Discectomía, artrodesis intersomática y estabilización en mielopatía espondilótica cervical. Presentación de un caso / Discectomy, artrodesis and stabilization in cervical spondylotic myelopathy. Presentation of a case

RESUMEN Las alteraciones degenerativas de la columna se engloban en el término de espondilosis cervical. La mielopatía espondilótica cervical (MEC) es la forma más común de disfunción del cordón espinal en mayores de 55 años. Se considera la intervención quirúrgica en la mayoría de los casos de mielopatía cervical espondilótica evidente desde el punto de vista clínico, dado el riesgo de deterioro neurológico. En la mayoría de los casos de mielopatía cervical, la descompresión de la médula espinal genera estabilización o mejoría de la función de los haces largos medulares. La función es mejor cuando se restablecen bien las dimensiones del conducto vertebral después de la descompresión, cuando la descompresión es más precoz y cuando no hay comorbilidad considerable.

ABSTRACT The degenerative alterations of the column are included in the term of cervical espondilosis. The cervical spondylotic myelopathy it is the form more common of disfuntion of the spinal cord in bigger than 55 years. It is considered the surgical intervention in most of the cases of cervical spondylotic myelopathy evident from the clinical, given point of view the risk of neurological deterioration. In most of the cases of cervical myelopathy, the decompression of the spinal marrow generates stabilization or improvement of the function of the medullary long sheaves. The function is better when they recover well the dimensions of the vertebral conduit after the decompression, when the decompression is more precocious and when there is not considerable comorbility.

Inflammatory biomarkers in sera of patients with intervertebral disc degeneration / Biomarcadores inflamatórios no plasma de pacientes com degeneração do disco intervertebral

ABSTRACT Objective: To evaluate intervertebral disc levels of inflammatory factor (interleukin 6) and proteinase activity (cathepsin B) in patients with a degenerative disease and serum levels of interleukin 6, serum cathepsin B activity and hyaluronic acid biomarkers. Methods: We conducted immunohistochemistry studies of intervertebral discs to analyze interleukin 6 and cathepsin B levels of patients with degenerative disease and spine fracture (Control Group) and to measure hyaluronic acid, interleukin 6 and cathepsin B activity from sera of intervertebral disc degeneration patients, fracture patients, and healthy individuals. Results: Interleukin 6 and cathepsin B seem to be related with physiopathology of intervertebral disc degeneration, since the levels of both were higher in discs of patients with intervertebral disc degeneration. Interleukin 6 and cathepsin B do not represent good biomarkers of degenerative intervertebral disc disease, since the level of such compounds is increased in the plasma of patients with fractures. Conclusion: Hyaluronic acid can be a biomarker for intervertebral disc degeneration, because hyaluronic acid levels were higher only in sera of patients with intervertebral disc degeneration.

RESUMO Objetivo: Avaliar os níveis de fatores inflamatórios nos discos intervertebrais (interleucina 6) e proteinase (catepsina B) em pacientes com doença degenerativa de disco intervertebral, além de verificar os níveis séricos de interleucina 6, ácido hialurônico e atividade sérica da catepsina B. Métodos: Foi realizado exame imuno-histoquímica dos discos intervertebrais de pacientes com doença degenerativa e fratura da coluna (Grupo Controle) e análise do plasma de pacientes com doença degenerativa de disco intervertebral. Como controle, foram utilizados plasma de pacientes com fraturas, além de indivíduos saudáveis. Resultados: Interleucina 6 e catepsina B sugerem relação com a fisiopatologia da doença degenerativa de disco intervertebral, uma vez que os níveis de ambos foram maiores nos discos de pacientes com doença degenerativa de disco intervertebral. Interleucina 6 e catepsina B não representam bons biomarcadores da doença degenerativa do disco intervertebral, já que também encontram níveis aumentados em plasma de pacientes com fratura. Conclusão: O ácido hialurônico é um possível biomarcador de doença degenerativa de disco intervertebral, porque os níveis de ácido hialurônico foram maiores apenas em plasma de pacientes com doença degenerativa de disco intervertebral.

Trasplante autólogo de células madre de médula ósea al disco intervertebral / Autologous bone marrow stem cells transplant to intervertebral disc / Autogreffe de cellules souches de la moelle osseuse au disque intervertébral

INTRODUCCIÓN: se realizó el trasplante de células madre en siete pacientes diagnosticados con enfermedad degenerativa de un solo disco intervertebral. OBJETIVO: evaluar la seguridad del proceder y la tolerancia a las células trasplantadas. MÉTODOS: las células fueron extraídas de medula ósea del propio paciente, aisladas por el método de Ficoll-Hypaque e implantadas en los discos seleccionados como grados II y III de la clasificación de Pfirrmann por imágenes de resonancia. Se evaluaron los resultados al año del injerto. RESULTADOS: no se registraron eventos adversos importantes derivados del procedimiento ni del injerto de células. Con la utilización del índice de Oswestry se evaluaron los resultados clínicos como beneficiosos, así como la posible mejoría en las imágenes de resonancia magnética antes y un año después. CONCLUSIÓN: los resultados demuestran que las células madre obtenidas de médula ósea del propio paciente pueden ser trasplantadas de manera segura, con excelente tolerancia y sin complicaciones usando el método descrito.

INTRODUCTION: stem cell transplant was performed in seven patients diagnosed with degenerative one intervertebral disc. OBJECTIVE: evaluate the safety and tolerance of the procedure to transplanted cells. METHODS: cells were extracted from the patient's own bone marrow. They were isolated by the Ficoll-Hypaque method and they were implemented in discs selected as grades II and III according to Pfirrmann classification resonance imaging. Graft outcomes were evaluated one year later. RESULTS: no significant adverse events were recorded from the procedure or graft cells. By using the Oswestry index, clinical outcomes were evaluated as beneficial, as well as the possible improvement in images from magnetic resonance imaging before and a year later. CONCLUSION: these results show that stem cells derived from the patient's own bone marrow can be safely transplanted with excellent tolerance and no complications using the method described.

INTRODUCTION: une greffe de cellules souches a été réalisée chez sept patients diagnostiqués de maladie dégénérative sur un seul disque intervertébral. OBJECTIF: le but de cette étude est d'évaluer cette procédure et la tolérance aux cellules transplantées. MÉTHODES: les cellules proviennent de la moelle osseuse du patient lui-même, isolées par la méthode de Ficoll-Hypaque et implantées au niveau des disques en grade II et III selon classification RM de Pfirrmann. Les résultats ont été évalués un an après la transplantation. RÉSULTATS: il n'y a pas eu de complications importantes au cours de l'opération ni de la greffe de cellules. Au moyen de l'indice d'Oswestry, les résultats cliniques ont été classifiés de bons ; une amélioration potentielle des images par RM a été aussi remarquée avant et après un an. CONCLUSIONS: les résultats montrent que les cellules souches prélevées de la moelle osseuse du propre patient peuvent être transplantées de manière sure, avec une tolérance excellente, et sans complications, en utilisant la méthode décrite.

MRI Measurement of Neuroforaminal Dimension at the Index and Supradjacent Levels after Anterior Lumbar Interbody Fusion: A Prospective Study

BACKGROUND: Anterior interbody fusion has previously been demonstrated to increase neuroforaminal height in a cadaveric model using cages. No prior study has prospectively assessed the relative change in magnetic resonance imaging (MRI) demonstrated neuroforaminal dimensions at the index and supradjacent levels, after anterior interbody fusion with a corticocancellous allograft in a series of patients without posterior decompression. The objective of this study was to determine how much foraminal dimension can be increased with indirect foraminal decompression alone via anterior interbody fusion, and to determine the effect of anterior lumbar interbody fusion on the dimensions of the supradjacent neuroforamina. METHODS: A prospective study comparing pre- and postoperative neuroforaminal dimensions on MRI scan among 26 consecutive patients undergoing anterior lumbar interbody fusion without posterior decompression was performed. We studies 26 consecutive patients (50 index levels) that had undergone anterior interbody fusion followed by posterior pedicle screw fixation without distraction or foraminotomy. We used preoperative and postoperative MRI imaging to assess the foraminal dimensions at each operated level on which the lumbar spine had been operated. The relative indirect foraminal decompression achieved was calculated. The foraminal dimension of the 26 supradjacent untreated levels was measured pre- and postoperatively to serve as a control and to determine any effects after anterior interbody fusion. RESULTS: In this study, 8 patients underwent 1 level fusion (L5-S1), 12 patients had 2 levels (L4-S1) and 6 patients had 3 levels (L3-S1). The average increase in foraminal dimension was 43.3% (p 0.05). CONCLUSIONS: Anterior interbody fusion with a coriticocancellous allograft can significantly increase neuroforaminal dimension even in the absence of formal posterior distraction or foraminotomy; anterior interbody fusion with a coriticocancellous allograft has little effect on supradjacent neuroforaminal dimensions.

Degenerative disc disease of the lumbar spine on MRI / La enfermedad degenerativa del disco de la espina lumbar en IRM

A retrospective analysis was done of all patients referred for MRI of the lumbar spine at the University Hospital of the West Indies, Kingston, Jamaica, during the three-year period January 1, 2005 and December 31, 2007. Data were collected to determine patients' age, gender, weight and the presence or absence of degenerative disc disease (DDD). The patients' presenting symptoms were not evaluated. There were 362 patients examined: 154 males, 204 females and four uncharacterized, aged between 8 and 87 (mean age = 50.45) years. Degenerative Disc Disease (DDD), was found in 283 (78.2%) patients: 121 males, 159 females and three unidentified, with a total of 669 degenerate discs. L 4/5 and L 5/S 1 were most frequently affected accounting for 31.2% and 30.6% of degenerate discs respectively. Patients with DDD were significantly heavier and significantly older than patients without disc disease. Gender was not predictive of DDD in general nor of involvement of any particular disc though a marginally significant tendency was found for males to more frequently have DDD at L1/2 and L5/S1. CONCLUSION: Degenerative disc disease of the lumbar spine occurred more frequently in older and heavier patients. Gender did not affect the presence or the extent of the disease; compared to females, males showed a marginally increased tendency to have DDD at L1/2 and L5/S1.

Se realizó un análisis retrospectivo de todos los pacientes remitidos para IRM de la espina lumbar en el Hospital Universitario de West Indies, Kingston, Jamaica, durante el periodo de tres años comprendido de enero 1 de 2005 a diciembre 31 de 2007. Se recogieron datos de los pacientes a fin de determinar su edad, género, peso y la presencia o ausencia de la enfermedad degenerativa del disco (EDD). Los síntomas presentes en los pacientes no fueron evaluados. Se examinaron 362 pacientes: 154 varones, 204 hembras y cuatro no caracterizados, de edades entre 8 y 87 (edad promedio = 50.45) años. La enfermedad degenerativa del disco (EDD) se halló en 283 (78.2%) pacientes: 121 varones, 159 hembras y tres no identificados, para un total de 669 discos degenerados. L 4 /5 y L 5 / S 1 fueron los más frecuentemente afectados, representando el 31.2% y 30.6% de los discos degenerados, respectivamente. Los pacientes con EDD tenían significativamente más peso y mayor edad que aquellos sin la enfermedad del disco. El género no era en general predictivo de EDD ni de involucración de disco alguno en particular, si bien se halló marginalmente una tendencia significativa a una mayor frecuencia en la manifestación de EDD en L1 / 2 y L5 / S1 entre los varones CONCLUSIÓN: La enfermedad degenerativa del disco de la espina lumbar se presentó en pacientes de mayor edad y mayor peso. El género no afectó la presencia o la magnitud de la enfermedad. Sin embargo, en comparación con las hembras, los varones mostraron una tendencia marginalmente mayor a presentar EDD en L1/2 y L5/S1.

Estudo comparativo dos mecanorreceptores dos discos intervertebrais normais e degenerados da coluna lombar de humanos pela radiografia, ressonância magnética e estudo anatomopatológico / Comparative study of normal and degenerated intervertebral discs' mechanoreceptors of human lumar spine X-ray, magnetic resonance and anatomopathologic study

Os autores fizeram um estudo da coluna lombar de humanos, objetivando avaliar e determinar os diferentes tipos de fibras nervosas no disco intervertebral normal e no degenerado. Foram usadas dez colunas lombares de cadáveres com aproximadamente 48 a 72 horas de óbito. As peças foram submetidas a exames de radiografia simples e ressonância magnética. Após os exames, os discos foram classificados em normais e degenerados. Em seguida, foram dissecados, divididos em regiões anterior e posterior, incluídos em parafina e realizado estudo de imuno-histoquímica com a proteína S100. Com o auxílio de um programa de computador Image-Pro Plus (media cybernetics®), as fibras nervosas tiveram seu diâmetro medidos em micrômetros e classificadas em quatro tipos de fibras. Foram encontrados quatro tipos de fibras nervosas nas diferentes regiões discais. O número e o tipo de fibras variaram de acordo com a região e grau de degeneração do disco intervertebral. Concluíram que as fibras do tipo III são mais freqüentes na região anterior; as fibras dos tipos II e IV são mais freqüentes na região posterior, e as fibras do tipo I não apresentaram diferenças entre a região anterior e a posterior; além disso, o disco degenerado tem mais fibras nervosas que o disco normal.

The authors conducted a study on human lumbar spine, aiming to assess and determine the different kinds of nervous fibers in normal and degenerated intervertebral discs. Ten cadavers lumbar spines with approximately 48 - 72 of death have been used. The pieces were submitted to simple X-ray and magnetic resonance tests. Subsequently to the tests, discs were divided into normal and degenerated. Then, they were dissected, divided into anterior and posterior according to the region, included in paraffin and an immunohistochemical study with S100 protein was performed. With the aid of Image-Pro Plus computer software (media cybernetics) ®, nervous fibers diameters were measured as micrometers and classified into four kinds of fibers. Four types of nervous fibers were found on different disc regions. The number and kind of fibers varied according to the region and degree of intervertebral disc degeneration. It was concluded that type-III fibers are more common at the anterior region; type-II and type-IV fibers are more common at the posterior region, and type-I fibers do not show any differences regarding anterior and posterior regions; in addition, a degenerated disc has a higher number of nervous fibers than a normal one.