Accuracy of imaging grading in comparison to open laminectomy to evaluate pedicle screws positioning.

Study design: Prospective experimental study. Objective: To compare the accuracy of O-Arm-acquired radiographic and computed tomography (CT) evaluation of thoracic pedicle screw placement with open laminectomy in a simulation laboratory. Summary of background data: Improving surgical safety and procedural efficiency during thoracic posterior spine instrumentation is essential for decreasing complication rates and possible related risks. The most common way of verifying the position of pedicle screws during the surgical procedure and immediately postoperatively is to acquire intraoperative fluoroscopic images and plain radiographs of the spine, respectively. Laboratory simulated surgery is a valuable tool to evaluate the accuracy of those exams. Methods: Twenty simulation models of scoliosis from T3 to T7 were instrumented by five spine fellows (total of 200 pedicle screws), followed by radiographic and CT images acquired with the assistance of the O-Arm which were evaluated by three independent raters. A fellowship-trained spine neurosurgeon performed laminectomies on the instrumented levels and assessed pedicle integrity (gold standard). Results: Forty-eight breaches were identified in the axial direct view after laminectomy. Of those, eighteen breaches were classified as unacceptable. Regarding the sagittal direct view, four breaches were observed, three of which were classified as unacceptable. Overall, both O-arm radiographic and CT evaluations had a significantly high negative predicted value but a low positive predicted value to identify unacceptable breaches, especially in the sagittal plane. The frequency of missed breaches by all three examiners was high, particularly in the sagittal plane. Conclusion: Postoperative evaluation of pedicle screws using O-arm-acquired radiographic or CT images may underdiagnose the presence of breaches. In our study, sagittal breaches were more difficult to diagnose than axial breaches. Although most breaches do not have clinical repercussions, this study suggests that this modality of postoperative radiographic assessment may be inaccurate. Level of evidence: 4.

Time to surgery for adolescent idiopathic scoliosis: How long does it take? A multicenter study.

Study design: Retrospective review of multicentric data. Objectives: To estimate the time from initial visit to surgery in adolescent idiopathic scoliosis (AIS) patients and the main reasons for the time to surgery in a multicenter study. Methods: This retrospective study evaluated 509 patients with AIS from 16 hospitals across six Latin American countries. From each hospital's deformity registry, the following patient data were extracted: demographics, main curve Cobb angle, Lenke Classification at the initial visit and time of surgery, time from indication-for-surgery to surgery, curve progression, Risser skeletal-maturity score and causes for surgical cancelation or delay. Surgeons were asked if they needed to change the original surgical plan due to curve progression. Data also were collected on each hospital's waiting list numbers and mean delay to AIS surgery. Results: 66.8% of the patients waited over six months and 33.9% over a year. Waiting time was not impacted by the patient's age when surgery first became indicated (p = 0.22) but waiting time did differ between countries (p < 0.001) and hospitals (p < 0.001). Longer time to surgery was significantly associated with increasing magnitude of the Cobb angle through the second year of waiting (p < 0.001). Reported causes for delay were hospital-related (48.4%), economic (47.3%), and logistic (4.2%). Oddly, waiting time for surgery did not correlate with the hospital's reported waiting-list lengths (p = 0.57). Conclusion: Prolonged waits for AIS surgery are common in Latin America, with rare exceptions. At most centers, patients wait over six months, most commonly for economic and hospital-related reasons. Whether this directly impacts surgical outcomes in Latin America still must be studied.

Unmet Needs of Surgical Care for Children: A Case Study in the Brazilian Publicly-Financed Health System.

Objective To measure and document the clinical impact of the waiting time for surgical treatment of patients with spinal deformities in a quaternary center in Brazil. Methods In total, 59 patients with spinal deformity waiting for surgery on our hospital's list were evaluated to observe the impact of the waiting time on the progression of the deformity. Patient evaluation was performed using the SRS-22r questionnaire for health-related quality of life (HRQL) and radiographic images to evaluate the deformity of the spine at the time the patients were included in the waiting list and at the most recent appointment. The radiographic parameters selected for comparison were: Cobb angle of the primary and secondary curves, coronal alignment, apical vertebral translation, pelvic obliquity, sagittal vertebral axis, kyphosis (T5-T12), and lordosis (L1-S1). Results Low HRQL scores according to the SRS-22r questionnaire were observed in patients waiting for surgery. The radiographic parameters showed progression of the deformity on the initial evaluation when compared with the most recent follow-up evaluation. Conclusion The patients waiting for surgical treatment of spinal deformities in our center showed relatively low HRQL scores and radiographic progression of the deformity.

Early Complications in Vertical Expandable Prosthetic Titanium Rib and Magnetically Controlled Growing Rods to Manage Early Onset Scoliosis.

OBJECTIVES: The aim of this study is to examine whether surgical treatment of early onset scoliosis (EOS) with magnetically controlled growing rods (MCGRs) or a vertical expandable prosthetic titanium rib (VEPTR) resulted in fewer short-term (24 months) complications and reoperations. BACKGROUND: EOS is a challenging problem for spine surgeons that has been managed with different growth-friendly instrumentation systems. Although rib-based devices encourage spinal growth via regular lengthening, the high rate of complications and reoperations leads us to use spine-based devices such as MCGRs to mitigate this concern. METHODS: A total of 35 EOS patients were included in the study. Twenty patients were included in the VEPTR group, and 15 patients were included in the MCGR group. Demographic data and 2 years of postoperative complications and reoperations were reviewed retrospectively. As secondary outcomes, radiographic outcomes were reported preoperatively and 1 year after surgery. Indications for this technique and complications were collected from the charts. RESULTS: Demographic data showed no significant differences between the 2 groups. Significant differences were found in the complications rate at 2 years, with 65% complications in the VEPTR group and 13.3% complications in the MCGR group (P < .001). The reoperation rate at 2 years was also significantly higher in the VEPTR group, with 50% versus 13.3% in the MCGR group (P = .0009). As secondary outcomes, radiological parameters such as main curve Cobb angle correction (P = .001) and apical vertebral translation (P = .002) were significantly higher in the MCGR group. Significant differences were also found in sagittal profile parameters; T1-T12 and T1-S1 were significantly higher in the MCGR group (P < .001). CONCLUSIONS: According to our results, VEPTR has significantly higher complication and reoperation rates at 2 years postsurgery compared with MCGR. LEVEL OF EVIDENCE: 4.

Staged instrumentation with magnetically controlled growing rods in early-onset scoliosis: indications and preliminary outcomes.

BACKGROUND: Severe scoliosis, kyphosis, stiffer curves, short trunk height, and poor bone density are known risk factors for instrumentation failure with traditional growing rods or magnetically controlled growing rods (MCGR). To minimize the risk of instrumentation failure in managing complex early-onset scoliosis (EOS) with MCGR, we propose a strategy for staged MCGR insertion. METHODS: We performed a single-center retrospective review of all consecutive MCGR cases with 24 months' minimum follow-up. Inclusion criteria included diagnosis of EOS of any etiology with severe and stiff curves in the coronal or sagittal planes, poor bone density, short trunk height (T1-T12 smaller than 150 mm) or previous instrumentation failure managed with staged MCGR. During the first stage, anchor points and halo-gravity were applied, followed by halo-gravity traction. At a second stage, halo-gravity was removed and MCGR were inserted. Outcome measures included pre- and postoperative radiographic measurements and complications. RESULTS: Seventeen patients with a median age of 7 (range 6-9) years were managed in two stages. Indications for two-stage surgery were short trunk height (T1-T12 height less than 150 mm) in six patients, five poor bone quality, three dislodgement of proximal anchor points in previous instrumentation, and three rigid curves. The rate of unplanned revision surgeries was 11.8%. No infections or traction-related complications were found. CONCLUSIONS: According to our results, the staged MCGR insertion strategy combined with halo-gravity traction to manage complex EOS yielded a relatively low instrumentation failure rate as compared with the rates previously reported in the current literature. To our knowledge, this is the first study reporting the staged strategy for instrumentation with MCGR. LEVEL OF EVIDENCE: IV.

Pedicle Screw Instrumentation in Scoliosis Surgery: On Site Simulation Data on Accuracy and Efficiency With Different Techniques.

STUDY DESIGN: Prospective experimental study with on-site simulation. OBJECTIVE: To compare the accuracy and efficiency of different techniques for pedicle screw instrumentation (PSI). SUMMARY OF BACKGROUND DATA: Improving the safety and efficiency of PSI is a critical step to reduce the complication rates and the cost of scoliosis surgery. Innovative operative techniques for PSI have shown to safely improve efficiency, thereby reducing cost. Surgical simulation is a valuable tool to study different operative techniques. METHODS: Five spine fellows instrumented 20 simulation models of a scoliotic spine with 10 pedicle screws per model. Four techniques were studied, including the conventional pedicle probe and the innovative sequential drilling technique, with or without computed tomography (CT)-based navigation. Our primary outcome measures were efficiency and accuracy of PSI. We analyzed the data with bivariate analyses using the Chi-square test for categorical variables and the Student t test or ANalysis Of VAriance with Bonferroni post-hoc tests for continuous variables. RESULTS: The drilling techniques (free hand and navigated) were more efficient as compared with the pedicle probe techniques (P < 0.01). The navigated techniques resulted in better accuracy as compared with the free hand techniques (P = 0.036). Most pedicle breaches were medial (n = 32/52). The concave apical pedicle (T4 right side) had the highest incidence of breaches. There was no significant difference in efficiency comparing the free hand and the navigated pedicle probe techniques (P = 0.261) or comparing the free hand drilling and the navigated drilling techniques (P = 1.00). CONCLUSION: On site surgical simulation is a promising concept for teaching advanced procedural skills. Our findings suggest that navigation improves the accuracy of PSI while sequential drilling safely improves efficiency. Combining navigation with sequential drilling can significantly improve the accuracy and the efficiency of PSI in scoliosis surgery, as previously suggested with our published clinical data. LEVEL OF EVIDENCE: 4.

Sagittal Balance in Adolescent Idiopathic Scoliosis Managed With Intraoperative Skull Femoral Traction.

STUDY DESIGN: This is a retrospective cohort, single-center quality improvement study. OBJECTIVES: To evaluate the effect of the intraoperative skull femoral traction (IOSFT) on sagittal balance in posterior spinal instrumentation (PSI) to manage scoliosis. SUMMARY OF BACKGROUND DATA: IOSFT has been used routinely as an adjunct technique for facilitating PSI to manage scoliosis in our institution since 2010. Previous studies have raised concerns regarding the negative effect of IOSFT on lumbar lordosis. MATERIALS AND METHODS: The medical records and radiographs of 113 patients with adolescent idiopathic scoliosis managed with single stage PSI were reviewed. Eighty-five patients were operated with IOSFT (traction group) and 28 patients were operated without traction (nontraction group). Patients who had double (anterior-posterior) approaches or nonidiopathic scoliosis were excluded. Sagittal balance and pelvic parameters at 2 years of postoperative follow-up were the primary outcome measures. Statistical analysis was done with R for statistical computing. Median values and interquartile range were compared between groups using Wilcoxon rank sum, Fischer exact, and Welch t tests. P-values of <0.05 were considered statistically significant. RESULTS: No significant differences were found comparing postoperative lumbar lordosis in the nontraction group (54 degrees) with the traction group (53 degrees) (P=0.4953). No significant differences were found in postoperative sagittal vertical axis medians comparing both groups, with 17 mm in the nontraction group and 18 mm in the traction group (P=0.3994). No significant differences were found in postoperative pelvic parameters. The median pelvic incidence was 52 degrees in the nontraction group and 50 degrees in the traction group (P=0.2711). CONCLUSIONS: According to our results, the use of IOSFT as an adjunct to facilitate PSI for managing adolescent idiopathic scoliosis had no measurable negative impact on sagittal balance in our IOSFT cohort.

Quality, Safety, and Value of Innovating Classic Operative Techniques in Scoliosis Surgery: Intraoperative Traction and Navigated Sequential Drilling.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aims to measure and describe the clinical and financial implications of the systematic implementation of intraoperative skull-femoral traction (IOSFT) and navigated sequential drilling (NSD) for posterior spinal instrumentation and fusion (PSIF) in adolescent idiopathic scoliosis (AIS) at our institution. SUMMARY OF BACKGROUND DATA: PSIF has been the standard surgical treatment for AIS. This retrospective single-center quality improvement study describes the perioperative outcomes and impact on health resource utilization following the systematic application of two classic surgical strategies modified using current technology: IOSFT and NSD. METHODS: We reviewed the medical records of 125 patients who underwent a single-stage PSIF for AIS. We identified three cohorts based on surgical strategies used intraoperatively. Traditional techniques (n = 28), IOSFT (n = 45), and IOSFT plus NSD (n = 52). The primary outcome measures were operative time, prevalence of cases requiring extended operating room time, need for blood transfusion, length of hospital stay, and cost per surgery. Secondary outcomes included implant density, degree of spine deformity correction, and perioperative complications. RESULTS: All primary outcome measures improved significantly (p < .001). Median operating time decreased by 59%. Use of late operating room hours fell from 89% to 0% and transfusion rates from 64% to 1.9%. Length of hospital stay decreased from 6 to 4 days. Comprehensive cost per case decreased by 24%. DISCUSSION: Together, IOSFT and NSD improved the quality, safety, and value of care. These surgical strategies were performed without increased perioperative complications, while reducing cost per case by 24%. CONCLUSIONS: The data presented may have significant implications in health resource utilization for AIS surgery. LEVEL OF EVIDENCE: Level III.

Reinventing the wheel in scoliosis surgery: effective strategies for safely improving efficiency

Posterior spinal instrumentation and fusion (PSIF) has been the standard operative treatment for adolescent idiopathic scoliosis (AIS) and is one of the most frequently performed elective pediatric surgeries in North America, incurring an expenditure of more than $1.1 billion annually in the United States alone. This commentary reflects on the outcomes of systematically implementing intraoperative skull femoral traction (IOSFT) combined with navigated sequential drilling (NSD) during PSIF for AIS as strategies for quality improvement at our tertiary children's hospital.

Quality of life evaluation in patients with mucopolysaccharidosis using PedsQL.

Mucopolysaccharidosis (MPS) is a rare and neglected disorder. Only a few studies to date have focused on humanistic impacts of the disease, particularly health-related quality of life (HRQOL). The objective of our research is to (1) evaluate HRQOL in Brazilian patients with MPS and (2) assess the validity of the PedsQL 4.0 Generic Core Scales (PedsQL) in this specific disease. We performed an analytical cross-sectional study using the Brazilian Portuguese version of the PedsQL in 22 patients with MPS between the ages of 8 and 21. With regard to assessing the validity of the PedsQL for MPS, we evaluated internal consistency using Cronbach's α coefficient and reliability using the Spearman-Brown estimate of agreement. The mean HRQOL score in our sample was 63.6 points. The worst score was obtained in the Psychosocial domain (61.9) on account of interference with school (56.1), while the Physical Health domain had the highest score (67.6). The total PedsQL internal consistency was .764 points. The Physical Health domain obtained the highest internal consistency (.914), whereas the Psychosocial Health domain obtained the lowest one (.754). MPS was demonstrated to decrease HRQOL, and PedsQL seems to be a valid instrument to perform this kind of analysis.

Hemolysis Following Intraoperative Cell Salvage Replacement in a Scoliosis Patient With Sickle Cell Trait: A Case Report.

MINI: Intraoperative cell salvage (ICS) is used to reduce blood loss in scoliosis spinal fusion. We report one case of hemolysis induced acute renal failure following ICS. This is the first reported case of acute renal failure associated with hemolysis following ICS in a scoliosis patient with sickle cell trait. STUDY DESIGN: Case report. OBJECTIVE: To describe a novel presentation of acute renal failure associated with hemolysis after intraoperative cell salvage (ICS) in a neuromuscular scoliosis patient with sickle cell trait (SCT). SUMMARY OF BACKGROUND DATA: Hemolysis-associated acute renal failure after ICS in patients with SCT has not been previously reported. Sickle cell disease is regarded as a relative contraindication for ICS due to the risk of red blood cell sickling in the hypoxic cell saver reservoir. A previous case series demonstrated successful ICS reinfusion after elective caesarean section in two patients with SCT. However, a decision to not reinfuse ICS collected blood due to increased sickling after blood processing was reported in general surgery. METHODS: A 14-year-old female with Group I neuromuscular scoliosis underwent a navigated T3-S1posterior spinal instrumentation fusion. Three hundred milliliters of blood collected by ICS was reinfused intraoperatively along with two units of packed red blood cells. RESULTS: Postoperatively, the patient had delayed emergence from the general anesthetic and gross hematuria was observed in the urinary catheter bag. The patient was transferred to the intensive care unit and was treated successfully for hemolysis-induced renal failure. CONCLUSION: Given the potential seriousness of hemolysis-associated acute renal failure associated with ICS, we recommend against the use of ICS in patients with SCT. LEVEL OF EVIDENCE: 5.

Intraoperative skull-femoral traction in posterior spinal arthrodesis for adolescent idiopathic scoliosis: the impact on perioperative outcomes and health resource utilization.

STUDY DESIGN: Retrospective, single-center cohort study. OBJECTIVE: To study how the systematic use of intraoperative skull-femoral traction (IOSFT) in posterior arthrodesis for adolescent idiopathic scoliosis impacts perioperative outcomes and health resource utilization. SUMMARY OF BACKGROUND DATA: Large scoliosis curves have been associated with increased morbidity and utilization of health resources. When used with reliable neurophysiological monitoring, IOSFT has shown to be safe and to reduce curve magnitude intraoperatively. Thus, we hypothesized that the systematic use of IOSFT may contribute to reducing health resource utilization by reducing curve magnitudes intraoperatively. METHODS: Seventy-three consecutive patients with adolescent idiopathic scoliosis who underwent single-stage posterior spinal arthrodesis from 2008 to 2012 at a tertiary children's hospital were identified. Forty-five patients were operated with IOSFT (traction group) and 28 patients were operated without IOSFT (nontraction group). Outcome measures included operative time, calculated blood loss, blood transfusion requirement, traction-related complications, and cost comparisons. RESULTS: Operative time was 375.6 minutes for the traction group (P=0.0001) and 447.6 minutes for the nontraction group. Calculated blood loss was significantly less in the traction group (P=0.027). Thirty-three percent of patients in the traction group required blood transfusion compared with 64% of patients in the nontraction group (P=0.01, absolute risk reduction of 31%). There was no significant difference in curve magnitude correction (P=0.49). There were no significant complications with the use of traction. There was a significant reduction in cost per surgical procedure in the traction group (P=0.0003). CONCLUSION: The systematic use of IOSFT in posterior spinal arthrodesis for adolescent idiopathic scoliosis contributed to significant reductions in health resource utilization, with no added morbidity. Further research is warranted to investigate the generalizability of these findings. LEVEL OF EVIDENCE: 4.

Subungual exostosis of the toes: a systematic review.

BACKGROUND: Subungual exostosis is a relatively common benign bone tumor that occurs in the distal phalanges of the toes and can be a source of pain and nail deformity. There is controversy about the treatment of these lesions and there are few studies that have synthesized what is known and provided meaningful information on treatment. QUESTIONS/PURPOSES: We performed a systematic review to address the following questions: (1) What is the best surgical approach for excising these lesions? (2) What is the age range, sex distribution, and presenting symptoms of subungual exostoses and which toe is most frequently affected? (3) What complications arise from treatment? METHODS: Two authors independently searched multiple databases (Medline, 1950-May 2013; Cochrane EBM database, and EMBASE, 1980-May 2013 provided by OVID; ACP Journal Club, 2003-May 2013; CINAHL by EBSCO, 1937-May 2013; and PubMed by NLM, 1940-May 2013), and key words were chosen to achieve a broad search strategy. We included studies on the management of toe exostoses with > 10 cases and we excluded studies that reported on upper extremity exostoses or osteochondromas. Demographic and treatment data were collected from each article by two independent authors and collated. A total of 124 abstracts were screened, and 116 articles were reviewed in full, of which 13 met the inclusion criteria. RESULTS: Complete marginal excision through a fish mouth incision protecting the nail led to a recurrence rate of 4% and satisfactory clinical results, defined as no requirement for postoperative intervention and a satisfactory clinical appearance in 73%. Most studies provided incomplete descriptions of specific surgical techniques used. Fifty-five percent of the patients were younger than 18 years of age. A history of toe trauma before diagnosis was present in approximately 30% of the cases. Delayed diagnosis occurred in approximately 10% of the cases and onychodystrophy occurred in more than 10%. CONCLUSIONS: There is weak evidence to guide management of subungual exostosis. Adequate wound management postexcision aiming to minimize disruption to the nail bed and matrix may prevent onychodystrophy, which is a common complication of treatment.

A novel management strategy for subungual exostosis.

Subungual exostosis is a relatively uncommon benign bone tumour that mostly affects the toes of young people and can be a source of significant impact on health-related quality of life. Treatment consists of marginal excision and meticulous wound closure. We presented a case of subungual exostosis in the hallux of a young Caucasian girl. Once diagnosed, the lesion was completely excised leaving a sizable defect in the nail bed and skin folds. A pedicled vacuum assisted closure (VAC) device was used postoperatively in an attempt to minimise the tissue deficit. At 1-year follow-up, the nail had regrown and tissue reformed producing an optimal functional and cosmetic result with no recurrence. Postoperative wound complications in the setting of subungual exostosis are significant and a great variability exists in their appropriate management. We presented the novel use of the VAC device in the successful management of subungual exostosis.

Atlantoaxial and craniocervical arthrodesis in children: a tomographic study comparing suitability of C2 pedicles and C2 laminae for screw fixation.

STUDY DESIGN: Analysis of C1-C2 tomographic anatomy in a cohort of healthy children. OBJECTIVE: Compare suitability of C2 laminae and C2 pedicles for screw placement. SUMMARY OF BACKGROUND DATA: Surgeons have applied several techniques for craniocervical and atlantoaxial spondylodesis to address congenital or developmental abnormalities in children. Constructs with pedicle or transarticular screws are effective to stabilize the craniocervical junction; however, these fixation points are not suitable in all patients. Translaminar screw placement in C2 has been safely performed in children; yet, suitability of C2 laminae and C2 pedicles has not been systematically compared. METHODS: Applying chi2 test, we compared suitability for screw placement in 46 C2 pedicles and 46 C2 laminae on digital images of axial reconstructions of cervical CT scans of 23 children who had been admitted to the same hospital due to head or neck injury. On the same scans, we estimated suitability for screw placement in 46 lateral masses of C1. RESULTS: Twenty-four percent of C2 pedicles and 65% of C2 laminae were deemed suitable for 3.5-mm screw placement, and the difference was statistically significant (P < or = 0.0001, chi2 15.88). Forty-one percent of C2 pedicles and 80% of C2 laminae were deemed suitable for 3.0-mm screw placement, and the difference was statistically significant (P < or = 0.0001, chi2 14.78). Ninety-five percent of C1 lateral masses were deemed suitable for 3.5-mm screw placement. CONCLUSION: C2 laminae represent a viable fixation point for C1-C2 and craniocervical arthrodesis in children. This information can be useful for preoperative planning.

Inequitable distribution of health resources in Brazil: an analysis of national priority setting / Distribución injusta de los recursos en salud en Brasil: un análisis del establecimiento de prioridades nacionales / Distribuição injusta dos recursos em saúde no Brasil: uma análise da definição de prioridades nacionais

The purpose of this paper is to describe the national priority setting process for the public health system in Brazil, evaluating the process using the ethical framework Accountability for Reasonableness, and equity considerations highlighted in the 2008 WHO Commission on Social Determinants of Health. We searched the Brazilian Ministry of Health website for documents that described priority setting within the Brazilian Universal Health Care System (SUS). The National Health Conference (CNS) has been defined by the Ministry of Health as the democratic priority setting forum for SUS. The most recent such conference (13th CNS, 2007) is the subject of this paper. Our analysis suggests that the process of priority setting within SUS has not yet achieved the ethical standards of legitimacy and fairness, and that inequitable distribution of decision making power under- represents users in poor areas. The unmet need for hospital care for children in Brazil, which reflects a remarkable inequality of opportunity for human development, may be a product of poor priority setting processes and inequity in representation.

Este artículo pretende describir el establecimiento de prioridades nacionales en el proceso de cuidado del sistema de salud en Brasil, evaluando el proceso con el empleo del marco ético de Administración Razonable, y de consideraciones de equidad destacadas por la Comisión sobre Determinantes Sociales de la Salud de la Organización Mundial de la Salud (OMS). Buscamos documentos que describieran el establecimiento de prioridades dentro del Sistema Único de Salud brasileño (SUS) en el sitio del Ministerio de Salud Brasileño. La Conferencia Nacional sobre Salud (CNS) ha sido definida por el Ministerio de Salud como el foro del SUS para el establecimiento de prioridades democráticas. La 13¬ CNS, 2007 -la más reciente de dichas conferencias- constituye el tema de este artículo. Nuestro análisis sugiere que el proceso de establecimiento de prioridades dentro del SUS no ha alcanzado aún los patrones éticos de legitimidad y justicia, y que la distribución injusta de las instancias de poder de decisión no representa realmente a las áreas más pobres. La meta aún no alcanzada de necesidad de hospitales para niños en Brasil significa una notable falta de igualdad en las oportunidades para el desarrollo humano y puede que sea producto de la mala definición del proceso de prioridades y de la falta de equidad en la representación.

Este artigo pretende descrever a definição de prioridades nacionais no processo de cuidado do sistema de saúde no Brasil, avaliando o processo com o emprego do marco ético de Administração Razoável e de considerações sobre a equidade, destacadas pela Comissão sobre Determinantes Sociais da Saúde da Organização Mundial da Saúde (OMS). Buscamos documentos que descreveram o estabelecimento de prioridades dentro do Sistema Único de Saúde brasileiro (SUS) no site do Ministério da Saúde brasileiro na web. A Conferência Nacional de Saúde (CNS) foi definida pelo Ministério da Saúde como o fórum do SUS para o estabelecimento de prioridades democráticas. A 13a CNS, 2007 -a mais recente das citadas conferências- constitui o tema deste artigo. Nossa análise sugere que o processo de estabelecimento de prioridades dentro do SUS não alcançou ainda os padrões éticos de legitimidade e justiça e que a distribuição injusta das instâncias do poder de decisão não alcança realmente as áreas mais pobres. A meta ainda não alcançada da necessidade de hospitais infantis no Brasil, o que significa uma notável falta de igualdade de oportunidades para o desenvolvimento humano e pode ser produto de uma má definição do processo de prioridades e da falta de equidade na representação.