Health-Related Predictive Factors of Brazilian Children With Early Onset Scoliosis Using the EOSQ-24 and CHQ-PF50 Questionnaires.

BACKGROUND: Assessing the quality of life (QOL) of children with early onset scoliosis (EOS) has been discussed recently. Therefore, the study aimed to apply and correlate the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) with the 50-item Childhood Health Questionnaire (CHQ-PF50) to find predictive factors impacting QOL. METHODS: Cross-sectional study involving a population of caregivers of patients with EOS. The sample consisted of 72 patients. Two research assistants applied the Portuguese version of the EOSQ-24 and CHQ-PF50 in 3 treatment centers. The EOSQ-24 assesses the subjective response of children with EOS from the parent's point of view. The CHQ is a self-administered questionnaire or parental proxy assessment of the psychological and social status of children aged 5 to 18 years. RESULTS: Of 72 patients, 41 (56.9%) were females, mean age of 11.9 ± 4.2 years. The most common scoliosis was of neuromuscular origin (32%). The CHQ-PF50 showed that family-related items had significant scores. The most affected subcategory was physical function (45.5), and the least affected was mental health (90.8). Thus, the CHQ-PF50 PhS summary index was 27, and the CHQ-PF50 PsS was 71.7. Moreover, the critical categories for the EOSQ-24 questionnaire were daily life and physical function (45.1 and 47.8, respectively), and the least affected categories were transfer and pulmonary function (70.8 and 68.9, respectively). Four subcategories showed a strong correlation between both questionnaires: general health (r = 0.749, P < 0.001), physical function (r = 0.645, P < 0.001), bodily pain (r = 0.714, P < 0.001), and mental health (r = 0.424, P < 0.001). Using CHQ-PF50 as a dependent variable in multiple regression analysis (P = 0.028), the only variable affecting the scores was syndromic scoliosis (P = 0.019; 95% CI -27.4 to -2.5). CONCLUSION: A strong correlation between both questionnaires was seen for general health, physical function, bodily pain, and mental health. Syndromic scoliosis was a predictor of worse QOL according to the CHQ-PF50.

IMPACT OF THE COVID-19 PANDEMIC ON SPINE SURGERY IN A TERTIARY HEALTH CARE INSTITUTION.

Objectives: To assess postoperative complications, including COVID-19 infection, among patients undergoing surgeries at a tertiary institution during the pandemic, and to develop a local epidemiological profile of spine surgery patients. Methods: Retrospective descriptive study of all patients who underwent spine surgery between March 2020 and 14 January 2021 in a tertiary institution in Latin America. All patients who underwent spine surgery were included, without age restrictions. The main outcomes were postoperative complications, including COVID-19 infection. Results: 74 patients were included in the study, 43 males and 31 females. The average age was 49.6 years. The mean duration of hospitalization was 11.5 days. Urgent surgeries were performed in 60.81% of cases. During hospitalization, only 5 of 74 patients were diagnosed with COVID-19, and only 1 patient had pulmonary involvement estimated to be greater than 50%. On average, 1.9 surgical debridements were required after postoperative surgical site infection. Conclusions: During the hospitalization period, only 6.7% of patients were diagnosed with COVID-19 infection. The COVID-19 infection death rate was 1 in 5 cases. The postoperative surgical site infection rate was 10.8%, similar to the level before the pandemic. Level of Evidence IV; Observational retrospective descriptive study .

Objetivos: Avaliar complicações pós-cirúrgicas, incluindo infecções por COVID-19, entre pacientes cirúrgicos numa instituição terciária de saúde durante a pandemia, e desenvolver um perfil epidemiológico local de pacientes de cirurgias da coluna. Métodos: estudo descritivo e retrospectivo de todos os pacientes que passaram por cirurgias da coluna entre março de 2020 e 14 de janeiro de 2021, numa instituição terciária na América Latina. Todos os pacientes que passaram por cirurgias na coluna foram incluídos, sem restrição de idade. Os principais resultados foram complicações pós-cirúrgicas, incluindo a infecção por COVID-19. Resultados: 74 pacientes foram incluídos no estudo, 43 do sexo masculino e 31 do feminino. A média de idade foi de 49.6 anos. A duração média da hospitalização foi de 11.5 dias. Cirurgias urgentes foram realizadas em 60.81% dos casos. Durante a hospitalização, apenas 5 dos 74 pacientes foram diagnosticados com COVID-19, e apenas 1 deles teve envolvimento pulmonar estimado em mais que 50%. Em média, 1,9 desbridamentos cirúrgicos foram necessários após infecção do sítio cirúrgico. Conclusões: Durante o período de hospitalização, apenas 6,37% dos pacientes foram diagnosticados com infeção por COVID-19. A taxa de mortes devido à infecção por COVID-19 foi de 1 em 5. Infecções do sítio cirúrgico atingiram uma taxa de 10.8%, nível similar àquele prévio à pandemia. Nível de evidência IV ; Estudo observacional retrospectivo descritivo .

Impact of the covid-19 pandemic on spine surgery in a tertiary health care institution / Impacto da pandemia de covid-19 nas cirurgias de coluna em uma instituição terciária de saúde

ABSTRACT Objectives: To assess postoperative complications, including COVID-19 infection, among patients undergoing surgeries at a tertiary institution during the pandemic, and to develop a local epidemiological profile of spine surgery patients. Methods: Retrospective descriptive study of all patients who underwent spine surgery between March 2020 and 14 January 2021 in a tertiary institution in Latin America. All patients who underwent spine surgery were included, without age restrictions. The main outcomes were postoperative complications, including COVID-19 infection. Results: 74 patients were included in the study, 43 males and 31 females. The average age was 49.6 years. The mean duration of hospitalization was 11.5 days. Urgent surgeries were performed in 60.81% of cases. During hospitalization, only 5 of 74 patients were diagnosed with COVID-19, and only 1 patient had pulmonary involvement estimated to be greater than 50%. On average, 1.9 surgical debridements were required after postoperative surgical site infection. Conclusions: During the hospitalization period, only 6.7% of patients were diagnosed with COVID-19 infection. The COVID-19 infection death rate was 1 in 5 cases. The postoperative surgical site infection rate was 10.8%, similar to the level before the pandemic. Level of Evidence IV; Observational retrospective descriptive study .

RESUMO Objetivos: Avaliar complicações pós-cirúrgicas, incluindo infecções por COVID-19, entre pacientes cirúrgicos numa instituição terciária de saúde durante a pandemia, e desenvolver um perfil epidemiológico local de pacientes de cirurgias da coluna. Métodos: estudo descritivo e retrospectivo de todos os pacientes que passaram por cirurgias da coluna entre março de 2020 e 14 de janeiro de 2021, numa instituição terciária na América Latina. Todos os pacientes que passaram por cirurgias na coluna foram incluídos, sem restrição de idade. Os principais resultados foram complicações pós-cirúrgicas, incluindo a infecção por COVID-19. Resultados: 74 pacientes foram incluídos no estudo, 43 do sexo masculino e 31 do feminino. A média de idade foi de 49.6 anos. A duração média da hospitalização foi de 11.5 dias. Cirurgias urgentes foram realizadas em 60.81% dos casos. Durante a hospitalização, apenas 5 dos 74 pacientes foram diagnosticados com COVID-19, e apenas 1 deles teve envolvimento pulmonar estimado em mais que 50%. Em média, 1,9 desbridamentos cirúrgicos foram necessários após infecção do sítio cirúrgico. Conclusões: Durante o período de hospitalização, apenas 6,37% dos pacientes foram diagnosticados com infeção por COVID-19. A taxa de mortes devido à infecção por COVID-19 foi de 1 em 5. Infecções do sítio cirúrgico atingiram uma taxa de 10.8%, nível similar àquele prévio à pandemia. Nível de evidência IV ; Estudo observacional retrospectivo descritivo .

Tomographic analysis of c7, t1 and t2 vertebrae anatomy in children / Estudo tomográfico das vértebras c7, t1 e t2 em crianças

ABSTRACT Objective: To evaluate and compare anatomical measurements of C7, T1 and T2 vertebrae in children from 3 to 12 years of age to provide useful epidemiological data for determining the safe anatomical margin for transpedicular and translaminar fixation with screws in this population. Methods: This observational retrospective cross-sectional study evaluated 76 computed tomography scans obtained over 6 months, analyzing the following parameters: the angle of attack, length, thickness and diameter of the pedicle; and the angle of attack, length and thickness of the lamina. Results: The lamina length and thickness, as well as pedicle length varied in size according to age. Although the angle of attack was similar across different ages, age-dependent variation occurred in the T1 vertebra. Conclusion: Screws with a 3.5 mm diameter are safe to use in the C7 and T2 pedicles, while the T1 pedicle allows the introduction of larger screws ranging from 3.5-4.5 mm in diameter. In the lamina, 3.5 mm screws are safe for use only in children older than 7 years. However, each case should be analyzed individually, with the present study not aiming to replace the preoperative use of CT. Level of Evidence III, Retrospective comparative study.

RESUMO Objetivo: Avaliar e comparar as medidas anatômicas das vértebras C7, T1 e T2 em crianças de 3 a 12 anos de modo a determinar margens seguras para fixação transpedicular e translaminar com parafusos nessa população. Métodos: Estudo transversal retrospectivo observacional. Um total de 76 tomografias computadorizadas foram analisadas em um período de 6 meses. Os seguintes parâmetros foram analisados: ângulo de ataque, comprimento, espessura e diâmetro do pedículo, comprimento e espessura da lâmina. Resultados: O comprimento e espessura da lâmina bem como o comprimento do pedículo aumenta em tamanho conforme a idade. Enquanto o ângulo de ataque permanece estável conforme variação de idade; variação dependente da idade ocorre somente na vértebra T1. Conclusão: Parafusos com diâmetro de 3.5mm podem ser inseridos de maneira segura nos pedículos de C7 e T2. Já no pedículo de T1 pode-se inserir parafusos com medidas de 3.5 a 4.5mm de diâmetro de maneira segura. Na lâmina, parafusos de 3.5mm podem ser usados de maneira segura somente em crianças maiores de 7 anos. No entanto, cada caso deve ser analisado de maneira individualizada, e o presente estudo não objetivo substituir o uso de tomografia computadorizada no pré-operatório. Nível de Evidência III, Estudo Comparativo Retrospectivo.

TOMOGRAPHIC ANALYSIS OF C7, T1 AND T2 VERTEBRAE ANATOMY IN CHILDREN.

OBJECTIVE: To evaluate and compare anatomical measurements of C7, T1 and T2 vertebrae in children from 3 to 12 years of age to provide useful epidemiological data for determining the safe anatomical margin for transpedicular and translaminar fixation with screws in this population. METHODS: This observational retrospective cross-sectional study evaluated 76 computed tomography scans obtained over 6 months, analyzing the following parameters: the angle of attack, length, thickness and diameter of the pedicle; and the angle of attack, length and thickness of the lamina. RESULTS: The lamina length and thickness, as well as pedicle length varied in size according to age. Although the angle of attack was similar across different ages, age-dependent variation occurred in the T1 vertebra. CONCLUSION: Screws with a 3.5 mm diameter are safe to use in the C7 and T2 pedicles, while the T1 pedicle allows the introduction of larger screws ranging from 3.5-4.5 mm in diameter. In the lamina, 3.5 mm screws are safe for use only in children older than 7 years. However, each case should be analyzed individually, with the present study not aiming to replace the preoperative use of CT. Level of Evidence III, Retrospective comparative study.

OBJETIVO: Avaliar e comparar as medidas anatômicas das vértebras C7, T1 e T2 em crianças de 3 a 12 anos de modo a determinar margens seguras para fixação transpedicular e translaminar com parafusos nessa população. MÉTODOS: Estudo transversal retrospectivo observacional. Um total de 76 tomografias computadorizadas foram analisadas em um período de 6 meses. Os seguintes parâmetros foram analisados: ângulo de ataque, comprimento, espessura e diâmetro do pedículo, comprimento e espessura da lâmina. RESULTADOS: O comprimento e espessura da lâmina bem como o comprimento do pedículo aumenta em tamanho conforme a idade. Enquanto o ângulo de ataque permanece estável conforme variação de idade; variação dependente da idade ocorre somente na vértebra T1. CONCLUSÃO: Parafusos com diâmetro de 3.5mm podem ser inseridos de maneira segura nos pedículos de C7 e T2. Já no pedículo de T1 pode-se inserir parafusos com medidas de 3.5 a 4.5mm de diâmetro de maneira segura. Na lâmina, parafusos de 3.5mm podem ser usados de maneira segura somente em crianças maiores de 7 anos. No entanto, cada caso deve ser analisado de maneira individualizada, e o presente estudo não objetivo substituir o uso de tomografia computadorizada no pré-operatório. Nível de Evidência III, Estudo Comparativo Retrospectivo.

Comparative tomographic study of the iliac screw and the S2-alar-iliac screw in children.

OBJECTIVES: The recent advancements in spine fixation aid in the treatment of complex spinal pathologies. Both the iliac screw (IS) and the S2-alar-iliac (S2AI) screw provide adequate stability in the fixation of complex lumbosacral spine pathologies, leading to a significant increased rate of using these techniques in the daily practice of the spine surgeons. This study aims to analyze, describe, and compare the insertion and positioning parameters of the S2AI screw and IS techniques in children without spinal deformities. METHODS: An observational retrospective study was conducted at a university hospital in 2018, with 25 computed tomography (CT) images selected continuously. Mann-Whitney-Shapiro-Wilk tests were performed. The reliability of the data was assessed using the intraclass correlation. The data were stratified by age group only for Pearson's correlation analysis. RESULTS: The mean age was 11.7 years (4.5 SD). The mean IS length was 106.63 mm (4.59 SD). The mean length of the S2AI screw was 104.13 mm (4.22 SD). The mean skin distance from the IS entry point was 28.13 mm (4.27 SD) and that for the S2AI screw was 39.96 mm (4.54 SD). CONCLUSIONS: Through CT, the S2AI screw trajectory was observed to have a greater bone thickness and skin distance than the IS. There was a linear correlation between age and screw length for both techniques. A similar relationship was observed between skin distance and age for the S2AI screw technique. In children, the S2AI screw technique presents advantages such as greater cutaneous coverage and implant thickness than the IS technique.

Percutaneous Endoscopic Lumbar Discectomy Versus Microdiscectomy for the Treatment of Lumbar Disc Herniation: Pain, Disability, and Complication Rate-A Randomized Clinical Trial.

PURPOSE: The objective was to compare the traditional microdiscectomy with percutaneous endoscopic lumbar discectomy for the treatment of disc herniations regarding pain, disability, and complications. METHODS: Randomized clinical trial with 47 patients with disc herniations treated with 2 different surgical techniques: traditional microdiscectomy or percutaneous endoscopic lumbar discectomy. Forty-seven patients were divided into 2 groups and monitored for 12 months. Irradiated and low back pain were evaluated with the visual analog scale. Surgery complications were recorded. RESULTS: After surgery, the sciatica and disability improved significantly but without significant differences between the groups. Improvements in back pain were significant until the third month. There were no statistical differences between groups regarding recurrence, infection, and the need for reoperation. CONCLUSIONS: Endoscopic discectomy results are similar to those of conventional microdiscectomy regarding pain and disability improvement. Postoperative lumbar pain is less intense with endoscopic discectomy than conventional microdiscectomy only during the first 3 months. Endoscopic discectomy is a safe and efficient alternative to microdiscectomy. CLINICAL TRIALS: Trial protocol registration number: RBR-5symrd (http://www.ensaiosclinicos.gov.br).

Does Kyphectomy Improve the Quality of Life of Patients With Myelomeningocele?

BACKGROUND: Lumbar kyphosis is a complex spinal deformity occurring in approximately 8% to 20% of patients with myelomeningocele. The resulting gibbosity may cause pressure ulcers, difficulty lying down in the supine position and sitting on the ischia without support, decreasing quality of life (QOL). Surgery is generally performed to correct kyphosis and maintain vertebral alignment, but high complication rates have been reported. Despite satisfactory radiological results, the impact of surgery and its complications on health-related QOL (HRQOL) has not yet been established. QUESTIONS/PURPOSES: Among children with myelomeningocele undergoing corrective surgery for lumbar kyphosis: (1) What is the risk of complications and reoperation after this procedure? (2) Does this procedure improve HRQOL scores in these patients? METHODS: Between 2012 and 2013, five surgeons at three centers treated 32 patients for myelomeningocele-related kyphosis with kyphectomy and posterior instrumentation. During that period, all surgeons used the same indications for the procedure, which were progressive postural decompensation and chronic ulceration at the apex of the deformity. Data were prospectively collected, and all patients who underwent surgery were considered in this retrospective study. The legal guardians of one patient declined to sign the informed consent form, resulting in 31 patients included. A total of 9.7% (3 of 31) were lost to follow-up before the 2-year period, and the remaining 90.3% (28 of 31) were seen at a mean of 3 years (± 9 months) after surgery. The average age was 10 years, 7 months (± 21 months) at the time of surgery. The patients had a mean kyphosis angle of 130° ± 36° before surgery. This technique involved posterior fixation using S-shaped rods inserted through the foramina of S1 and pedicle screws inserted in the thoracic spine. The patients' caregivers answered both the generic and specific (neuromuscular module) Pediatric Quality of Life Inventory questionnaires preoperatively and 2 years postoperatively. The minimum clinically important difference (MCID) considered for the instruments used was 5. RESULTS: Reoperation was performed in 68% of patients (19 of 28), mostly to treat deep infection. In all, 18% of patients (five of 28) underwent implant removal to control infection. Eleven percent (three of 28) had a loss of reduction and pseudarthrosis. The HRQOL increased from 71 ± 11 preoperatively to 76 ± 10 postoperatively (p < 0.001), resulting in a 5-point increase (95% CI 3 to 7) in the generic questionnaire score and from 71 ± 13 to 79 ± 11 (p < 0.001), resulting in an 8-point increase (95% CI 5 to 10) in the neuromuscular Paediatric Quality of Life Inventory questionnaire score, mainly in the physical health domain on both questionnaires. CONCLUSIONS: Kyphectomy was associated with a high risk of complications and reoperations and did not seem to deliver a substantial clinical benefit for patients who underwent the procedure. Most of our HRQOL score improvements were below the minimum clinically important difference for the Pediatric Quality of Life Inventory questionnaires. Although it seems that surgeons lack a better surgical alternative when facing the challenging health impairments these patients suffer, efforts should be made to improve the technique and reduce surgical complications. Additionally, patients and caregivers should be advised of the high reoperation rate and notified that the procedure may not result in a better QOL and should thus be avoided when possible. Future studies should verify whether decreasing the complication rate could imply improvement in the HRQOL of these patients after surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Comparative tomographic study of the iliac screw and the S2-alar-iliac screw in children

OBJECTIVES: The recent advancements in spine fixation aid in the treatment of complex spinal pathologies. Both the iliac screw (IS) and the S2-alar-iliac (S2AI) screw provide adequate stability in the fixation of complex lumbosacral spine pathologies, leading to a significant increased rate of using these techniques in the daily practice of the spine surgeons. This study aims to analyze, describe, and compare the insertion and positioning parameters of the S2AI screw and IS techniques in children without spinal deformities. METHODS: An observational retrospective study was conducted at a university hospital in 2018, with 25 computed tomography (CT) images selected continuously. Mann-Whitney-Shapiro-Wilk tests were performed. The reliability of the data was assessed using the intraclass correlation. The data were stratified by age group only for Pearson's correlation analysis. RESULTS: The mean age was 11.7 years (4.5 SD). The mean IS length was 106.63 mm (4.59 SD). The mean length of the S2AI screw was 104.13 mm (4.22 SD). The mean skin distance from the IS entry point was 28.13 mm (4.27 SD) and that for the S2AI screw was 39.96 mm (4.54 SD). CONCLUSIONS: Through CT, the S2AI screw trajectory was observed to have a greater bone thickness and skin distance than the IS. There was a linear correlation between age and screw length for both techniques. A similar relationship was observed between skin distance and age for the S2AI screw technique. In children, the S2AI screw technique presents advantages such as greater cutaneous coverage and implant thickness than the IS technique.

Evaluation of Alternative Halo Ring Positions in Children Using Tomography.

OBJECTIVES: The halo ring can be applied in children, through skeletal traction or a halo vest device, to treat many cervical spine pathologies, including traumatic injuries and pathologies related to deformities. However, the procedure is associated with various complications, such as infection, pin loosening, and respiratory and neurological problems. Although widely studied in adults, the best pin insertion site in children and the correlations of pin insertion sites with outcomes and complications have not been completely elucidated. This study aimed to determine alternative pin placement sites based on a morphological analysis of the infant skull by computerized tomography (CT). METHODS: An analytical-descriptive study was performed using 50 CT scans from children. The Wilcoxon and Friedman tests were used. RESULTS: A linear and directly proportional relation was found between cranial thickness and patient age. The average thicknesses of the anterior points across all ages analyzed ranged from 4.16 mm to 4.98 mm. The thicknesses of the posterior points varied from 3.94 mm to 4.27 mm. Within each age range, points 1 cm above the standard insertion sites had thicknesses similar to those of the standard sites, and points 2 cm above the standard insertion sites had thicknesses greater than those of the standard sites. CONCLUSIONS: The cranial thickness at all points increases linearly with age. Points 1 and 2 cm above the standard insertion sites are viable alternatives for the placement of halo pins. Preoperative CT can aid in choosing the best positioning sites for pins in the skull.

ROTATION ASSESSMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS WITH ROD DEROTATION.

OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is characterized by rotational and lateral deformity of the spine. The measurement of vertebral rotation is important for prognosis and treatment. Our objective was to evaluate whether the Nash-Moe method can be used to measure axial deformity correction with surgical treatment using the rod derotation maneuver at both the apex and extremities of the deformity in patients with AIS. METHODS: Rotation was assessed using the Nash and Moe criteria, on preoperative and postoperative radiographs. We also evaluated the severity on the coronal plane using the Cobb method, ratio of correction achieved, screw density, and number of vertebrae involved in the instrumentation. RESULTS: The Cobb method correction average was 54.8%. When we disregarded vertebrae that presented preoperative Nash-Moe grade 0, the average measurable correction was 54.5% in the first non-instrumented vertebra above, 69.2% in the first instrumented vertebra, 32.2% in the apical vertebra, 36.8% in the last instrumented vertebra, and 30% in the first non-instrumented vertebra below. In our study, 32.14% of the patients presented a measurable correction in the apical vertebra. CONCLUSION: On the axial plane, correction can be satisfactorily evaluated using the Nash-Moe method. Level of Evidence VI. Case Series.

OBJETIVO: A escoliose idiopática do adolescente é caracterizada por deformidade rotacional e lateral da coluna vertebral. A medição da rotação vertebral é importante para o prognóstico e tratamento. Nosso objetivo foi avaliar se o método de Nash-Moe pode ser usado para medir a correção da deformidade axial com o tratamento cirúrgico usando a manobra de derotação em ambos os ápices e extremidades da deformidade em pacientes com EIA. MÉTODOS: A rotação foi avaliada usando os critérios de Nash e Moe em radiografias pré e pós-operatórias. Também avaliamos a severidade no plano coronal pelo método de Cobb, a razão de correção alcançada, a densidade do parafuso e o número de vértebras envolvidas na instrumentação. RESULTADOS: A correção do método de Cobb foi de 54,8%. Quando desconsideramos vértebras que apresentavam grau 0 no pré-operatório de Nash-Moe, encontramos, em média, 54,5% de correção mensurável na primeira vértebra não instrumentada acima, 69,2% na primeira vértebra instrumentada, 32,2% na vértebra apical, 36,8% na última vértebra instrumentada e 30% na primeira vértebra não instrumentada abaixo. Em nosso estudo, ٣٢,١٤٪ dos pacientes apresentaram uma correção mensurável na vértebra apical. CONCLUSÃO: No plano axial, a correção pode ser avaliada satisfatoriamente pelo método de Nash-Moe. Nível de Evidência VI. Série de casos.

Rotation assessment in adolescent idiopathic scoliosis with rod derotation / Avaliação da rotação na escoliose idiopática do adolescente com derrotação da haste

ABSTRACT Objective: Adolescent idiopathic scoliosis (AIS) is characterized by rotational and lateral deformity of the spine. The measurement of vertebral rotation is important for prognosis and treatment. Our objective was to evaluate whether the Nash-Moe method can be used to measure axial deformity correction with surgical treatment using the rod derotation maneuver at both the apex and extremities of the deformity in patients with AIS. Methods: Rotation was assessed using the Nash and Moe criteria, on preoperative and postoperative radiographs. We also evaluated the severity on the coronal plane using the Cobb method, ratio of correction achieved, screw density, and number of vertebrae involved in the instrumentation. Results: The Cobb method correction average was 54.8%. When we disregarded vertebrae that presented preoperative Nash-Moe grade 0, the average measurable correction was 54.5% in the first non-instrumented vertebra above, 69.2% in the first instrumented vertebra, 32.2% in the apical vertebra, 36.8% in the last instrumented vertebra, and 30% in the first non-instrumented vertebra below. In our study, 32.14% of the patients presented a measurable correction in the apical vertebra. Conclusion: On the axial plane, correction can be satisfactorily evaluated using the Nash-Moe method. Level of Evidence VI. Case Series.

RESUMO Objetivo: A escoliose idiopática do adolescente é caracterizada por deformidade rotacional e lateral da coluna vertebral. A medição da rotação vertebral é importante para o prognóstico e tratamento. Nosso objetivo foi avaliar se o método de Nash-Moe pode ser usado para medir a correção da deformidade axial com o tratamento cirúrgico usando a manobra de derotação em ambos os ápices e extremidades da deformidade em pacientes com EIA. Métodos: A rotação foi avaliada usando os critérios de Nash e Moe em radiografias pré e pós-operatórias. Também avaliamos a severidade no plano coronal pelo método de Cobb, a razão de correção alcançada, a densidade do parafuso e o número de vértebras envolvidas na instrumentação. Resultados: A correção do método de Cobb foi de 54,8%. Quando desconsideramos vértebras que apresentavam grau 0 no pré-operatório de Nash-Moe, encontramos, em média, 54,5% de correção mensurável na primeira vértebra não instrumentada acima, 69,2% na primeira vértebra instrumentada, 32,2% na vértebra apical, 36,8% na última vértebra instrumentada e 30% na primeira vértebra não instrumentada abaixo. Em nosso estudo, ٣٢,١٤٪ dos pacientes apresentaram uma correção mensurável na vértebra apical. Conclusão: No plano axial, a correção pode ser avaliada satisfatoriamente pelo método de Nash-Moe. Nível de Evidência VI. Série de casos.

Comparative tomographic study of the S2-alar-iliac screw versus the iliac screw.

AIMS: Iliac screws and S2-alar-iliac screws provide adequate mechanical stability for the fixation of lumbosacral spine pathologies, which has led to a significant increase in the use of these techniques in the routine practice of spine surgeons. However, studies on the ideal technical positioning for both techniques are limited. STUDY DESIGN: This is an observational, retrospective, analytical descriptive study. OBJECTIVE: To analyze, describe and compare the insertion and positioning parameters of the S2-alar-iliac and iliac screw techniques in adult patients without spinal deformities. METHODS: The present study comprises a retrospective analysis of lumbosacral computed tomography images selected continuously in 2016 from 25 patients at a university hospital. Mann-Whitney-Shapiro-Wilk tests were performed. Data reliability was assessed using intraclass correlation. RESULTS: The mean length of the iliac screw was greater than that of the S2-alar-iliac screw, and the S2-alar-iliac screw sat 20.5 mm deeper than the iliac screw. The mean of the greatest bone thickness for the iliac screw was 20.72 mm; that of the S2-alar-iliac screw was 23.24 mm. The mean distance from the iliac screw entry point to the skin was 32.46 mm, and the mean distance from the S2-alar-iliac screw entry point to the skin was 52.87 mm. CONCLUSION: The trajectory of the S2-alar-iliac screws studied via computed tomography was greater in terms of bone thickness and deeper relative to the skin compared with the iliac screws. The S2-alar-iliac technique may have desirable clinical advantages in terms of the diameter of the screws and reduced protrusion when used in adults. These slides can be retrieved from Electronic supplementary material.

Evaluation of alternative halo ring positions in children using tomography

OBJECTIVES: The halo ring can be applied in children, through skeletal traction or a halo vest device, to treat many cervical spine pathologies, including traumatic injuries and pathologies related to deformities. However, the procedure is associated with various complications, such as infection, pin loosening, and respiratory and neurological problems. Although widely studied in adults, the best pin insertion site in children and the correlations of pin insertion sites with outcomes and complications have not been completely elucidated. This study aimed to determine alternative pin placement sites based on a morphological analysis of the infant skull by computerized tomography (CT). METHODS: An analytical-descriptive study was performed using 50 CT scans from children. The Wilcoxon and Friedman tests were used. RESULTS: A linear and directly proportional relation was found between cranial thickness and patient age. The average thicknesses of the anterior points across all ages analyzed ranged from 4.16 mm to 4.98 mm. The thicknesses of the posterior points varied from 3.94 mm to 4.27 mm. Within each age range, points 1 cm above the standard insertion sites had thicknesses similar to those of the standard sites, and points 2 cm above the standard insertion sites had thicknesses greater than those of the standard sites. CONCLUSIONS: The cranial thickness at all points increases linearly with age. Points 1 and 2 cm above the standard insertion sites are viable alternatives for the placement of halo pins. Preoperative CT can aid in choosing the best positioning sites for pins in the skull.

Feasibility of anterior screw fixation in children: a tomographic study.

PURPOSE: Morphology measures of the odontoid process in children under 12 years old were carried out to demonstrate the viability of anterior internal fixation in this population once their active profile may not be compatible with successful conservative treatment. METHODS: During a 6-month period, 36 tomographic examinations of the cervical spine region that provided visualization of the odontoid process were selected. Group 1 included children between 6 and 9 years of age, and group 2 contained children from 9 to 12 years of age. There were 23 (63.8%) male patients and 13 (36.2%) female patients. Patients diagnosed with a tumor, an infection, fracture non-union, or congenital malformation were excluded. Exams were ordered as part of a protocol applied to non-specific neck pain and pediatric trauma entries. The following parameters were analyzed: (1) screw attack angle, (2) height of the odontoid process, and (3) minimal transverse diameter of the odontoid process. RESULTS: In Groups 1 and 2, the average values of the screw attack angle were 55.9° ± 2.3° and 54.8° ± 4.5°, respectively; the average heights of the odontoid process were 26.58 ± 3.28 and 29.48 ± 3 mm, respectively, and the average minimal transverse diameter of the odontoid process were 6.57 ± 1.08 and 6.23 ± 0.88 mm, respectively. The minimal transverse diameter of the odontoid process was statistically higher in males than that in females, regardless of age (p = 0.007). CONCLUSION: In both groups, the minimal transverse diameter of the odontoid process allowed for the use of one 3.5-4.5 mm screw for anterior internal fixation. These slides can be retrieved under Electronic Supplementary Material.

Epidemiology of cauda equina syndrome. What changed until 2015 / Epidemiologia da síndrome da cauda equina. O que mudou até 2015

ABSTRACT Objective: The primary objective of this study was to analyze the characteristics and outcomes of cases admitted to hospital with cauda equina syndrome (CES) at the Institute of Orthopedics and Traumatology (IOT) from 2005 to 2015. Secondly, this article is a continuation of the epidemiological work of the same base published in 2013, and will be important for other comparative studies to a greater understanding of the disease and its epidemiology. Methods: This was a retrospective study of the medical records of admissions due to CES at IOT in the period 2005-2015 with diagnosis of CES and neuropathic bladder. The following variables were analyzed: gender, age, etiology of the disease, topographic level of the injury, time interval between injury and diagnosis, presence of neurogenic bladder, time interval between diagnosis of the CES and surgery, and reversal of the deficit or of the neurogenic bladder. Results: Since this is a rare disease, with a low global incidence, it was not possible, just with the current study to establish statistically significant correlations between the variables and outcomes of the disease. However, this study demonstrates the shortcomings of the Brazilian public health system, both with the initial management of these patients and the need for urgent surgical treatment. Conclusion: The study shows that despite well-defined basis for the conduct of CES, a higher number of sequelae caused by the pathology is observed in Brazil. The delay in diagnosis and, therefore, for definitive treatment, remains as the major cause for the high number of sequelae. Level of evidence: 4, case series.

RESUMO Objetivo: Analisar as características e os desfechos dos casos internados por síndrome da cauda equina (SCE) no Instituto de Ortopedia e Traumatologia (IOT) da Faculdade de Medicina da Universidade de São Paulo de 2005-2015. Secundariamente, este artigo é a continuação do trabalho epidemiológico de mesma base publicado em 2013 e servirá de base para outros estudos comparativos com vistas a um entendimento maior da doença e de sua epidemiologia. Métodos: Estudo retrospectivo dos prontuários das internações por SCE no IOT de 2005 a 2015 com diagnósticos de SCE e bexiga neuropática. As seguintes variáveis foram analisadas: sexo, idade, etiologia da doença, nível topográfico da lesão, tempo de história da lesão até o diagnóstico, presença de bexiga neurogênica, tempo entre o diagnóstico da SCE e a cirurgia e reversão do déficit ou da bexiga neurogênica. Resultados: Por se tratar de uma doença rara, com uma incidência global baixa, não foi possível, somente com o estudo atual, estabelecer correlações estatisticamente significativas entre as variáveis analisadas e os desfechos da doença. Porém, este estudo continua a evidenciar as deficiências do sistema público de saúde brasileiro, tanto no manejo inicial desses pacientes quanto na necessidade de tratamento cirúrgico de urgência. Conclusão: O trabalho mostra que, apesar de bem definidas as bases para conduta da SCE, observa-se no Brasil um número maior de sequelas causadas pela patologia. O atraso no diagnóstico e, a partir desse, no tratamento definitivo mantém-se como a causa para o alto número de sequelas. Nível de evidência: 4, série de casos.

Epidemiology of cauda equina syndrome. What changed until 2015.

OBJECTIVE: The primary objective of this study was to analyze the characteristics and outcomes of cases admitted to hospital with cauda equina syndrome (CES) at the Institute of Orthopedics and Traumatology (IOT) from 2005 to 2015. Secondly, this article is a continuation of the epidemiological work of the same base published in 2013, and will be important for other comparative studies to a greater understanding of the disease and its epidemiology. METHODS: This was a retrospective study of the medical records of admissions due to CES at IOT in the period 2005-2015 with diagnosis of CES and neuropathic bladder. The following variables were analyzed: gender, age, etiology of the disease, topographic level of the injury, time interval between injury and diagnosis, presence of neurogenic bladder, time interval between diagnosis of the CES and surgery, and reversal of the deficit or of the neurogenic bladder. RESULTS: Since this is a rare disease, with a low global incidence, it was not possible, just with the current study to establish statistically significant correlations between the variables and outcomes of the disease. However, this study demonstrates the shortcomings of the Brazilian public health system, both with the initial management of these patients and the need for urgent surgical treatment. CONCLUSION: The study shows that despite well-defined basis for the conduct of CES, a higher number of sequelae caused by the pathology is observed in Brazil. The delay in diagnosis and, therefore, for definitive treatment, remains as the major cause for the high number of sequelae. Level of evidence: 4, case series.

OBJETIVO: Analisar as características e os desfechos dos casos internados por síndrome da cauda equina (SCE) no Instituto de Ortopedia e Traumatologia (IOT) da Faculdade de Medicina da Universidade de São Paulo de 2005-2015. Secundariamente, este artigo é a continuação do trabalho epidemiológico de mesma base publicado em 2013 e servirá de base para outros estudos comparativos com vistas a um entendimento maior da doença e de sua epidemiologia. MÉTODOS: Estudo retrospectivo dos prontuários das internações por SCE no IOT de 2005 a 2015 com diagnósticos de SCE e bexiga neuropática. As seguintes variáveis foram analisadas: sexo, idade, etiologia da doença, nível topográfico da lesão, tempo de história da lesão até o diagnóstico, presença de bexiga neurogênica, tempo entre o diagnóstico da SCE e a cirurgia e reversão do déficit ou da bexiga neurogênica. RESULTADOS: Por se tratar de uma doença rara, com uma incidência global baixa, não foi possível, somente com o estudo atual, estabelecer correlações estatisticamente significativas entre as variáveis analisadas e os desfechos da doença. Porém, este estudo continua a evidenciar as deficiências do sistema público de saúde brasileiro, tanto no manejo inicial desses pacientes quanto na necessidade de tratamento cirúrgico de urgência. CONCLUSÃO: O trabalho mostra que, apesar de bem definidas as bases para conduta da SCE, observa-se no Brasil um número maior de sequelas causadas pela patologia. O atraso no diagnóstico e, a partir desse, no tratamento definitivo mantém-se como a causa para o alto número de sequelas. Nível de evidência: 4, série de casos.

A Comparative Study of Sagittal Balance in Patients with Neuromuscular Scoliosis.

OBJECTIVES:: Spinopelvic alignment has been associated with improved quality of life in patients with vertebral deformities, and it helps to compensate for imbalances in gait. Although surgical treatment of scoliosis in patients with neuromuscular spinal deformities promotes correction of coronal scoliotic deformities, it remains poorly established whether this results in large changes in sagittal balance parameters in this specific population. The objective of this study is to compare these parameters before and after the current procedure under the hypothesis is that there is no significant modification. METHODS:: Sampling included all records of patients with neuromuscular scoliosis with adequate radiographic records treated at Institute of Orthopedics and Traumatology of Clinics Hospital of University of São Paulo (IOT-HCFMUSP) from January 2009 to December 2013. Parameters analyzed were incidence, sacral inclination, pelvic tilt, lumbar lordosis, thoracic kyphosis, spinosacral angle, spinal inclination and spinopelvic inclination obtained using the iSite-Philips digital display system with Surgimap and a validated method for digital measurements of scoliosis radiographs. Comparison between the pre- and post-operative conditions involved means and standard deviations and the t-test. RESULTS:: Based on 101 medical records only, 16 patients met the inclusion criteria for this study, including 7 males and 9 females, with an age range of 9-20 and a mean age of 12.9±3.06; 14 were diagnosed with cerebral palsy. No significant differences were found between pre and postoperative parameters. CONCLUSIONS:: Despite correction of coronal scoliotic deformity in patients with neuromuscular deformities, there were no changes in spinopelvic alignment parameters in the group studied.

A Comparative Study of Sagittal Balance in Patients with Neuromuscular Scoliosis

OBJECTIVES: Spinopelvic alignment has been associated with improved quality of life in patients with vertebral deformities, and it helps to compensate for imbalances in gait. Although surgical treatment of scoliosis in patients with neuromuscular spinal deformities promotes correction of coronal scoliotic deformities, it remains poorly established whether this results in large changes in sagittal balance parameters in this specific population. The objective of this study is to compare these parameters before and after the current procedure under the hypothesis is that there is no significant modification. METHODS: Sampling included all records of patients with neuromuscular scoliosis with adequate radiographic records treated at Institute of Orthopedics and Traumatology of Clinics Hospital of University of São Paulo (IOT-HCFMUSP) from January 2009 to December 2013. Parameters analyzed were incidence, sacral inclination, pelvic tilt, lumbar lordosis, thoracic kyphosis, spinosacral angle, spinal inclination and spinopelvic inclination obtained using the iSite-Philips digital display system with Surgimap and a validated method for digital measurements of scoliosis radiographs. Comparison between the pre- and post-operative conditions involved means and standard deviations and the t-test. RESULTS: Based on 101 medical records only, 16 patients met the inclusion criteria for this study, including 7 males and 9 females, with an age range of 9-20 and a mean age of 12.9±3.06; 14 were diagnosed with cerebral palsy. No significant differences were found between pre and postoperative parameters. CONCLUSIONS: Despite correction of coronal scoliotic deformity in patients with neuromuscular deformities, there were no changes in spinopelvic alignment parameters in the group studied.

Anatomical and radiological characteristics in adolescent idiopathic scoliosis with surgical indication.

OBJECTIVE: This study aims to analyze the anatomical and radiological characteristics of adolescent idiopathic scoliosis patients with surgical indication. METHODS: Retrospective, descriptive study of 100 medical records pertaining to patients included in the group of scoliosis with surgical indication from the years 2008 to 2015. Descriptive statistics were used for statistical analysis. RESULTS: 28 patients met the inclusion and exclusion criteria, and were selected for the study. The average age was 15.4 (SD ± 1.2 years); in the selected sample, the female/male ratio was 6:1; the kyphosis measured in degrees by Cobb angle between T5-T12 had an average 32.10 (SD ± 13.37); according to the Lenke classification, the most prevalent type was type 2, representing 28.6% of cases. CONCLUSION: The mean patient age in the present study was 15.4 (SD ± 1.2 years); the most prevalent type was type 2 in the Lenke classification. There is a need for new anatomical and radiological studies to elucidate the morphological characteristics common in adolescent idiopathic scoliosis patients.

OBJETIVO: Avaliar as características anatomorradiológicas em pacientes com escoliose idiopática do adolescente com indicação cirúrgica. MÉTODOS: Estudo descritivo retrospectivo de 100 prontuários de pacientes do grupo de escoliose com indicação cirúrgica de 2008 a 2015. A análise usada foi a estatística descritiva. RESULTADOS: Preencheram os critérios de inclusão e exclusão 28 pacientes e foram selecionados para o estudo. A média foi de 15,4 ± 1,2 anos DP; na amostra selecionada, a proporção menina:menino foi de 6:1; a cifose foi medida em graus pelo ângulo de Cobb entre T5-T12 e teve como média 32,10° ± 13,37° DP; segundo a classificação de Lenke, o mais prevalente foi o tipo 2, observado em 28,6% dos casos. CONCLUSÃO: A idade média dos pacientes no presente estudo foi de 15,4 anos; o mais prevalente foi o tipo 2 da classificação de Lenke. Novos trabalhos anatomorradiológicos são necessários para elucidar características morfológicas comuns nos pacientes com escoliose idiopática do adolescente.