Factores influyentes en el desarrollo de competencias en Ortopedia y Traumatología durante el internado médico / Influential Factors in The Development of Competencies in Orthopedics and Traumatology During the Medical Internship

RESUMEN Introducción: Actualmente la salud es concebida como un derecho fundamental y para garantizarlo se debe propender por una adecuada formación de los profesionales de la salud. El internado rotatorio es la última etapa y la más importante del pregrado en Medicina. Objetivo: Explorar los factores desde la perspectiva de estudiantes y docentes, que influyen en el desarrollo de competencias en la rotación de Ortopedia y Traumatología durante el internado médico. Métodos: Estudio cualitativo con enfoque en teoría fundamentada. Para la recolección de datos se realizó un cuestionario semiestructurado a una muestra aleatoria de 14 participantes, 7 estudiantes y 7 docentes, que cumplían los criterios de inclusión. El análisis se basó en la codificación y categorización de los datos que posteriormente fueron sometidos a un proceso de triangulación para lograr la teorización final. Resultados: Los factores que favorecen el desarrollo de competencias están relacionados con la motivación intrínseca del estudiante, la flexibilidad y disponibilidad de recursos académicos, las características del programa de la rotación y el ambiente de práctica. Se identificaron como factores limitantes aquellos asociados a una formación deficiente en ciencias básicas médicas, la priorización del componente asistencial sobre el académico, la disponibilidad limitada de espacios y recursos de aprendizaje y los métodos de enseñanza tradicionales. Conclusiones: Es de vital importancia la identificación de los factores que favorecen y limitan el desarrollo de las competencias de los estudiantes de medicina en su última etapa de formación en ortopedia.

ABSTRACT Introduction: Few areas of orthopedic surgery have had such important technical changes in recent decades as in corrective spinal surgery. Fundamental changes have come with the new spinal instrumentation systems, which have been substantially modified and improved to facilitate three-dimensional correction of the deformity and provide secure spinal fixation, correction and stability. Objective: To evaluate the results achieved with the spinal instrumentation systems used in the correction of thoracolumbar kyphosis due to ankylosing spondylitis. Methods: A descriptive, retrospective and longitudinal study was carried out on 16 patients with thoracolumbar kyphosis due to ankylosing spondylitis operated on with the pedicle subtraction osteotomy technique and instrumented with Luque-type pedicle and sublaminar systems, in the Orthopedics service at Hermanos Ameijeiras Surgical Clinical Hospital, from March 2001 to March 2021. Results: All the patients were male, white skin color and average age of 39 years. More than 80% correction was achieved in the sagittal profile and an average of 34.3° per osteotomy, without major neurological complications. Good functional results were obtained, with high degree of patient satisfaction and improvement in their quality of life. Conclusions: The use of both spinal instrumentation systems is effective in maintaining the correction of thoracolumbar kyphosis due to ankylosing spondylitis.

Sistemas de instrumentación espinal en la corrección de la cifosis toracolumbar por espondilitisanquilopoyética / Spinal Instrumentation Systems in The Correction of Thoracolumbar Kyphosis Due to AnkylosingSpondylitis

Introducción: En pocas áreas de la cirugía ortopédica se han producido cambios técnicos tan importantes en las últimas décadas como en la cirugía correctora espinal. Los cambios fundamentales han sobrevenido con los nuevos sistemas de instrumentación espinal, que se han modificado y mejorado sustancialmente para facilitar la corrección tridimensional de la deformidad y aportar fijación segura de la columna, corrección y estabilidad. Objetivo: Evaluar los resultados alcanzados con los sistemas de instrumentación espinal utilizados en la corrección de la cifosis toracolumbar por espondilitis anquilopoyética. Método: Se realizó un estudio tipo descriptivo, retrospectivo y longitudinal a 16 pacientes con cifosis toracolumbar por espondilitis anquilopoyética intervenidos con la técnica de osteotomía de sustracción pedicular e instrumentados con sistemas pediculares y sublaminar tipo Luque, en el servicio de Ortopedia del Hospital Clínico Quirúrgico Hermanos Ameijeiras, durante el período comprendido entre marzo de 2001 y marzo de 2021. Resultados: La totalidad de los pacientes correspondieron al sexo masculino, color de la piel blanca y edad promedio de 39 años. Se logró más del 80 por ciento de corrección en el perfil sagital y un promedio de 34,3° por osteotomía, sin complicaciones neurológicas mayores. Se obtuvo un buen resultado funcional, con un alto grado de satisfacción de los pacientes y mejora de su calidad de vida. Conclusiones: La utilización de ambos sistemas instrumentación espinal es eficaz para mantener la corrección de la cifosis toracolumbar por espondilitis anquilopoyética(AU)

Introduction: Few areas of orthopedic surgery have had such important technical changes in recent decades as in corrective spinal surgery. Fundamental changes have come with the new spinal instrumentation systems, which have been substantially modified and improved to facilitate three-dimensional correction of the deformity and provide secure spinal fixation, correction and stability. Objective: To evaluate the results achieved with the spinal instrumentation systems used in the correction of thoracolumbar kyphosis due to ankylosing spondylitis. Methods: A descriptive, retrospective and longitudinal study was carried out on 16 patients with thoracolumbar kyphosis due to ankylosing spondylitis operated on with the pedicle subtraction osteotomy technique and instrumented with Luque-type pedicle and sublaminar systems, in the Orthopedics service at Hermanos Ameijeiras Surgical Clinical Hospital, from March 2001 to March 2021. Results: All the patients were male, white skin color and average age of 39 years. More than 80 percent correction was achieved in the sagittal profile and an average of 34.3° per osteotomy, without major neurological complications. Good functional results were obtained, with high degree of patient satisfaction and improvement in their quality of life. Conclusions: The use of both spinal instrumentation systems is effective in maintaining the correction of thoracolumbar kyphosis due to ankylosing spondylitis(AU)

Computed Tomographic Study of Occipital Thickness in Ethnic Malays

@#Introduction: Occipitocervical fusion is performed to address craniocervical and atlantoaxial instability. A screw of at least 8mm is needed for biomechanical stability. Occipital thickness of Malay ethnicity is unknown, and this study presents the optimal screw placement positions for occiput screw in this population. This was a retrospective crosssectional study of 100 Malays who underwent computed tomography (CT) scan for brain assessment. To measure the occipital bone thickness of Malay ethnicity at the area of common screw placement for occipitocervical fusion. The subject’s data was obtained from the institutional database with consent from the administrations and the patients. None of the patients had any head and neck pathology. Materials and methods: The subject’s data was obtained from the institutional database with consent from the administrations and the patients. None of the patients had any head and neck pathology. Computed tomography (CT) of 100 Malay patients who underwent head and neck CT were analysed, based on our inclusion and exclusion criteria. Measurements were taken using a specialised viewer software where 55 points were measured, followed a grid with 10mm distance using external occipital protuberance (EOP) as the reference point. Results: There were 57 males and 43 females of Malay ethnicity with a mean age of 36.7 years analysed in this study. The EOP was the thickest bone of the occiput which measured 16.15mm. There was an area of at least 8mm thickness up to 20mm on either side of the EOP, and at level 10mm inferior to the EOP. There is thickness of at least 8mm, up to 30mm inferior to the EOP at the midline. The males have significantly thicker bone especially along the midline compared to females. Conclusion: Screws of at least 8mm can be safely inserted in the Malay population at 20mm on either side of the EOP at the level 10mm inferior to the EOP and up to 30mm inferior to the EOP at the midline.

Effect of perioperative transcutaneous electrical acupoint stimulation on postoperative cellular immune function in patients undergoing posterior spinal internal fixation / 中华麻醉学杂志

Objective:To evaluate the effect of perioperative transcutaneous electrical acupoint stimulation (TEAS) on postoperative cellular immune function in the patients undergoing posterior spinal internal fixation.Methods:Ninety patients, aged 40-70 yr, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing elective posterior spinal internal fixation in our hospital, were divided into 2 groups ( n=45 each) using a computer-generated table of random numbers: routine group and experiment group.Total intravenous anesthesia was used in routine group, while total intravenous anesthesia combined with TEAS was applied in experiment group.In experiment group, bilateral Zusanli and Sanyinjiao acupoints were stimulated with 2/15 Hz disperse-dense waves at the intensity that could be tolerated by patients at 30 min before induction of anesthesia, maintaining with 2/100 Hz disperse-dense waves from the end of induction until the end of operation at the same stimulation intensity before induction.Bilateral Neiguan and Taichong acupoints were stimulated for 30 min each time with 2/15Hz disperse-dense waves once a day at 1st-4th days after operation.In routine group, the electrodes were connected at the same time period, but no stimulation was given.Venous blood samples were collected before induction of anesthesia, at 1 h after surgery, and on 1st, 3rd, and 5th days after surgery, and the percentage of CD3 + , CD4 + , CD8 + T lymphocytes, CD4 + /CD8 + ratio, WBC count and percentage of neutrophils (NE%) were determined by flow cytometry, and the consumption of intraoperative anesthetics, use of postoperative analgesics, nausea and vomiting, dizziness, infection and length of hospital stay were recorded. Results:Compared with routine group, the total consumption and consumption index of remifentanil were significantly decreased, the percentage of CD3 + T lymphocytes was increased on 3rd and 5th postoperative days, the NE% was decreased on 1st postoperative day, and the incidence of dizziness was decreased ( P<0.05), and no significant change was found in the other indicators in experiment group ( P>0.05). Conclusions:Perioperative TEAS can improve postoperative cellular immune function and has a certain potential value in preventing postoperative infection in the patients undergoing posterior spinal internal fixation.

A Review of Anterior Thoracoscopic Surgery for Thoracic Idiopathic Scoliosis / 中国微创外科杂志

[Summary] Traditional anterior thoracotomy surgery for thoracic idiopathic scoliosis has amount of disadvantages such as large trauma,postoperative pain,and pulmonary function decrease.Video-assisted thoracoscopic surgery (VATS),which is considered as an effective method for the treatment of idiopathic thoracic scoliosis,can avoid those disadvantages as compared with thoracotomy surgery.Common surgical procedures include anterior spinal release with intervertebral fusion and instrumentation through video-assisted thoracoscopic surgery (IVATS).This article reviewed the history,indications,contraindications,advantages,disadvantages and outcomes of VATS in the treatment of idiopathic thoracic scoliosis.

A Comparative Study of Lateral Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion in Degenerative Lumbar Spondylolisthesis

STUDY DESIGN: Level 4 retrospective review. PURPOSE: To compare the radiographic and clinical outcomes between posterior lumbar interbody fusion (PLIF) and lateral lumbar interbody fusion (LLIF) with posterior segmental spinal instrumentation (SSI) for degenerative lumbar spondylolisthesis. OVERVIEW OF LITERATURE: Both PLIF and LLIF have been performed for degenerative spondylolisthesis with good results, but no study has directly compared these two techniques so far. METHODS: The electronic medical and radiographic records of 78 matched patients were analyzed. In one group, 39 patients underwent PLIF with SSI at 41 levels (L3-4/L4-5), while in the other group, 39 patients underwent the LLIF procedure at 48 levels (L3-4/L4-5). Radiological outcomes such as restoration of disc height and neuroforaminal height, segmental lumbar lordosis, total lumbar lordosis, incidence of endplate fracture, and subsidence were measured. Perioperative parameters were also recorded in each group. Clinical outcome in both groups was assessed by the short form-12, Oswestry disability index and visual analogue scale scores. The average follow-up period was 16.1 months in the LLIF group and 21 months in the PLIF group. RESULTS: The restoration of disc height, foraminal height, and segmental lumbar lordosis was significantly better in the LLIF group (p<0.001). The duration of the operation was similar in both groups, but the average blood loss was significantly lower in the LLIF group (p<0.001). However, clinical outcome scores were similar in both groups. CONCLUSIONS: Safe, effective interbody fusion can be achieved at multiple levels with neuromonitoring by the lateral approach. LLIF is a viable treatment option in patients with new onset symptoms due to degenerative spondylolisthesis who have had previous lumbar spine surgery, and it results in improved sagittal alignment and indirect foraminal decompression.

Migration of Rod into Retroperitoneal Region: A Case Report and Review of the Literature

Spinal stabilization with fusion is the widely used method for traumatic or pathologic fracture of spine, spinal stenosis, and spondylolisthesis. Complications may emerge during or after the operations. Infection, hematoma and neurological deficits are early noticed findings. Screw and/or rod fractures present in long-term after surgery. Rod migration in out of the spinal column is a rare entity. A 67-year-old woman was visited our clinic for right leg pain. She had a previous spinal instrumentation surgery for spondylolisthesis in another center 6 years before. After radiological work-up, a distally migrated rod piece was observed in the retroperitoneal portion. The patient was operated for degenerative change; old instruments were replaced and extended to the L2 level with posterior spinal fusion. After the operation, her right leg pain improved. The asymptomatic migrated rod piece has regularly been followed clinically and radiologically, since then. Although it has rarely been reported, migration of the instrumentation material should be kept in mind. Spinal fixation without fusion makes the mechanical system vulnerable to motion effects of spine, especially in a degenerative and osteoporotic background. Long-term, even life-long follow-up is necessary for late term complications.

Anatomical variations and clinical relevance of dorsal sacral foramina in North Indians.

Lateral side of each intermediate crest has four dorsal sacral foramina for the passage of posterior division of the sacral nerves. Not only they serve as an important landmark in placement of spinal instrumentation but are also of great importance in transsacral block of sacral nerves for producing analgesia and anesthesia in pelvic surgeries. Therefore a study on the variation in number of dorsal sacral foramina was conducted in 60 adult dry North Indian sacra. Three dorsal sacral foramina were seen on the lateral side of each intermediate crest in four sacra (6.6%) and five in 6 sacra (10%) amongst all the sacra examined. Either a single pair, double pair or totally absent foramina were not observed in any of the sacra seen. This study revealed that there is variation in the number of dorsal sacral foramina. Anaesthetists should be aware of this disparity to be able to perform trans-sacral nerve block successfully. Radiologists must also know about this variation to interpret the radiographs of lumbosacral region. Neurologist and orthopedist should also be cognizant of this fact to diagnose patients presenting with bizarre clinical findings.

Cervical Pedicle Screw Placement in Sawbone Models and Unstable Cervical Traumatic Lesions by Using Para-Articular Mini-Laminotomy: A Novice Neurosurgeon's Experience / 대한신경손상학회지

OBJECTIVE: This retrospective study was conducted to analyze the novice neurosurgeon's experience of cervical pedicle screw placement by using the technique with direct exposure of pedicle via para-articular mini-laminotomy. METHODS: Fifteen sawbone models of subaxial spine were used (124 pedicles) to evaluate efficacy of repetitive training improving accuracy of cervical pedicle screw insertion. After that, we retrospectively reviewed 9 consecutive patients presented with traumatic cervical lesion. A total 38 cervical pedicle screws had been inserted. We analyzed the direction and grade of pedicle perforation on the postoperative computed tomography scan, and learning curve by using sawbone model. RESULTS: In sawbone model group, the correct position was found in 102 (82.3%) screws, and the incorrect position in 22 (17.7%) screws. The incidence of incorrect screw position was 26.9% in the initial 9 sawbone model, and 0% after that. Among the 38 screws inserted in 9 patients, the correct position was found in 36 (94.7%) screws, and the incorrect position in a 2 (5.3%) screw. There was no neurovascular complications related with cervical pedicle screw insertion. CONCLUSION: In vitro training to insert pedicle screw by using sawbone models could improve an accuracy of cervical pedicle screw placement by using this technique. Preliminary result revealed that cervical pedicle screw placement would be feasible and provide good clinical results in traumatic cervical lesions.

Valor predictivo de la estimulación eléctrica de los tornillos pediculares torácicos en la mal posición medial de los mismos en la instrumentación de cirugía de columna / Valor preditivo da estimulação elétrica em casos de mal posicionamento de parafusos pediculares torácicos na cirurgia de coluna / Predictive value of electrical stimulation in cases of malposition of thoracic pedicle screws in spine surgery

OBJETIVO: Demostrar si la técnica de estimulación eléctrica permite la detección de la mal posición medial de los tornillos pediculares torácicos. RESULTADOS: Se analizaron 421 tornillos torácicos. Tuvimos alertas a la estimulación en 25 (5,93%) de los casos. A todos los pacientes se les realizó radiografía posoperatoria demostrando 22 tornillos (5,2%) medializados. Realizamos TAC en 17 pacientes (37%), con ningún tornillo en posición 1 y 10 tornillos en posición 2 (8,5%). Se consideraron tornillos medializados los que tenían respuesta positiva a estimulación inferior a 6 mA. CONCLUSIONES: la estimulación eléctrica nos ha permitido reducir el riesgo de posición medial de los tornillos torácicos, minimizando además el uso de radiografía intraoperatoria.

OBJETIVO: Demonstrar se a técnica de estimulação elétrica permite a detecção de mal posicionamento medial dos parafusos pediculares torácicos. RESULTADOS: Foram analisados 421 parafusos torácicos. Os alertas da estimulação ocorreram em 25 (5,93%) dos casos. Todos os pacientes foram submetidos à radiografia pós-operatória que demonstrou 22 parafusos (5,2%) medializados. Realizamos TC axial em 17 pacientes (37%), e não se encontrou nenhum parafuso na posição 1, sendo que 10 parafusos estavam na posição 2 (8,5%). Foram considerados parafusos medializados os que apresentaram resposta positiva à estimulação inferior a 6 mA. CONCLUSÕES: a estimulação elétrica permitiu a redução de risco de posição medial dos parafusos torácicos, minimizando o uso de radiografias intraoperatórias.

OBJECTIVE: To demonstrate that the electrical stimulation technique allows the detection of medial malpositioning of thoracic pedicle screws. RESULTS: We analyzed 421 thoracic screws. Stimulation alerts occurred in 25 (5.93%) cases. All patients underwent postoperative radiographs showing 22 medialized screws (5.2%). Axial CT scans were performed on 17 patients (37%), and no screw was found in position 1 and 10 of them were in position 2 (8.5%). Medialized screws were considered those who had a positive response to stimulation of less than 6 mA. CONCLUSIONS: Electrical stimulation allowed a reduction of risk of medial positioning of thoracic screws, minimizing the use of intraoperative radiographs.

History of Spinal Deformity Surgery Part II: The Modern Era

Following Dwyer introduction of anterior spinal instrumented fusion surgery, Zielke, Moss-Miami, and Kaneda had made a significant progression on anterior spinal instrumented fusion which allowed excellent correction without significant loss of correction or implant failure. King and Moe deveoped classification of thoracic major curve following Harrington rod intrumentation. King classification presented a stable vertebra concept and selective fusion concept. Surgical classification of Adolescent Idiopathic Scoliosis (AIS) developed by Harms study group provided a more sophisticated two dimensional understanding of curve nature. Surgical intervention of adult scoliosis and sagittal imbalance is still challenging and evolving. Several evidences such as sacropelvic fixation and bone morphogenetic protein helped us to deal with adult deformity. The surgical decision making on spinal deformity surgery is still yet evolving.

Rod stiffness effect on adjacent segmental degeneration: a comparative long-term study.

Background: Adjacent segment disease (ASD) is a major complication following spinal instrumentation and fusion. The search for of the rod flexibility factors responsible for junctional degeneration is still ongoing. Objective: Determine the rod stiffness and ASD following posterior instrumentation and fusion for lumbar spine and find the proper rod diameter for adult spinal instrumentation for fusion. Subject and methods: Retrospective evaluation of all patients requiring spinal instrumentation to determine the different rod diameter that predispose toward junctional degeneration was completed. All patients requiring spinal instrumentation over a one-year period were studied retrospectively. One-hundred eight-seven patients (mean age 61.6 years) who had undergone decompression and fusion with pedicle screw instrumentation were evaluated. The average follow-up was 4.2 years. The average number of levels fused was 2.9 segments (range: 1-8). Adjacent spinal level pre- and post-operatively was determined on the plain X-rays. Junctional degeneration was defined as new episode of degeneration of the adjacent level on radiologic finding. Asymptomatic patients did not demonstrate junctional degeneration on the routine post-operative X-rays. Results: ASD developed in 15 (8.0%) out of 187 patients, including compression fractures (n=2), spinal stenosis (n=6), and symptomatic disc collapse (n=7). There was a close correlation between the posterior instrument stiffness and the development of ASD (p=0.011). For fusion and fixation with 5.5 mm and 6.0 mm rod diameter, ASD occurred in four (3.7%) out of 108 patients and in 11 (13.9 %) out of 79 patients, resepectively. The incidences of ASD were greater when the posterior instrument used were stiffer in lumbar spine fusion. The pre-operative age, gender, and indication for surgery were not associated with the development of ASD. Conclusion: The prevalence of symptomatic ASD relatively increased with increasing stiffness of spinal implant. The diameter of the longitudinal rod strongly affected the fixator loads, and influenced the stresses in the vertebral endplates. The rod diameter had influence on the stresses in the adjacent spinal motion segment.

Fracturas inestables de la columna vertebral: presentación de una serie de casos / Vertebral column unstable fractures: presentation of a case series

INTRODUCCIÓN. Este trabajo se realizó debido a la alta incidencia de lesiones vertebrales por traumatismos, con lesión medular o sin ella, observada en cuerpo de guardia del Hospital Enrique Cabrera. El objetivo fue documentar una serie de pacientes tratados por fracturas vertebrales inestables y valorar además su evolución clínica. MÉTODOS. Se realizó un estudio prospectivo de intervención de 15 pacientes con fracturas vertebrales inestables, atendidos entre el 1990 y el 2001. A todos los pacientes se les realizó estudio radiológico simple pre y posoperatorio, anteroposterior y lateral. Se registró el cuadro clínico neurológico pre y posoperatorio según la clasificación de Frankel. RESULTADOS. Predominó el sexo masculino (86,6 por ciento) y la edad promedio fue de 35,2 años. El segmento vertebral más afectado fue el T12-L1 y los mecanismos de producción de las lesiones predominantes fueron las caídas de altura y los accidentes automovilísticos. Se operaron en total 10 pacientes; todos fueron instrumentados y a 5 se les realizó descompresión de los elementos nerviosos. Se usaron técnicas como la instrumentación de Luque, corpectomía transpedicular e instrumentación de Luque, Harrington-Luque y descompresión anterior con osteosíntesis AO. Se obtuvieron buenos resultados en 6 pacientes, regulares en 2 y malos, en otros 2 pacientes. Como complicaciones se registraron la lesión de la duramadre y sepsis del sitio operatorio en un caso, y rotura de una de las varillas del Luque en otro paciente. CONCLUSIONES. La descompresión medular y la estabilización espinal, lo más tempranamente posibles, continúan siendo una necesidad

INTRODUCTION: Present paper was conducted due to the high incidence of traumatic vertebral lesions with medullary lesion or not present in patients seen in the Emergency Department of "Enrique Cabrera" Hospital. The aim of present paper was to verify a series of patients with unstable vertebral fractures and also to assess its clinical course. METHODS: An interventional prospective study was conducted in 15 patients presenting with unstable vertebral factures from 1990 to 2001. All patients underwent a lateral and preoperative and postoperative routine radiological study. According the Frankel's classification the preoperative and postoperative clinical picture was registered. RESULTS: There was a male sex predominance (86.6 percent) and mean age was of 35,2 years. The more involved vertebral segment was the T12-L1 and the mechanisms causing the predominant lesions were the height falls and the road accidents. Ten patients were operated on; in all there was instrumentation and in five we used decompression of nervous elements, as well as the Luque instrumentation, transpedicular corpectomy and Luque instrumentation, Harrington-Luque and anterior decompression with AO osteosynthesis. In six patients we achieved good results, regular in two and poor in other two patients. As complication were registered the dura mater and sepsis in the operative site in a case and a rupture in one of the Luque wires in other patient. CONCLUSIONS: Early medullary decompression and spinal stabilization are very necessary

INTRODUCTION. Ce travail est dû à la haute incidence de lésions vertébrales traumatiques, avec lésion médullaire ou pas, trouvée au Service d'urgence de l'hôpital « Enrique Cabrera ». Le but de ce travail a été d'examiner une serie de patients atteints des fractures vertébrales instables, et d'évaluer aussi leur évolution clinique.MÉTHODES. Une étude prospective d'intervention de 15 patients atteints de fractures vertébrales instables, traités entre 1990 et 2001, a été réalisée. Tous les patients ont subi des examens radiologiques simples pré et postopératoires, antéro-postérieurs et latéraux. Un tableau clinique neurologique pré et postopératoire a été créé d'après la classification de Frankel.RÉSULTATS. La prédominance du sexe masculin a été significative (86,6%), et l'âge moyen a été 35,2 ans. Le segment vertébral T12-L1 a été le plus lésé, et les lésions ont été notamment causées par des chutes et des accidents de route. Un total de 10 patients ont été opérés; tous ont été appareillés, et cinq ont subi une décompression nerveuse. Les techniques utilisées ont été l'instrumentation de Luque, la corpectomie transpédiculaire et l'instrumentation de Luque, d'Harrington-Luque et la décompression antérieure à ostéosynthèse AO. On a obtenu des résultats satisfaisants chez 6 patients, des résultats passables chez 2, et des résultats desfavorables chez les autres 2 patients. Parmi les complications on a rencontré la lésion de la dure-mère et l'infection du site opératoire dans un cas, et la rupture d'une des tiges de Luque dans un autre cas.CONCLUSIONS. La décompression médullaire et la stabilisation spinale, réalisées le plus tôt que possible, continuent à être une nécessité

Surgical Treatment of Craniovertebral Junction Instability : Clinical Outcomes and Effectiveness in Personal Experience

OBJECTIVE: Craniovertebral junction (CVJ) consists of the occipital bone that surrounds the foramen magnum, the atlas and the axis vertebrae. The mortality and morbidity is high for irreducible CVJ lesion with cervico-medullary compression. In a clinical retrospective study, the authors reviewed clinical and radiographic results of occipitocervical fusion using a various methods in 32 patients with CVJ instability. METHODS: Thirty-two CVJ lesions (18 male and 14 female) were treated in our department for 12 years. Instability resulted from trauma (14 cases), rheumatoid arthritis (8 cases), assimilation of atlas (4 cases), tumor (2 cases), basilar invagination (2 cases) and miscellaneous (2 cases). Thirty-two patients were internally fixed with 7 anterior and posterior decompression with occipitocervical fusion, 15 posterior decompression and occipitocervical fusion with wire-rod, 5 C1-2 transarticular screw fixation, and 5 C1 lateral mass-C2 transpedicular screw. Outcome (mean follow-up period, 38 months) was based on clinical and radiographic review. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score. RESULTS: Nine neurologically intact patients remained same after surgery. Among 23 patients with cervical myelopathy, clinical improvement was noted in 18 cases (78.3%). One patient died 2 months after the surgery because of pneumonia and sepsis. Fusion was achieved in 27 patients (93%) at last follow-up. No patient developed evidence of new, recurrent, or progressive instability. CONCLUSION: The authors conclude that early occipitocervical fusion to be recommended in case of reducible CVJ lesion and the appropriate decompression and occipitocervical fusion are recommended in case of irreducible craniovertebral junction lesion.

La corpectomía transpedicular en fracturas de columna toracolumbar / Transpedicular vertebrectomy in thoracolumbar spine fractures / La corpectomie transpédiculaire dans les fractures du rachis thoraco-lombaire

INTRODUCCIÓN. El objeto de este estudio fue analizar la evolución clínica de una serie de pacientes con fracturas vertebrales postraumáticas y trastornos neurológicos añadidos, operados mediante la técnica de corpectomía transpedicular, y relacionar además esta evolución con el tiempo preoperatorio transcurrido. MÉTODOS. Se realizó un estudio prospectivo de intervención, de 18 pacientes con paraplejia postraumática, a los cuales se les realizó descompresión medular por corpectomía transpedicular e instrumentación con la técnica de Luque. Los pacientes fueron atendidos entre 1987 y 1989 en el Hospital «Hermanos Ameijeiras¼. RESULTADOS. De 15 pacientes que no deambulaban, 9 recuperaron esa función (60 %). No se halló relación entre el tiempo de la lesión y la recuperación neurológica. La complicación más frecuente fue la infección, y hubo un fallecido. El tiempo promedio de duración de la lesión fue de 11,7 meses, y el tiempo promedio de evolución posoperatoria fue de 10,7 meses. CONCLUSIONES. Se concluyó que la descompresión del canal y la instrumentación vertebral en pacientes con lesiones medulares postraumáticas puede mejorar el estado neurológico de éstos, independientemente del tiempo de lesión preoperatorio.

INTRODUCTION: The aim of present study was to analyze the clinical course of a group of patients presenting with post-traumatic vertebral fractures and added neurologic disorders operated on by transpedicular vertebrectomy and to relate this course to intervening preoperative time. METHODS: An interventional and descriptive study was conducted in 18 patients presenting with post-traumatic paraplegia underwent medullar decompression by transpedicular vertebrectomy and instrumentation using Luque’s technique. Patients were seen in “Hermanos Ameijeiras” Clinical Surgical Hospital from 1987 to 1989. RESULTS: From 15 non-ambulatory patients 9 recovered that function (60%). There was not relation between the lesion time and neurologic recovery. The more frequent complication was the infection with deceased patient. Mean time of lesion duration was of 11,7 months, and the mean time of postoperative course was of 10,7months. CONCLUSIONS: We conclude that canal decompression and vertebral instrumentation in patients presenting with post-traumatic lesions, can to improve the neurologic status independently of preoperative lesion time.

INTRODUCTION. Le but de cette étude est d'analyser l'évolution clinique d'une série de patients atteints de fractures vertébrales post-traumatiques et de troubles neurologiques qui ont été opérés par la technique de corpectomie transpédiculaire, et d'associer aussi cette évolution au temps préopératoire écoulé. MÉTHODES. Une étude prospective de 18 patients atteints de paraplégie post-traumatique et traités par décompression médullaire (corpectomie transpédiculaire et instrumentation), selon la technique de Luque, a été réalisée. Les patients ont été soignés entre 1987 et 1989 à l'Hôpital “Hermanos Ameijeiras”. RÉSULTATS. Neuf patients sur quinze ont récupéré cette fonction (60%). Il n'y a pas eu de relation entre le temps de la lésion et la récupération neurologique. La complication la plus fréquente a été l'infection, et un patient est décédé. Le temps moyen de la lésion a été 11,7 mois tandis que le temps moyen de l'évolution postopératoire a été 10,7 mois. CONCLUSIONS. On a conclu que la décompression du canal et la instrumentation rachidienne chez des patients atteints des lésions médullaires post-traumatiques peuvent améliorer leur état neurologique, indépendemment du temps préopératoire de la lésion.

Anterior Interbody Grafting and Instrumentation for Advanced Spondylodiscitis

OBJECTIVE: To evaluate the surgical outcomes of ventral interbody grafting and anterior or posterior spinal instrumentation for the treatment of advanced spondylodiscitis in patients who had failed medical management. METHODS: A total of 28 patients were evaluated for associated medical illness, detected pathogen, level of involved spine, and perioperative complications. Radiological evaluation including the rate of bony union, segmental Cobb angle, graft- and instrumentation-related complications, and clinical outcomes by mean Frankel scale and VAS score were performed. RESULTS: There are 14 pyogenic spondylodiscitis, 6 postoperative spondylodiscitis, and 8 tuberculous spondylodiscitis. There were 21 males and 7 females. Mean age was 51 years, with a range from 18 to 77. Mean follow-up period was 10.9 months. Associated medical illnesses were 6 diabetes, 3 pulmonary tuberculosis, and 4 chronic liver diseases. Staphylococcus was the most common pathogen isolated (25%), and Mycobacterium tuberculosis was found in 18% of the patients. Operative approaches, either anterior or posterior spinal instrumentation, were done simultaneously or delayed after anterior aggressive debridement, neural decompression, and structural interbody bone grafting. All patients with neurological deficits improved after operation, except only one who died from aggravation as military tuberculosis. Mean Frankel scale was changed from 3.78+/-0.78 preoperatively to 4.78+/-0.35 at final follow up and mean VAS score was improved from 7.43+/-0.54 to 2.07+/-1.12. Solid bone fusion was obtained in all patients except only one patient who died. There was no need for prolongation of duration of antibiotics and no evidence of secondary infection owing to spinal instrumentations. CONCLUSION: According to these results, debridement and anterior column reconstruction with ventral interbody grafting and instrumentation is effective and safe in patients who had failed medical management and neurological deficits in advanced spondylodiscitis.

Comparison between posterior lumbar fusion with pedicle screws and posterior lumbar interbody fusion with pedicle screws in adult spondylolisthesis

The purpose of this study was to compare patients with lumbar spondylolisthesis submitted to two different surgical approaches, and evaluate the results and outcomes in both groups. In a two-year period, 60 adult patients with lumbar spondylolisthesis, both isthmic and degenerative, were submitted to surgery at the Biocor Institute, Brazil. All patients were operated on by the same surgeon (FLRD) in a single institution, and the results were analyzed prospectively. Group I comprised the first 30 consecutive patients that were submitted to a posterior lumbar spinal fusion with pedicle screws (PLF). Group II comprised the last 30 consecutive patients submitted to a posterior lumbar interbody fusion procedure (PLIF) with pedicle screws. All patients underwent foraminotomy for nerve root decompression. Clinical evaluation was carried out using the Prolo Economic and Functional Scale and the Rolland-Morris and the Oswestry questionnaire. Mean age was 52.4 for Group I (PLF), and 47.6 for Group II (PLIF). The mean follow-up was 3.2 years. Both surgical procedures were effective. The PLIF with pedicle screws group presented better clinical outcomes. Group I presented more complications when compared with Group II. Group II presented better results as indicated in the Prolo Economic and Functional Scale.

O objetivo foi comparar dois grupos de pacientes portadores de espondilolistese lombar que foram submetidos a dois procedimentos cirúrgicos distintos, avaliando os resultados clínicos levando em consideração a qualidade de vida. Durante o período de 1998 a 2001 sessenta pacientes portadores de espondilolistese da coluna lombar ístmica e degenerativa foram submetidos a tratamento cirúrgico no Hospital Biocor em Belo Horizonte, por um mesmo cirurgião foram analisados prospectivamente. Os primeiros trinta pacientes foram submetidos a fusão posterior com parafusos pediculares e os trinta seguintes a fusão posterior com parafusos pediculares associada a fusão intersomática posterior. Os pacientes foram submetidos a liberação radicular com laminectomia e foraminotomia. A avaliação clínica foi feita utilizando as escalas de Prolo Econômico e Funcional, o questionário de Rolland-Morris e de Oswestry. Os resultados clínicos apresentaram que os dois procedimentos realizados foram eficazes. Houve maior número de complicações relacionadas com a biomecânica no grupo que foi submetido somente à fusão posterior e o grupo submetido à fusão posterior associada a fusão intersomática apresentou melhores resultados com retorno as atividades diárias e melhora da qualidade de vida.

A Clinical Analysis of Surgical Treatment for Spontaneous Spinal Infection

OBJECTIVE: The purpose of the study was to determine the clinical effects of anterior radical debridement on a series of patients with spontaneous spinal infection. METHODS: We retrospectively analyzed the clinical characteristics of 32 patients who underwent surgical treatment from January 2000 to December 2005 in our department. The average follow-up Period was 33.4 months (range, 6 to 87 months). Thirty-two patients presented with the following : 23 cases with pyogenic spondylitis, eight with tuberculous spondylitis and one with fungal spondylitis. The indications for surgery were intractable pain, failure of medical management, neurological impairment with or without an associated abscess, vertebral destruction causing spinal instability and/or segmental kyphosis. RESULTS: The study included 15 (46.9%) males and 17 (53.1%) females ranging in age from 26 to 75 years (mean, 53.1 years). Diabetes mellitus (DM) and pulmonary Tbc were the most common predisposing factors for pyogenic spondylitis and tuberculous spondylitis. Staphylococcus aureus (13%) was the main organism isolated. The most prevalent location was the lumbar spine (75%). Changes in the pain score, Frankel's classification, and laboratory parameters demonstrated a significant clinical improvement in all patients. However, there were recurrent infections in two patients with tuberculous spondylitis and inappropriate debridement and intolerance of medication and noncompliance. Autologous rib, iliac bone and allograft (fibular) were performed in most patients. However, 10 patients were grafted using a titanium mesh cage after anterior radical debridement. There were no recurrent infections in the 10 cases using the mesh cage with radical debridement. CONCLUSION: The findings of this study indicate that surgery based on appropriate surgical indications is effective for the control of spinal infection and prevention of recurrence with anterior radical debridement, proper drug use and abscess drainage.

Thoracic Fracture-Dislocations Without Spinal Cord Injury: Two Cases Reports / 대한척추외과학회지

Thoracic fracture-dislocations reportedly lead to an 80% incidence of complete paraplegia. Thus, thoracic fracture-dislocations without cord injury are uncommon. There are a few cases of thoracic fracture-dislocations in which the neural sparing status was associated with separation of the posterior spinal structures, such as the pedicles and laminae. The authors experienced two cases of thoracic fracture-dislocations without spinal cord injury: one was a 50-year-old man who fell from the fourth floor of a building and sustained a T6-7 fracture-dislocation; and the other was a 43-year-old man who was involved in motorcycle accident and sustained a T12 fracture-dislocation. Segmental spinal instrumentation and fusion without open reduction was performed in each of the two cases and there has not been any abnormality detected on neurological examination at a minimum follow-up period of 2 years.

The Influence of Fixation Rigidity on Intervertebral Joints - An Experimental Comparison between a Rigid and a Flexible System

OBJECTIVE: Spinal instrumentation without fusion often fails due to biological failure of intervertebral joints (spontaneous fusion, degeneration, etc). The purpose of this study is to investigate the influence of fixation rigidity on viability of intervertebral joints. METHODS: Twenty pigs in growing period were subjected to posterior segmental fixation. Twelve were fixed with a rigid fixation system(RF) while eight were fixed with a flexible unconstrained implant(FF). At the time of the surgery, a scoliosis was created to monitor fixation adequacy. The pigs were subjected to periodic radiological examinations and 12pigs (six in RF, six in FF) were euthanized at 12-18months postoperatively for analysis. RESULTS: The initial scoliotic curve was reduced from 31+/-5degrees to 27+/-8degrees in RF group (p=0.37) and from 19+/-4degrees to 17+/-5degrees in FF group (p=0.21). Although severe disc degeneration and spontaneous fusion of facet joints were observed in RF group, disc heights of FF group were well maintained without major signs of degeneration. CONCLUSION: The viability of the intervertebral joints depends on motion spinal fixation. Systems allowing intervertebral micromotion may preserve the viability of intervertebral discs and the facet joint articular cartilages while maintaining a reasonably stable fixation.