Management of spinal gunshot wound injuries / Manejo das lesões por arma de fogo na coluna vertebral / Manejo de lesiones por arma de fuego en la columna

ABSTRACT Objectives Elaborate a care protocol for spinal gunshot wounds (GSWs), based on the experience of more than fifteen years of treating this type of injury. Methods A retrospective cross-sectional analysis of the electronic medical record data of a tertiary hospital related to the treatment of spinal GSWs between January 2002 and January 2018. Results The management proposed was applied to 700 patients. Epidemiological data collected describes the population served. Conclusions An easy-to-use treatment flowchart was developed that, according to factors related to the neurological condition, projectile location, lesion stability and additional criteria, allows the objective determination of the best treatment option for each case. Level of evidence II; Retrospective Study.

RESUMO Objetivos Elaborar um protocolo de atendimento para ferimentos por arma de fogo (FAF) na coluna vertebral, com base na experiência de mais de quinze anos de atendimento desse tipo de lesão. Métodos Realizou-se uma análise transversal retrospectiva dos dados do prontuário eletrônico de um hospital terciário referentes ao atendimento de FAF na coluna vertebral entre janeiro de 2002 e janeiro de 2018. Resultados O manejo proposto foi aplicado a 700 pacientes. Os dados epidemiológicos coletados mostram a população atendida. Conclusões Foi elaborado um fluxograma de tratamento de uso fácil que, de acordo com fatores relacionados com o quadro neurológico, a localização do projétil, a estabilidade da lesão e critérios adicionais, permite determinar objetivamente a melhor opção de tratamento para cada caso. Nível de evidência II; Estudo Retrospectivo.

RESUMEN Objetivos Desarrollar un protocolo de atención a las heridas por arma de fuego (HAF) en la columna vertebral, basado en la experiencia de más de quince años en la atención a este tipo de lesiones. Métodos Se realizó un análisis transversal retrospectivo de los datos de la historia clínica electrónica de un hospital terciario sobre la atención en casos de HAF en la columna vertebral entre enero de 2002 y enero de 2018. Resultados Se aplicó el tratamiento propuesto a 700 pacientes. Los datos epidemiológicos recopilados muestran la población atendida. Conclusiones Se desarrolló un diagrama de flujo de tratamiento de fácil de usar que, de acuerdo a factores relacionados con la condición neurológica, ubicación del proyectil, estabilidad de la lesión y criterios adicionales, permite determinar objetivamente la mejor opción de tratamiento para cada caso. Nivel de evidencia II; Estudio Retrospectivo.

Colgajo muscular de esternocleidomastoídeo para el manejo de perforación esofágica tardía: reporte de dos casos / Muscle flap of sternocleidomastoid for the management of late esophageal perforation: report of two cases

Resumen Introducción: La perforación esofágica es una complicación poco frecuente en la cirugía de columna cervical por vía anterior, sin embargo, puede tener graves consecuencias cuando hay demoras en diagnóstico y tratamiento. Casos Clínicos: Presentamos dos casos clínicos de pacientes con perforación esofágica secundaria a cirugía de columna cervical por vía anterior. Se usaron para su reparación colgajo muscular de esternocleidomastoideo (ECM). Conclusión: La perforación esofágica secundaria a cirugía de columna cervical es poco frecuente, variable desde el punto de vista clínico, el TC y estudio radiológico contrastado son fundamentales en el diagnóstico de esta patología. El colgajo muscular ECM en estos casos es una herramienta fiable y extremadamente útil debido a sus características anatómicas, fácil disección quirúrgica y baja morbilidad asociada.

Introduction: Esophageal perforation is a rare complication in cervical spine surgery by anterior way, however it can have serious consequences when there are delays in diagnosis and treatment. Cases Report: We present two clinical cases of patients with esophageal perforation secondary to cervical spine surgery by anterior way. Sternocleido-mastoid muscle flaps were used for repair. Conclusion: Esophageal perforation secondary to cervical spine surgery is rare, clinically variable, CT and radiologic study are fundamental in the diagnosis of this pathology. The Sternocleidomastoid muscle flap in these cases is a reliable and extremely useful tool due to its anatomical characteristics, easy surgical dissection and low associated morbidity.

Outcome Evaluation of Patients with Burst Thoracolumbar Fractures: A Case Series

Objective The aim of the present study was to evaluate the outcome of short segment instrumentation in patients affected by burst thoracolumbar fractures. Methods A total of 19 patients with unstable burst fractures of the thoracolumbar spine were eligible for short segment instrumentation. Their functional outcome (by using the Oswestry and Denis scales) and back pain (using the visual analog scale) were evaluated after 12 months. Results Themean age of the patients was 30.7 years old, andmost of them weremale (n » 15). The mean hospital stay was 4.6 days. The mean standard deviation (SD) of the pain score according to the visual analog scale was 1.63 1.25 after 12 months of surgery, and there were no patients classified with grades 4 or 5 on the Denis work scale. The average Oswestry disability index (ODI) was 17% during the follow-ups. Conclusions The outcome of the studied patients, including the clinical pain and the functional outcome of postsurgical patients, suggested that the short-segment instrumentation could be an appropriate method for patients with unstable thoracolumbar junction fractures. However, a long-term follow-up is recommended.

Reliability and safety of a new upper cervical spine injury treatment algorithm / Avaliação de reprodutibilidade e segurança de um novo algoritmo de tratamento das lesões cervicais altas

ABSTRACT In the present study, we evaluated the reliability and safety of a new upper cervical spine injury treatment algorithm to help in the selection of the best treatment modality for these injuries. Methods Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer) using the Kappa index. Results The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons’ personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agreement with the treatment actually performed was obtained in more than 89% of the cases. Conclusion The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.

RESUMO Avaliamos a reprodutibilidade e segurança do algoritmo Upper Cervical Spine Injuries Treatment Algorithm (UCITA) recém proposto para a escolha do tratamento das lesões traumáticas da junção crânio-cervical. Métodos Trinta casos previamente tratados de acordo com o algoritmo foram apresentados a quatro cirurgiões de coluna, sendo questionada a conduta pessoal dos mesmos e a conduta segundo a aplicação do algoritmo. Após 4 semanas, foram refeitas as mesmas perguntas para avaliar a reprodutibilidade (intra e interobservador) do algoritmo, através do índice estatístico “Kappa”. Resultados A reprodutibilidade da conduta com o uso do algoritmo foi superior a reprodutibilidade da conduta pessoal dos cirurgiões. Com o uso do UCITA, a concordância do tratamento realmente efetivado foi encontrada em mais de 89% dos casos. Conclusão O uso do UCITA foi seguro e reprodutível, podendo ser usado como ferramenta auxiliar na tomada de decisão entre tratamento cirúrgico versus conservador dos traumatismos da junção crâniocervical.

Perfil epidemiológico dos pacientes com fratura da coluna cervical tratados cirurgicamente no serviço de neurocirurgia do Hospital de Base do Distrito Federal (Brasília, Brasil) / Epidemiological Profile of Patients with Cervical Spine Fractures Treated Surgically in the Neurosurgery Service at Hospital de Base do Distrito Federal (Brasília, Brazil)

Introdução As fraturas cervicais correspondem a um grande espectro de lesões. Em alguns trabalhos a coluna cervical é o segmento mais acometido nas fraturas vertebrais, representando cerca de 45-60% de todos os casos. Apresentamos o perfil epidemiológico de 48 pacientes com fratura traumática da coluna cervical tratados cirurgicamente no serviço de neurocirurgia do Hospital de Base do Distrito Federal. Métodos Trata-se de um trabalho retrospectivo, baseado na revisão de prontuários médicos, de pacientes com fratura da coluna cervical operados no período de julho de 2007 a julho de 2012. Resultados Predomínio do sexo masculino (89,5%); a faixa etária mais comum é de 20-40 anos (50%); idade média do sexo masculino é de 36,6 anos e do feminino, 19,8 anos (teste t: p » 0,04); vértebra mais fraturada: C5 (53,3%); 54,1% dos indivíduos apresentam algum déficit neurológico; fratura do tipo B é mais comum na coluna cervical (62,2%); mecanismos do trauma: acidente automobilístico (41,6%), queda de altura (20,8%), acidente motociclístico (12,5%), outros (25,1%); déficit neurológico da cervical alta (zero) e subaxial de 57,7% (p » 0,052); déficit neurológico masculino de 53,4% e feminino de 60% (p > 0,05); déficit neurológico do tipo A de 71,4%, do tipo B de 55,5%, e do tipo C de 54,5% (p > 0,05). Conclusão A maioria dos pacientes era do sexo masculino e da faixa etária entre 20 e 40 anos de idade, sendo as mulheres mais jovens que os homens. Cerca de 54,1% dos pacientes apresentavam déficit neurológico à admissão hospitalar e tinham C5 como principal vértebra fraturada. A fratura tipo distração (tipo B da AO) foi a mais encontrada. O principal mecanismo do trauma foram os acidentes de trânsito seguido pelas quedas de altura.

Introduction The cervical fractures represent a wide spectrum of injuries. In some works, the cervical spine is the segment most affected vertebral fractures, representing 45­60% of all cases.We present the epidemiological profile of forty-eight patients with traumatic cervical spine fracture surgically treated in the neurosurgery service at the Hospital of the Federal District. Methods This was a retrospective study, based on a review of medical records of patients with cervical spine fracture surgery from July 2007 to July 2012. Results Predominance of males (89.5%), the most common age group is 20­40 years (50%), mean age: males (36.6 years) and females (19.8 years) (t-test p » 0.04); fractured vertebra: C5 (53.3%), 54.1% of subjects have a neurological deficit, fracture type B is more common in the cervical spine (62.2%), mechanism of injury: motor vehicle accidents (41.6%), fall (20.8%), motorcycle (12.5%), other (25.1%), neurological deficit: high cervical 0 cases, subaxial 57.7% (p » 0.052); neurological deficit: male 53.4%, female 60% (p> 0.05); neurological deficit: 71.4% Type A, Type B 55.5% 54.5% Type C (p> 0.05). Conclusion Most patients were male and the age group between 20­40 years of age, with younger women than men. Approximately 54.1% of the patients had neurologic deficit on admission and had as main fractured vertebra C5. The distraction fractures (AO Type B) was found most frequently. The main mechanism of injury were traffic accidents followed by falls from height.

Evaluation of the SLICS use in the treatment of subaxial cervical spine injuries / Avaliação do SLICS no tratamento das lesões da coluna cervical sub-axial

The SLICS (Sub-axial Cervical Spine Injury Classification System) was proposed to help in the decision-making of sub-axial cervical spine trauma (SCST), even though the literature assessing its safety and efficacy is scarce. Method We compared a cohort series of patients surgically treated based on surgeon’s preference with patients treated based on the SLICS. Results From 2009-10, 12 patients were included. The SLICS score ranged from 2 to 9 points (mean of 5.5). Two patients had the SLICS < 4 points. From 2011-13, 28 patients were included. The SLICS score ranged from 4 to 9 points (mean of 6). There was no neurological deterioration in any group. Conclusion After using the SLICS there was a decrease in the number of patients with less severe injuries that were treated surgically. This suggests that the SLICS can be helpful in differentiating mild from severe injuries, potentially improving the results of treatment. .

O SLICS (Sub-axial Cervical Spine Injury Classification System) foi proposto para auxílio na tomada de decisão no tratamento do traumatismo da coluna cervical sub-axial. Contudo, existem poucos trabalhos que avaliem sua segurança e eficácia. Método Realizamos estudo comparativo de série histórica de pacientes operados baseados na indicação pessoal do cirurgião com pacientes tratados baseados na aplicação do SLICS. Resultados Entre 2009-10, 12 pacientes foram incluídos. O SLICS escore variou de 2 a 9 pontos (média de 5,5) com dois pacientes com escore menor que 4. Entre 2011-13, 28 pacientes foram incluídos. O escore de SLICS variou de 4 a 9 pontos, com média de 6. Conclusão Observamos que após o uso do SLICS houve uma diminuição do número de pacientes operados com lesões mais estáveis. Isso sugere que o SLICS pode ser útil para auxiliar a diferenciação de lesões leves das graves, eventualmente melhorando os resultados do tratamento. .

Reproducibility analysis of the stability and treatment of vertebral metastatic lesions / Análise da reprodutibilidade da estabilidade e do tratamento de lesões metastáticas vertebrais / Análisis de la reproductibilidad de la estabilidad y del tratamiento de lesiones metastáticas vertebrales

OBJECTIVES: To investigate the reproducibility among spine surgeons in defining the treatment of vertebral metastatic lesions, taking into account the mechanical stability of injuries. METHODS: Twenty cases of isolated vertebral metastatic lesions were presented to ten experts. Their opinion was then asked about the stability of the lesion, as well as their treatment option. RESULTS: The interobserver Kappa coefficient obtained both for stability analysis as to the decision of the treatment was poor (0.334 and 0.248, respectively). CONCLUSIONS: Poor interobserver reproducibility was observed in deciding the treatment of vertebral metastatic lesions when considering the stability of the lesions. .

OBJETIVO: Investigar a reprodutibilidade entre cirurgiões de coluna quanto à definição do tratamento de lesões metastáticas vertebrais, levando em consideração a estabilidade mecânica das lesões. MÉTODOS: Vinte casos de lesões metastáticas vertebrais isoladas foram apresentados a dez especialistas. Foi então solicitada sua opinião sobre a estabilidade da lesão e a seguir, sua opção de tratamento. RESULTADOS: O coeficiente Kappa interobservadores obtido tanto para análise da estabilidade quanto para a decisão do tratamento foi ruim (0,334 e 0,248, respectivamente). CONCLUSÕES: Foi observada reprodutibilidade ruim interobservadores na decisão do tratamento de lesões metastáticas vertebrais ao considerar a estabilidade das lesões. .

OBJETIVO: Investigar la reproducibilidad entre cirujanos de la columna vertebral en la definición del tratamiento de las lesiones metastásicas vertebrales, considerando la estabilidad mecánica de esas lesiones. MÉTODOS: Veinte casos de lesiones metastásicas vertebrales aisladas fueron presentados a diez expertos. Luego se les pidió su opinión sobre la estabilidad de la lesión y su opción de tratamiento. RESULTADOS: El coeficiente Kappa entre observadores obtenido tanto para el análisis de la estabilidad y para la decisión de tratamiento fue pobre (0,334 y 0,248 respectivamente). CONCLUSIONES: Se observó mala reproducibilidad entre observadores en decidir el tratamiento de lesiones vertebrales metastásicas basada en la estabilidad de esas lesiones. .

Total cervical disk replacement with a prestige LP® prosthesis: clinical and functional outcomes / Artroplastia total do disco cervical com prótese prestige LP®: resultados clínicos e funcionais / Artroplastia total del disco cervical con prótesis prestige LP®: resultados clínicos y funcionales

Objective: To determine the clinical and functional results of short- and medium-term cervical arthroplasty with the Prestige LP® prosthesis for the treatment of compressive myelopathy, radiculopathy and axial pain with radiculopathty. Methods: This retrospective study, conducted from 2009 to 2012, included 18 patients. Only 16 were found for the second stage of research, conducted in 2011 and 2012. Pre- and postoperative assessments were carried out using the CSOQ (Cervical Spine Outcomes Questionnaire). Odom criteria were used only in the postoperative evaluation. Both were translated and adapted to the local culture. Results: There was no postoperative radiculopathy or other complications requiring prolonged hospitalization. In most patients, there was a significant improvement in axial pain and radiculopathy, and there was only one indication of conversion to fusion. Conclusions: In selected cases of cervical degenerative disc disease, herniated cervical disc and compressive myeolopathy, cervical arthroplasty proved to be an effective and safe treatment in the short and medium terms.

Objetivo: Investigar os resultados clínicos e funcionais a curto e médio prazo da artroplastia cervical total com a prótese Prestige LP® para tratamento da mielopatia compressiva, radiculopatia e dor axial com radiculopatia. Métodos: Estudo retrospectivo realizado no período de 2009 a 2012, incluindo 18 pacientes. Somente 16 foram localizados e participaram da segunda etapa da pesquisa, realizada em 2011 e 2012. Foram feitas avaliações pré e pós-operatórias utilizando-se o questionário CSOQ (Cervical Spine Outcomes Questionnaire). Os critérios de Odom foram utilizados somente na avaliação pós-operatória. Ambos foram traduzidos e adaptados para a cultura local. Resultados: Não houve radiculopatia pós-operatória ou qualquer outra complicação que exigisse hospitalização prolongada. Na maioria dos pacientes, observou-se grande melhora da dor axial e da radiculopatia, constatando-se somente um caso de indicação de conversão para artrodese. Conclusão: Em casos bem selecionados de discopatia cervical degenerativa, hérnia de disco cervical e mieolopatia compressiva, a artroplastia cervical mostrou-se um tratamento eficaz e seguro a curto e médio prazo.

Objetivo: Investigar los resultados clínicos y funcionales en el corto y mediano plazo de la artroplastia cervical total con la prótesis LP Prestige® prótesis para el tratamiento de la mielopatia compresiva, radiculopatía y dolor axial con radiculopatía. Métodos: Este estudio retrospectivo se llevó a cabo desde 2009 hasta 2012, incluyendo 18 pacientes. Sólo 16 fueron encontrados para participar de la segunda etapa de la investigación realizada del 2011 al 2012. Se realizaron evaluaciones pre y postoperatorias mediante el cuestionario CSOQ (Cervical Spine Outcomes Questionnaire). Se utilizaron los criterios de Odom sólo en la evaluación postoperatoria. Ambos fueron traducidos y adaptados a la cultura local. Resultados: No hubo radiculopatía postoperatoria u otras complicaciones que necesitaronhospitalización prolongada. En la mayoría de los pacientes, se observó una mejoría significativa en el dolor axial y radiculopatía, encontrándose sólo un caso con indicación de conversión a la artrodesis. Conclusión: En los casos cuidadosamente seleccionados de la enfermedad degenerativa de disco cervical, hernia de disco cervical y mielopatia compresiva, la artroplastia cervical demostró ser un tratamiento eficaz y seguro a corto y medio plazo.

Surgical management of missile trauma to thoraco -lumbar spine

To evaluate the optimum treatment for Spinal Missile Injury with respect to missile trajectory, functional outcome, surgical indications, and timing of surgical intervention. Analysis of the patients with spinal missile injury. This study was conducted in the Emergency Department of Assir Central Hospital Abha Kingdom of Saudi Arabia over a period of three years from June 2001 - May 2004. A prospective series of Nineteen Missile trauma patients to the Thoraco-lumbar spine is presented. A total of 20 patients [13 in the surgical group A, 7 in the conservative group B] were monitored for functional recovery. One female patient died preoperatively. Twelve were treated surgically, of whom 9 [75%] had incomplete injuries [Frankel scores B, C, and D],6 [66.66%] showed improvement, 2 [22.22%] showed no change, and 1 [11.11%] worsened[Table3] . In the conservative group, five [71.42%] had incomplete injuries, 3[60%] improved, one [20.0%] remained unchanged and one [20%] worsened. Five patients [including both groups] were with complete injury [Frankel scores A]. Mean postoperative hospital stay was 18 days. The wounds were caused by splinters in 12 [71.4%] and bullets in 7 [28.7%]. Eight patients received more than one shrapnel. Associated injuries were present in eleven patients. The best results were obtained by the patients who received operations because of rapid neurologic deterioration cauda equina compression. If spinal cord is not injured by the trajectory, the best approach is conservative. It was concluded that surgical intervention is essential for spinal gunshot injury patients with instability or rapid neurological deterioration and beneficial for patients with CSF fistula, infections and compressing foreign bodies in the injury site. The initial neurological grade was found to be the best prognostic indicator. Most of the management revolves around consequences of the neurological deficit

Improvement in JOA score of treatment for complex atlas-axis fractures

The aim of this study was to explore the role of treatment for complex Atlas-Axis fractures, and compare the JOA score of surgical and conservation methods. From June 2008 to May 2012, 33 patients suffering from Atlas-Axis fracture were included in our study. Fifteen patients received posterior cervical pedicle screw fixation, and 18 patients received the conservation treatment. All the patients were followed up for 12 months after discharge. The mean operative time was about 128 minutes [ranged: 92 to 165 minutes], the mean hospital stay time was 15.5 days [ranged: 8-21 days], and the mean follow-up of all the patients was 27months [ranged: 7 to 43 months]. All patients gained a solid fusion, and no one showed any disability at the end of the follow-up. The JOA scores before treatment were 6.4 +/- 0.3 and 7.1 +/- 0.4 before and after treatment, and they significantly increased to 13.8 +/- 0.8 and 13.7 +/- 0.9 when following up for 12 months [P < 0.05]. Posterior cervical pedicle screw fixation is a feasible, effective and safe method for complex atlantoaxial fractures. This technique could achieve high JOA score, decreased blood loss and post-operative complications

Análise pós-operatória tardia da artrodese por via posterior em pacientes ASIA/Frankel e com trauma raquimedular toracolombar em serviço universitário / Postoperative late analysis of posterior arthrodesis in patients ASIA/Frankel e with thoracolumbar spine trauma in university hospital

Objetivo: O propósito deste estudo foi avaliar retrospectivamente o tratamento cirúrgico de pacientes vítimas de trauma raquimedular desse segmento sem déficit neurológico, quanto à evolução da dor local e à deformidade cifótica local e regional do segmento acometido, em um serviço universitário. Método: Foram utilizados dados de prontuário e avaliações clínicas e radiológicas de 16 pacientes submetidos à artrodese pedicular por via posterior, no período de maio de 2003 a dezembro de 2006, operados há pelo menos dois anos. Resultados: A média de idade foi de 43,43 ± 11,44 anos e o nível mais acometido L1. O mecanismo principal do trauma foi queda de altura. Após realização de raios X em perfil e cálculo dos ângulos local sagital (ALS) e regional sagital (ARS), de pós-operatório precoce e tardio, não houve diferença estatisticamente significativa entre os dados obtidos, apesar da diminuição de -15,3º para -10,7º nas cifoses locais e do aumento de -13,7º para 15,9º nas cifoses regionais. Houve diferença estatística na avaliação de dor pela Escala Analógica de Dor (EAD), entre o pré-operatório e o pós-operatório tardio (maior que dois anos), com redução de quatro vezes da intensidade da dor entre os pacientes analisados (p < 0,05). Conclusão: A artrodese pela via posterior é uma proposta alternativa de tratamento quando se discute a dor desses pacientes. Fica a necessidade de abranger um número maior de pacientes com essa patologia, a fim de dispor dados mais fidedignos, respaldando o tratamento como uma alternativa viável no manejo de pacientes com fraturas toracolombares e neurologicamente intactos.

Objective: The aim of this study was a retrospective valuation of surgical treatment of patients with spinal thoracolumbar spine without neurological deficit, for that local pain, local and regional kyphotic deformity at an university hospital. Method: There were used hospital datum from 16 operated patients and clinical and radiological evaluation submitted a pedicular screw instrumentation from May 2003 until December 2006, operated for at least 2 years. Results: The mean age was 43.43 ± 11.44 years and the most fractured level L1. The principal mechanism was height fall. After the x-rays realized and calculated the local sagittal angle and regional sagittal angle, there's no significative difference between them, despite the reduction of -15.3º to -10.7º, at local kyphosis and augmentation of -13.7º to 15.9º at regional kyphosis. There was statistics difference at pain evaluation using the Analogic Pain Scale, between the pre-operative and postoperative (beyond two years), with four times reduction of intensity pain among the analyzed patients (p < 0.05). Conclusion: The arthrodesis by posterior approach is an alternative proposal of treatment when discussing the pain of these patients. It is the need to include a larger number of patients with this pathology, in order to dispose more data reliable, endorsing the treatment as a viable alternative in the management of patients with thoracolumbar fractures and neurologically intact.

Comparative study between the use of Macintosh laryngoscope and Airtraq in patients with cervical spine immobilization

Airway management is a major responsibility for anesthetist. This study was carried out to evaluate and compare the efficacy of Airtraq [AL] and Macintosh Laryngoscopes [ML] in intubating patients with cervical spine immobilization using manual inline axial stabilization technique [MIAS]. This randomized controlled study was carried out in Alexandria Main University Hospital on 40 adult ASA I and II patients after written informed consent and approval of the ethical committee, randomly categorized into two equal groups. All patients were subjected to same anesthetic protocol. Group I patients were intubated using AL and group II patients were intubated using ML. Hemodynamic measurements and oxygen saturation were recorded. Intubation criteria for both groups including [duration of intubation procedure, number of attempts, number of optimization maneuvers, Cormack and Lehane grade at laryngoscopy, Intubation Difficulty Scale score [IDS], rate of successful placement of endotracheal tube, neck mobility during laryngoscopy and intubation complications were recorded. Data statistically analyzed using SPSS[R] software using [t and x[2] tests] and P < 0.05 considered significant. There was statistically significant increase in both heart rate and mean arterial blood pressure values following intubation in ML group than AL, oxygen saturation showed no significant difference between the two groups. Duration of intubation was statistically significant longer in ML group and needed more optimization maneuvers than the AL group, while for the number of intubation attempts; there was no statistically significant difference between the two groups. Both the Cormack and Lehane grading and IDS score values have shown statistically significant higher values in ML group. The Airtraq Laryngoscope offers a new approach for the management of difficult airway like patients with potential cervical spine injury, it is fast, easy to use, gets an easy view of the larynx without moving the cervical spines or causing hemodynamic stimulation

Effectiveness of Home Health Care Service for Elders after Spinal Surgery

PURPOSE: This study was done to evaluate effectiveness of home healthcare services (HHCS) specialized for elders who received spinal surgeries. METHODS: A non-equivalent control group pre-post test quasi-experimental study was performed. HHCS was developed based on the Rice model of dynamic self-determination for self-care. For data collection, a control group (n=23) and an experimental group (n=23) were selected by matching age, BMI, pain, general characteristics and type of spine surgery. Measurement tools to evaluate uncertainty and knowledge were developed by the authors. The Numeric Rating Scale (NRS) and Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were used to evaluate pain levels. Muscular strength in the legs was measured using a digital muscle tester and tape ruler. Questionnaires were used to evaluate disability in performing ADL and psychological distress levels. RESULTS: The experimental group showed significant decrease in uncertainty (p=.028), increased knowledge (p=.038), and partially decreased pain (p=.003-.331). Partial muscle strength increased significantly (p=.021-.644). Disability in performing ADL and psychological distress in the experimental group decreased significantly compared to control group (p=.002, p=.004). CONCLUSION: Results indicate HHCS is an efficient home care nursing program for these elders. Further experimental studies with larger samples are required to confirm effects of HHCS.

Tratamento das fraturas do processo odontóide / Treatment of odontoid fractures

OBJETIVO: Este artigo faz a avaliação retrospectiva clínica e radiológica das fraturas do odontóide de 20 pacientes atendidos no IOT-HCFMUSP, durante o período de 2004-2010. MÉTODOS: Foi realizado a estratificação destas fraturas segundo sua classificação (AO/Anderson e D'Alonzo), perfil epidemiológico, tipo de tratamento, tempo de consolidação e complicações. RESULTADOS: Observou-se maior número de casos da fratura do odontóide em pacientes do sexo masculino (4:1), com idade entre 3ª e 4ª década de vida (60 por cento), vítimas de quedas de altura (60 por cento) e acidentes automobilísticos (25 por cento) como principais mecanismos de trauma, e 15 por cento dos casos apresentaram-se com déficit neurológico. A fraturas do odontóide de maior prevalência foram as do tipo II (55 por cento), seguidas pelas fraturas do tipo III (40 por cento). Os tratamentos mais empregados nas fraturas do tipo II e III foram, respectivamente, o cirúrgico (73 por cento) e conservador (87,5 por cento). A consolidação ocorreu em até 16 semanas para 87,5 por cento dos casos de tratamento cirúrgico e para 54,5 por cento dos tratados conservadoramente. Não houve casos de pseudoartrose. CONCLUSÃO: O tratamento cirúrgico das fraturas do odontóide do tipo II apresentou resultados satisfatórios em relação ao tempo consolidação e baixa incidência de complicações, bem como o tratamento conservador destinado às fraturas do tipo III.Nivel de Evidência IV, série de casos.

OBJECTIVE: This article describes a clinical and radiologic retrospective analysis of odontoid fractures in20 patients accompanied byThe IOT-HCFMUSP,from 2004 to 2010. METHODS: These fractures were stratified according to their classification (AO/Anderson andD'Alonzo), epidemiologic profile, type of treatment, time to consolidation of the fracture, and complications. RESULTS: It was observed that there was a higher number of odontoid fractures in males (4:1), between the third and fourth decades of life (60 percent), and that the main causes of the trauma were falling from heights (60 percent) and car accidents (25 percent). Also, 15 percent of the cases presented neurological deficits. The most prevalent type of odontoid fracture was Type II (55 percent) followed by Type III (40 percent). The most prevalent type of treatment used for Type II and III fractures was surgical (73 percent) and non-surgical (87.5 percent), respectively. Consolidation of the fracture took place within 16 weeks in 87.5 percent of surgically treated cases, and in 54.5 percent of those treated non-surgically. No cases of pseudoarthrosis were found. CONCLUSION: The surgical treatment of Type II odontoid fractures showed satisfactory results in relation totime to consolidation of the fracture and low incidence of complications, as did the non-surgical treatment used for the Type III fractures. Level of Evidence: Level IV, case series.

Epidemiologia das fraturas toracolombares cirúrgicas na zona leste de São Paulo / Epidemiology of thoracolumbar surgical fractures in the east side of São Paulo / Epidemiología de las fracturas toracolumbares quirúrgicas en la región Leste de São Paulo

OBJETIVO: fazer uma análise prospectiva de cem pacientes com fratura da coluna toracolombar submetidos a tratamento cirúrgico em um hospital terciário da zona leste de São Paulo. MÉTODOS: estudo prospectivo com início em Janeiro de 2006 até Julho de 2009, sendo incluído um total de 100 pacientes com fratura da coluna toracolombar submetidos a tratamento cirúrgico. Avaliou-se o sexo, a idade, o mecanismo de trauma, o déficit neurológico e o tipo de fratura. RESULTADOS: foi observado que queda de altura foi o principal fator causador deste tipo de fratura seguido de acidentes com veículos automotores. O sexo masculino foi responsável por 66 por cento dos casos, porém não foi observada diferença entre o mecanismo de trauma e o sexo. Observamos também que a lesão neurológica apresenta relação direta com a gravidade de fratura e que a junção toracolombar é a região mais acometida. CONCLUSÃO: concluímos que a incidência de fraturas na zona leste de São Paulo é elevada e associam-se a quedas acidentais. Verifica-se que estes dados são importantes para que medidas de prevenção possam ser tomadas com vistas a diminuir a morbidade deste grave tipo de trauma.

OBJECTIVE: to carry out a prospective analysis of 100 patients with thoracolumbar spine fractures who underwent surgery at a tertiary hospital in the east side of São Paulo, Brazil. METHODS: a prospective study from January 2006 until July 2009, including an overall of 100 patients with fractures of the thoracolumbar spine who underwent surgery. Data such as gender, age, mechanism of injury, neurologic deficit and type of fracture were assessed. RESULTS: it was observed that the fall of slab was the main cause of fracture, followed by car accidents, and males accounted for 66 percent of the cases; however, no difference was observed between the mechanism of trauma and the gender. We also observed that neurological damage is directly related to severity of fracture and that the thoracolumbar junction is the most affected region. CONCLUSION: we conclude that the incidence of fractures in the east side of São Paulo and it is highly associated with accidental falls. These data are important so that preventive measures can be undertaken to reduce the morbidity of this type of severe trauma.

OBJETIVO: hacer un análisis prospectivo de cien pacientes con fracturas de la columna toracolumbar sometidos al tratamiento quirúrgico en un hospital de tercer nivel de la región Leste de la ciudad de São Paulo. MÉTODOS: estudio prospectivo con inicio en Enero de 2006 hasta Julio de 2009, donde fueron incluidos un total de cien pacientes con fractura de la columna toracolumbar sometidos al tratamiento quirúrgico. Se evaluaron el sexo, la edad, el mecanismo del trauma, el déficit neurológico y el tipo de fractura. RESULTADOS: fue observado que la caída de una altura fue el principal factor causante de este tipo de fractura, seguido de accidentes con vehículos automotores. El sexo masculino fue responsable por el 66 por ciento de los casos, sin embargo no fue observada una diferencia entre el mecanismo del trauma y el sexo. Se observó también que la lesión neurológica presenta relación directa con la gravedad de la fractura y que la junción toracolumbar es la región más comprometida. CONCLUSIÓN: la incidencia de fracturas en la región Leste de São Paulo es elevada y asociada con caídas accidentales. Fue observado que estos datos son importantes para que medidas de prevención puedan ser realizadas, de forma que disminuya la morbilidad de este tipo de trauma grave.

Anterior cervical fixation with casper plate and locked screws in trauma patients - a study of thirty patients at Nishtar hospital, Multan

To analyze the results of anterior cervical fixation as regards the effective stabilization, immobilization and solid bony fusion in lower cervical spine injuries by the use of one Caspar plate attached with locked screws. This study was carried out in the Department of Neurosurgery, Nishtar Medical College and Hospital, Multan from May 2006 to May 2007. Thirty cases of cervical spine injuries ranging from 10 to 60 years of age excluding patients with firearm injuries, upper cervical spine [C1, C2] injuries and patients who were unfit for general anaesthesia due to associated medical diseases. Anterior cervical spine fixation was performed by Caspar plate attached with locked screws. Total patients studied were thirty in number. Males were 27 [90%] and females were 3 [10%]. 15 [50%] patients had history of fall from a height and out of these 14 [93%] patients nad history of fall from a tree. Most common level of fracture dislocation was C5-C6 inter space. The results showed the supremacy of anterior cervical fixation with Caspar plate and locked screws as regards effective stabilization, early mobilization and solid bony fusion. Anterior cervical fixation with Capsar plate and locked screws is the preferred treatment modality in lower cervical spine injuries

Discectomía cervical anterior con artrodesis intersomática con cesta de titanio: experiencia en 102 casos (2002-2008)

La elevada frecuencia de pacientes con trastornos cervicales, ha llevado a estudiar estas afecciones, cuya diferenciación de otras enfermedades en muchas ocasiones resulta difícil. En la práctica neuroquirúrgica las enfermedades cervicales y degenerativas son unas de las más frecuentes, las hernias de columna cervical representan el segundo lugar de frecuencia de la patología discal. Este trabajo está basado en la revisión de la técnica de artrodesis cervical anterior posdiscectomía y fusión utilizando la cesta roscada de titanio, sin uso de injertos óseos, placas o tornillos, el cual es continuación de una revisión realizada dada la experiencia del autor en el 2004. Se analizan los procedimientos diagnósticos más frecuentemente utilizados y los criterios para la selección del tratamiento quirúrgico. Se presenta la experiencia en 102 casos. Las principales ventajas que ofrece esta técnica son: menor instrumentación; acortamiento del tiempo quirúrgico; estabilización inmediata de la columna cervical con recuperación y deambulación precoz de los pacientes, con retorno precoz a sus actividades normales, con mínimas complicaciones y reducción de costos

Cervical spinal degenerative and discal diseases are among the most common conditions encountered in medical practice. Herniated discs are more common in patients under 40 years of age and degenerative processes are more common after that age. In this study, the most common diagnostic methods and the current criteria for surgical management are reviewed. The author presents his experience of 102 cases with cervical discal and degenerative disease treated by discectomy and fusion through anterior approach, using the titanium cage without use of bone grafts, plates or screws. The main advantages of this technique include shortening of surgical time and fewer instrumentation, immediate stabilization of the cervical spine, early functional recovery and return to normal activities within two weeks with minimal complications, and lower cost

Vigilancia neurofisiológica transoperatoria multimodal en cirugía de columna / Neurophysiological monitoring in spinal cord surgery

Introducción: La vigilancia neurofisiológica durante la cirugía de columna vertebral y de la médula espinal consiste en pruebas de potenciales evocados somatosensoriales, potenciales motores musculares, potenciales dermatomales y electromiografía. El riesgo de daño neurológico permanente después de una cirugía medular sin monitorización es significativo y el costo alto. El objetivo de la vigilancia neurofisiológica es identificar, prevenir y corregir de forma inmediata el daño neurológico que puede pasar inadvertido durante la cirugía de columna vertebral y médula espinal. Material y métodos: Estudio transversal, observacional y descriptivo de los pacientes sometidos a cirugía de columna entre 2007 y 2008 con vigilancia neurofisiológica transoperatoria. Resultados: La muestra estuvo integrada por 351 pacientes, 135 del sexo masculino (38.46 %) y 216 del femenino (61.54 %); 82 % correspondió a patología osteodiscal con o sin afectación medular, 12 % a etiología traumática, 4 % a corrección de escoliosis y 2 % a tumores medulares; por localización, 62.1 % a patología lumbar, 33 % a cervical, 4.3 % a nivel dorsal y 0.5 % a nivel sacro. El 12.4 % de los pacientes presentó mejoría de la respuesta basal de sus potenciales evocados somatosensoriales; 56.8 % los mantuvo similares a sus controles prequirúrgicos, 28.4 % requirió llamada de alerta al cirujano por riesgo de daño y 2.4 % caída severa de respuesta. En ningún caso hubo pérdida permanente. Conclusiones: La vigilancia neurofisiológica constituye una herramienta de gran valor que evita daños que pueden producirse durante esta cirugía.

BACKGROUND: Intraoperative neurophysiological monitoring (IOM) during spine surgery consists of several functional tests including somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), dermatomal potentials (DPs) and EMG (electromyography). Permanent neurological damage after spine surgery performed without intraoperative neurophysiological monitoring is frequent and often very costly. The main goal of IOM is the immediate detection, prevention and correction of neurological damage during surgery, which may go unnoticed without using these tests. METHODS: A total of 351 clinical files of patients with spinal surgery and continuous neurophysiological monitoring were transversally and descriptively reviewed from 2007 to 2008. RESULTS: There were 135 male patients (38.46%) and 216 female patients (61.54%); 82% of the cases were osteodiscal pathology with or without medullar involvement, 12% were patients with traumatic injuries, 4% with scoliosis and 2% had medullary tumors. Regarding localization, 62.1% were lumbar, 33% cervical, 4.3% thoracic and 0.5% sacral involvement; 12.4% of our cases showed significant improvement of the basal responses on SSEPs, and 56.8% showed no significant change during the procedure. In 28.4% of the cases, the surgical team had to be advised of potential neurological damage and in 2.4% there was absence of neurophysiological responses. No patient showed complete loss of any neurophysiological response. All patients reported clinical improvement after hospital discharge. CONCLUSIONS: Intraoperative neurophysiological monitoring may help avoid certain neurological risks during spine surgery, which may go unnoticed without the use of this technique.