite PACS Philips Healthcare Informatics(r) y los valores se expresaron en milímetros (mm). Las variables se correlacionaron con los grupos de edad y sexo de los individuos. Se realizó un análisis estadístico mediante la prueba t y los resultados se consideraron significativos cuando p < 0,05. Resultados : Por medio de análisis tomográficos de 24 pacientes, se encontró que la edad no se correlaciona con el ángulo de ataque para tornillos intralaminares T1. Sin embargo, la longitud y el grosor de la lámina T1 aumentan proporcionalmente con la edad. La longitud promedio total de las láminas fue 28,62 ± 4,42 mm. El espesor promedio total fue 4,75 ± 0,95 mm (3,2 a 6,5). Conclusión : Este estudio muestra datos relevantes sobre el uso de tornillos translaminares que actualmente están disponibles en el mercado con un espesor mínimo de 3,5 mm. Por tanto, es posible afirmar que, en esta muestra, se puede utilizarlos en el 87,5% de todas las láminas siendo aplicable en todas las láminas de pacientes mayores de 44 meses de edad.

Effects of estrogen on functional and neurological recovery after spinal cord injury: An experimental study with rats

OBJECTIVES:To evaluate the functional and histological effects of estrogen as a neuroprotective agent after a standard experimentally induced spinal cord lesion.METHODS:In this experimental study, 20 male Wistar rats were divided into two groups: one group with rats undergoing spinal cord injury (SCI) at T10 and receiving estrogen therapy with 17-beta estradiol (4mg/kg) immediately following the injury and after the placement of skin sutures and a control group with rats only subjected to SCI. A moderate standard experimentally induced SCI was produced using a computerized device that dropped a weight on the rat's spine from a height of 12.5 mm. Functional recovery was verified with the Basso, Beattie and Bresnahan scale on the 2nd, 7th, 14th, 21st, 28th, 35th and 42nd days after injury and by quantifying the motor-evoked potential on the 42nd day after injury. Histopathological evaluation of the SCI area was performed after euthanasia on the 42nd day.RESULTS:The experimental group showed a significantly greater functional improvement from the 28th to the 42nd day of observation compared to the control group. The experimental group showed statistically significant improvements in the motor-evoked potential compared with the control group. The results of pathological histomorphometry evaluations showed a better neurological recovery in the experimental group, with respect to the proportion and diameter of the quantified nerve fibers.CONCLUSIONS:Estrogen administration provided benefits in neurological and functional motor recovery in rats with SCI beginning at the 28th day after injury.

Kyphectomy in patients with myelomeningocele: surgical results and complications / Cifosectomia em pacientes com mielomeningocele: resultados cirúrgicos e complicações / Cifosectomía en pacientes con mielomeningocele: resultados quirúrgicos y complicaciones

Objectives:The lumbar kyphosis in patients with myelomeningocele is a complex deformity whose treatment is mainly surgical. The objective of this study is to summarize the results and complications obtained by the group in 2012 with respect to this group of patients.Method:Performed a retrospective analysis of the medical records and radiographs of patients consecutively operated in 2012. The technique was originally described by Dunn-McCarthy and consists of kyphectomy and posterior fixation using S-shaped Luque rods through the foramina of S1 associated with pedicle screws in the thoracic spine.Results:Six patients were included in the study. The age at surgery was 11 years and 7±22 months and the weight was 29.1±11.9 kg. The procedure lasted 271±87 minutes, with the removal of one or two (mean 1.5) vertebrae from the apex of the kyphosis. Hospitalization time was 10±9 days. The lumbar kyphosis measuring 116.3±37 degrees preoperatively was reduced to 62.5±21 degrees. All patients began to sit without support and to lie in the supine position. Four patients developed postoperative infection and required surgical debridement at the follow-up. One patient had the implant removed after a year due to loosening of the rod in the sacrum.Conclusion:The surgical technique allows excellent functional results in the correction of lumbar kyphosis in patients with myelomeningocele despite high complication rates. It is necessary to conduct studies with a larger number of patients and duration of follow-up to assess whether the use of pedicle screws will decrease the rate of loosening and pseudoarthrosis.

Objetivos:A cifose lombar em pacientes com mielomeningocele é uma deformidade complexa cujo tratamento é eminentemente cirúrgico. O objetivo deste estudo é resumir os resultados e complicações obtidos pela equipe, em 2012, com relação a esse grupo de pacientes.Método:Foi feita análise retrospectiva dos prontuários e radiografias de pacientes operados consecutivamente em 2012. A técnica utilizada foi descrita originalmente por Dunn-McCarthy e consiste em cifosectomia e fixação posterior utilizando-se hastes moldadas em "S" através dos forames de S1 associados a parafusos pediculares na coluna torácica.Resultados:Foram incluídos seis pacientes no estudo. A idade à realização da cirurgia foi de 11 anos e 7 ± 22 meses e o peso foi 29,1 ± 11,9 kg. O procedimento durou 271 ± 87 minutos, com a retirada de uma ou duas (média de 1,5) vértebras do ápice da cifose. O tempo de internação foi de 10 ± 9 dias. A cifose lombar que media 116,3 ± 37 graus no pré-operatório foi reduzida para 62,5 ± 21 graus. Todos os pacientes passaram a sentar sem apoio e a deitar na posição supina. Quatro pacientes evoluíram com infecção pós-operatória e necessitaram de limpeza cirúrgica no seguimento. Um paciente teve o implante retirado após um ano, devido à soltura da haste no sacro.Conclusão:A técnica cirúrgica utilizada permite resultados funcionais excelentes na correção da cifose lombar em pacientes com mielomeningocele, apesar das altas taxas de complicações. É preciso realizar estudos com maior número de pacientes e tempo de seguimento para se avaliar se a utilização de parafusos pediculares diminuirá a taxa de soltura e pseudoartrose.

Objetivos:La cifosis lumbar en pacientes con mielomeningocele es una deformidad compleja cuyo tratamiento es principalmente quirúrgico. El objetivo de este estudio es resumir los resultados y complicaciones obtenidos por el equipo en 2012, con respecto a este grupo de pacientes.Método:Se realizó un análisis retrospectivo de las historias clínicas y las radiografías de los pacientes intervenidos consecutivamente en 2012. La técnica fue descrita originalmente por Dunn-McCarthy y constituye en cifosectomía y fijación posterior con los tallos en forma de "S" a través de los forámenes de S1 asociados con tornillos pediculares en la columna torácica.Resultados:Se incluyeron 6 pacientes en el estudio. La edad a la cirugía fue de 11 años y 7 ± 22 mmeses y el peso fue 29,1 ± 11,9 kg. El procedimiento duró 271 ± 87 minutos, con la eliminación de una o dos (media 1,5) vértebras desde el ápice de la cifosis. El tiempo de hospitalización fue de 10 ± 9 días. La cifosis lumbar midiendo 116,3 ± 37 grados antes de la operación se redujo a 62,5 ± 21 grados. Todos los pacientes empezaron a sentarse sin apoyo y acostarse en la posición supina. Cuatro pacientes desarrollaron infección postoperatoria y requirieron limpieza quirúrgica en el seguimiento. Un paciente tuvo el implante retirado después de un año debido al aflojamiento del tallo en el sacro.Conclusión: La técnica quirúrgica utilizada permite excelentes resultados funcionales en la corrección de la cifosis lumbar en pacientes con mielomeningocele a pesar de altas tasas de complicaciones. Es necesario realizar estudios con mayor número de pacientes y tiempo de seguimiento para evaluar si el uso de tornillos pediculares puede reducir el aflojamiento y la pseudoartrosis.

Cervical disc prosthesis: 2-year follow-up / Prótese de disco cervical: 2 anos de seguimento / Prótesis de disco cervical: 2 años de seguimiento

To review the medical records of patients who underwent surgery for placement of cervical disc prosthesis after two years of postoperative follow-up, showing the basic epidemiological data, the technical aspects and the incidence of complications.

Revisar las historias clínicas de los pacientes que se sometieron a cirugía para colocación de prótesis de disco cervical después de dos años de seguimiento postoperatorio, que muestran los datos epidemiológicos básicos, los aspectos técnicos y la incidencia de complicaciones.

Revisar os prontuários de pacientes que foram submetidos à cirurgia para colocação de prótese de disco cervical, após dois anos de seguimento pós-operatório, evidenciando os dados epidemiológicos básicos, os aspectos da técnica e a incidência de complicações.

Predictive factors for perioperative blood transfusion in surgeries for correction of idiopathic, neuromuscular or congenital scoliosis

OBJECTIVE: To evaluate the association of clinical and demographic variables in patients requiring blood transfusion during elective surgery to treat scoliosis with the aim of identifying markers predictive of the need for blood transfusion. METHODS: Based on the review of medical charts at a public university hospital, this retrospective study evaluated whether the following variables were associated with the need for red blood cell transfusion (measured by the number of packs used) during scoliosis surgery: scoliotic angle, extent of arthrodesis (number of fused levels), sex of the patient, surgery duration and type of scoliosis (neuromuscular, congenital or idiopathic). RESULTS: Of the 94 patients evaluated in a 55-month period, none required a massive blood transfusion (most patients needed less than two red blood cell packs). The number of packs was not significantly associated with sex or type of scoliosis. The extent of arthrodesis (r = 0.103), surgery duration (r = 0.144) and scoliotic angle (r = 0.004) were weakly correlated with the need for blood transfusion. Linear regression analysis showed an association between the number of spine levels submitted to arthrodesis and the volume of blood used in transfusions (p = 0.001). CONCLUSION: This study did not reveal any evidence of a significant association between the need for red blood cell transfusion and scoliotic angle, sex or surgery duration in scoliosis correction surgery. Submission of more spinal levels to arthrodesis was associated with the use of a greater number of blood packs. .

Controlled medial branch anesthetic block in the diagnosis of chronic lumbar facet joint pain: the value of a three-month follow-up

OBJECTIVES: To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables. METHODS: Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients. RESULTS: A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05). CONCLUSION: Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives. .