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

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

Spinal subarachnoid haematoma after spinal anaesthesia: case report / Hematoma espinhal subaracnoideo após raquianestesia: relato de caso

Abstract Subarachnoid haematoma after spinal anaesthesia is known to be very rare. In the majority of these cases, spinal anaesthesia was difficult to perform and/or unsuccessful; other risk factors included antiplatelet or anticoagulation therapy, and direct spinal cord trauma. We report a case of subarachnoid haematoma after spinal anaesthesia in a young patient without risk factors.

Resumo Hematoma subaracnoideo após anestesia espinal é conhecido por ser muito raro. Na maioria desses casos, a anestesia espinal foi difícil de executar e/ou malsucedida; outros fatores de risco incluem terapia anticoagulante ou antiplaquetária e trauma medular direto. Relatamos um caso de hematoma subaracnoideo após raquianestesia em paciente jovem sem fatores de risco.

Histiocitosis de células de Langerhans con compromiso vertebral y de partes blandas: Caso clínico / Langerhans cell histiocytosis with vertebral involvement and soft tissue extension: Clinical case

La histiocitosis de células de Langerhans es una enfermedad heterogénea de etiología desconocida, que se caracteriza por la proliferación no controlada de histiocitos. Es poco frecuente y, si bien el compromiso óseo es común, la afectación vertebral es rara. Se presenta una niña de 4 años que consultó por dolor abdominal difuso de un mes de evolución, al que se agregó constipación y, posteriormente, debilidad en los miembros inferiores. El examen físico mostraba clonus e hiperreflexia en los miembros inferiores y la marcha era inestable. Se realizó una resonancia magnética, que mostró la vértebra dorsal 9 (D9) plana con tejido blando patológico en el espacio epidural y laterovertebral. Se realizó una cirugía descompresiva, artrodesis para fijar la columna y toma de biopsia, que confirmó el diagnóstico de histiocitosis de células de Langerhans. Recibió 6 meses de tratamiento con metilprednisona y vinblastina, de acuerdo con el protocolo LCH III, con excelente evolución y remisión completa. Conclusión. Frente a una imagen radiológica de vértebra plana o colapso vertebral, debe pensarse en histiocitosis de células de Langerhans como diagnóstico diferencial.

Langerhans cell histiocytosis is a heterogeneous disease of unknown etiology characterized by proliferation of Langerhans cells. It is a rare disease. Bone involvement is common but vertebral disease is rare. We present a 4 year old patient with abdominal pain and neurologic symptoms. Magnetic resonance showed vertebra plana in D9 with involvement of paravertebral soft tissues. The child underwent surgery for decompression and biopsy. Biopsy confirmed Langerhans cell histiocytosis. She was treated with vinblastine and prednisone during 6 months following LCH-III with complete recovery of neurologic symptoms. Conclusion. Langerhans cell histiocytosis is a differential diagnosis in a radiograph with vertebra plana or collapse of vertebral body.

Cervical spine dysfunction signs and symptoms in individuals with temporomandibular disorder / Frequência de sinais e sintomas de disfunção cervical em indivíduos com disfunção temporomandibular

PURPOSE: To study the frequency of cervical spine dysfunction (CCD) signs and symptoms in subjects with and without temporomandibular disorder (TMD) and to assess the craniocervical posture influence on TMD and CCD coexistence. METHODS: Participants were 71 women (19 to 35 years), assessed about TMD presence; 34 constituted the TMD group (G1) and 37 comprised the group without TMD (G2). The CCD was evaluated through the Craniocervical Dysfunction Index and the Cervical Mobility Index. Subjects were also questioned about cervical pain. Craniocervical posture was assessed by cephalometric analysis. RESULTS: There was no difference in the craniocervical posture between groups. G2 presented more mild CCD frequency and less moderate and severe CCD frequency (p=0.01). G1 presented higher percentage of pain during movements (p=0.03) and pain during cervical muscles palpation (p=0.01) compared to G2. Most of the TMD patients (88.24%) related cervical pain with significant difference when compared to G2 (p=0.00). CONCLUSION: Craniocervical posture assessment showed no difference between groups, suggesting that postural alterations could be more related to the CCD. Presence of TMD resulted in higher frequency of cervical pain symptom. Thus the coexistence of CCD and TMD signs and symptoms appear to be more related to the common innervations of the trigeminocervical complex and hyperalgesia of the TMD patients than to craniocervical posture deviations.

OBJETIVOS: Investigar a frequência de sinais e sintomas de disfunção da coluna cervical (DCC) em indivíduos com e sem disfunção temporomandibular (DTM) e avaliar a influência da postura craniocervical sobre a coexistência da DTM e da DCC. MÉTODOS: Participaram 71 mulheres, com idades entre 19 e 35 anos, que foram avaliadas quanto à presença de DTM. Destas, 34 constituíram o grupo com DTM (G1) e 37 participaram compuseram o grupo sem DTM (G2). A DCC foi avaliada pelo Índice de Disfunção Clínica Craniocervical e pelo Índice de Mobilidade Cervical. Questionou-se, ainda, a queixa de dor cervical. A postura craniocervical foi aferida por meio do traçado cefalométrico. RESULTADOS: Não houve diferença na entre os grupos quanto à postura craniocervical. O G2 apresentou maior frequência de DCC leve e menor frequência de DCC moderada ou grave (0,01). O G1 apresentou maiores percentuais de frequência de dor durante a execução do movimento e dor à palpação dos músculos cervicais. No G1, a maioria (88,24%) das participantes relatou dor cervical, com diferença em relação ao G2. CONCLUSÃO: Não houve diferença na postura craniocervical entre os grupos, o que sugere que as alterações posturais estejam mais relacionadas à ocorrência de DCC. A presença de DTM resultou em maior frequência de sintomas dolorosos na região cervical. Assim, a coexistência de sinais e sintomas de DCC e DTM parece estar mais relacionada à inervação comum do complexo trigêmino-cervical e à hiperalgesia de indivíduos com DTM do que à alteração postural craniocervical.

Enfermedades del segmento adyacente secundaria a intrumentación en cirugía de columna lumbar / Adjacent segment disease after spinal fusion

La enfermedad del Segmento Adyacente o Patología Transicional es considerada como una complicación cada vez más frecuente asociada a las instrumentaciones en columna lumbar, siendo considerada como un potencial problema a largo plazo, tanto en relación a la obtención de pobres resultado funcionales como la necesidad de reintervenciones quirúrgicas. El objetivo de este estudio fue determinar la presencia o no de esta complicación en pacientes sometidos a instrumentación de columna lumbar y lumbosacra, y su comparación con la literatura internacional. Se realizó una evaluación retrospectiva de radiografías estáticas y dinámica, utilizando la escala de graduación de la Universidad de California en Los Ángeles para la degeneración del espacio intervertebral, tanto pre como post operatorias de 51 pacientes entre 36 y 79 años de edad, a los cuales se les había realizado una instrumentación más artrodesis posterolateral, ya que presentaba una espondilolistesis degenerativa, en dos centros hospitalarios: el Hospital de la Fuerza Aérea de Chile y la Clínica Las Condes entre el año 1997 y 204. Los puntos evaluados fueron la incidencia y el tiempo de aparición de esta patología, su asociación al sexo, determinar si es que existía o no un empeoramiento de la función a largo plazo, siendo evaluado esto a través de la escala de Oswestry. Se observaron además la cantidad de segmentos comprometidos y si la ubicación de la complicación era hacia cefálico o caudal en relación a la instrumentación. También se analizaron aquellos pacientes que, presentando esta complicación, requirieron de una segunda cirugía. Las pruebas estadísticas utilizadas fueron las pruebas de correlación de Spearman y Kendall para variables no continuas. Como conclusión, podemos decir que no existen evidencias del punto de vista estadístico de que la presencia de esta patología implique un deterioro de la capacidad funcional, y que si bien este proceso podría estar influenciado por un estrés biomecánico...

Adjacent segment disease or transition syndrome is recognized as a postoperative complication after lumbar or lumbosacral spinal fusion. This entity can be responsible of poor results in functional capacity in the long term or the need of second surgery. The aim of this study is to look the development of this complication after lumbar or lumbosacral spine fusion in our patients, and to compare our results with the international literature. This is a retrospective study. We evaluated the static and dynamic lumbar spine radiographies. UCLA grading scale for intervertebral space degeneration was used. Our study group is 51 patients between 36 and 79 years old from Chilean Air Force Hospital and Las Condes Clinic. These patients had degenerative spondylolisthesis and underwent instrumented arthrodesis. We evaluated sex, age, adjacent segment disease incidence, long term functional outcome using Oswestry scale. The number of involved segments and their position in relation with instrumentation were recorded. The incidence of second surgery was recorded. Spearman´s and Kendall´s correlation test for no continues variable were used. We found no statistical evidence between the presence of adjacent segment degeneration and poor functional results. Although this disease can be influenced by biomechanical stress; it is not evident his relation with previous segment fusion. Adjacent segment degeneration may be a normal aging process of the lumbar spine.

Doença do nível adjacente após artrodese da coluna lombar: revisão da literatura / Adjacent segment disease after lumbar spine fusion: literature review

A degeneração do nível adjacente acima ou abaixo da fusão na coluna lombar é definida como doença do nível adjacente. Atualmente é considerada como uma complicação tardia e freqüente. Do ponto de vista radiográfico apresenta uma incidência de 5,2 a 100%. No entanto a incidência de pacientes sintomáticos é menor,variando de 5,2 a 18,5%. A etiologia é incerta. Provavelmente a origem está no aumento da pressão intradiscal,no aumento da carga facetária e no aumento da mobilidade. Os potenciais fatores de risco incluem: instrumentação, tamanho de fusão, mau alinhamento sagital, lesão facetária, idade e degeneração pré-existente. Otratamento pode ser clínico ou cirúrgico. O tratamento cirúrgico consiste na descompressão dos elementos neurais e extensão da fusão. Os resultados após a nova cirurgia são modestos.

The midpedicular and interpedicular distance of thoracolumbar vertebrae.

OBJECTIVES: 1. To introduce the measurement of the midpedicular distance (MPD) as an alternative to the interpedicular distance (IPD). 2. To measure the IPD and MPD of T11, T12, L1 and L2 vertebrae on anteroposterior (AP) plain film of the normal spine. 3. To study the relationship of the IPD and MPD of T11 to L2 of the normal spine. STUDY DESIGN: Thoracolumbar AP plain film of 89 subjects (39 males, 50 females) with an average age of 47.6 years (range 21-78 years) from the roentgenographic files were included. Both the IPD and MPD of T11, T12, L1 and L2 were measured by two observers. The mean difference of IPD and MPD at these four levels were compared by using a one-way ANOVA. The relationship of the IPD and MPD measured from the T11 to L2 levels were evaluated using the simple linear regression model. RESULTS: The mean IPD was progressively wider (p = 0.000) from the T11 to L1 level, but no significant difference (p = 0.308) was found between the mean IPDs of L1 and L2. The mean MPD of each level was significantly different from the others (p = 0.000) except the mean MPDs of T12 and L1 (p = 1.000). Both the IPD and MPD had a statistically significant linear relationship with the level of the vertebrae from T11 to L2 (p = 0.000) with the coefficients of determination (R2) of 0.39 and 0.28, respectively. CONCLUSION: More care should be taken in clinical practice when measuring the IPD of a fractured vertebra relative to those of adjacent lower levels in order to determine whether or not widening has occurred, especially IPD L1 vis-à-vis IPD L2. MPD measurement has no advantage over the IPD measurement but is a useful alternative when a comparison of the pedicular distance of L1 and L2 is needed.

Spinal extradural abscess following local steroid injection.

A case of spinal extradural abscess following local steroid injection for back ache, in a 26 years old male is described. The abscess presented as a swelling externally. MRI localised the lesion to L2-S1 segments. Mechanism of such an infection has been discussed.

Cervical spine involvement in rheumatoid arthritis: prevalence and relationship with overall disease severity.

Rheumatoid arthritis (RA) affects the cervical spine in 20-90% of patients in Western countries. We report the prevalence of cervical spine involvement in RA and its relationship with duration of disease, seropositivity, hand joint erosions and symptoms and signs suggestive of cervical spine involvement. 100 patients with RA criteria were included. Apart from clinical history and examination, study included X-rays of the cervical spine in AP, open mouth and lateral views and posteroanterior view of hands and rheumatoid factor estimation. All X-rays were read by a radiologist who was unaware of the clinical details. Cervical spine involvement was seen in 65% of patients. The commonest abnormality was erosions of the odontoid process (47%), followed by atlanto-axial dislocation and apophyseal joint involvement (24%). Only 5% of patients had abnormalities of spinous processes or vertebral bodies. Patients with abnormal cervical spine radiographs had higher prevalence of rheumatoid factor and erosions on hand radiographs. Severity of cervical spine changes was related to duration of disease (> 5 years). No correlation was seen between symptoms and radiological abnormalities except when neurological deficit was present. Patients with seropositivity, erosive disease and disease duration greater than five years should be screened for cervical spine disease.

Dolor osteomuscular en niños y adolescentes a nivel de columna cervical

El origen del dolor puede provenir de diversas causas, éstas pueden ser congénitas, alteraciones del desarrollo, inflamatorias, infecciosas o tumorales entre las más frecuentes. Es de suma importancia conocer muy bien la anatomía, el desarrollo normal y la osificación progresiva de la columna cervical con sus variantes normales y representaciones radiológicas. Para aclarar el origen del dolor se hace necesario tomar una buena historia clínica, practicar un excelente examen físico y complementarse con estudios radiológicos

Frequency of cervical spine involvement in rheumatoid arthritis.

The cervical spine x-rays of a random number of patients with confirmed rheumatoid arthritis were taken. The presence of atlanto-axial subluxation, atlanto-axial impaction, subaxial subluxation and any other associated abnormalities was noted. The spinal canal diameter was also measured which was not significantly altered in rheumatoid arthritis cases. Cervical spine disorders were seen to occur in 16 cases (69.6%) out of 23 patients. Spondylosis was the most frequent disorder ie, in 10 cases (62.5%) out of 16. Obliteration of the normal lordotic curve and disc lesions occurred in 3 cases (18.7%) each out of 16. The mean spinal canal diameter was 16.30 +/- 2 mm with a range of 13-23 mm. Female patients (73.3%) had an increased cervical spine disorder than males (62.5%). Seropositive rheumatoid arthritis cases (87.5%) were mostly involved in occurrence of disorder than those of seronegative arthritis cases (46%).

A coluna vertebral dos trabalhadores: alteraçöes da coluna relacionadas com o trabalho / The spine of the workers: spine alterations related with the work

Esta exposiçäo visa apresentar alguns pontos importantes sobre a coluna vertebral e procura oferecer subsídios para pensarmos nossos próprios conhecimentos sobre o assunto. A primeira parte cita dois estudos sobre as várias causas de lombalgia, enfatizando a importância dos aspectos psicológicos. Na segunda parte, säo comentadas onze pesquisas internacionais sobre radiologia e biomecânica, destacando-se aspectos tais como vibraçäo e flexibilidade. Também apresenta um novo tipo de contraçäo muscular denominado isoinercial, bem como constata a controvérsia entre dois autores de renome, acerca da correta postura de levantamento de pesos. A terceira e última parte, mostra uma experiência nacional em termos de prevençäo de lombalgia, baseada em dez principios de ergonomia bem como, comenta dois trabalhos quanto ao tratamento global de pacientes com patologia lombares

Cisticercose espinhal leptomeníngea pura / Pure spinal leptomeningeal cysticercosis

Relato de um caso com verificaçäo cirúrgica de cisticercose espinhal, forma leptomeníngea restrita à cauda eqüina, em paciente adulto. E discutido o papel do sistema venoso vertebral na infestaçäo dos espaços subaracnóideos na neurocisticercose, originando formas clínicas primariamente espinhais

Infecciones de la columna vertebral / Infectious of the spine

Se hace una revisión de las infecciones no tuberculosas de la columna vertebral haciendo énfasis sobre la etiología e incidencia por sexo y edad, indicando factores etiológicos y factores agregados. Se revisa el cuadro clínico. Se estudian los métodos, diagnósticos y terapéuticos aconsejados, dependiendo del tipo de proceso. Se concluye en la necesidad de tener en cuenta el proceso en todo paciente joven que consulta por dolor espinal