Superior Mesenteric Artery Syndrome - An Uncommon Complication After Surgical Corrections of Spinal Deformities.

Vascular compression of the third part of the duodenum by the superior mesenteric artery results in an unusual occlusion of the duodenal transit known as superior mesenteric artery syndrome. This syndrome can occur after surgeries to correct spinal deformities in a rate ranging from 0.5% to 4.7%. It results from a positional alteration of the artery emergency point due to a change in trunk length after surgery. It is associated with risk factors such as low body mass index and weight loss. Patients usually present with intestinal occlusion, abdominal pain, nausea, bilious vomiting, and early satiety. Superior mesenteric artery syndrome must be recognized early to institute an adequate treatment, which can be clinical (with gastric tube for decompression and nutritional support) or require a surgical procedure. Secondary complications related to superior mesenteric artery syndrome include delayed surgical and nutritional recovery, healing problems, and prolonged hospitalization. The present study aims to report a case of superior mesenteric artery syndrome in a patient with neuromuscular scoliosis secondary to a transverse myelitis who underwent surgical treatment for spinal deformity correction.

Superior Mesenteric Artery Syndrome - An Uncommon Complication After Surgical Corrections of Spinal Deformities / Síndrome da artéria mesentérica superior - Uma complicação incomum após correções cirúrgicas de deformidades da coluna

Abstract Vascular compression of the third part of the duodenum by the superior mesenteric artery results in an unusual occlusion of the duodenal transit known as superior mesenteric artery syndrome. This syndrome can occur after surgeries to correct spinal deformities in a rate ranging from 0.5% to 4.7%. It results from a positional alteration of the artery emergency point due to a change in trunk length after surgery. It is associated with risk factors such as low body mass index and weight loss. Patients usually present with intestinal occlusion, abdominal pain, nausea, bilious vomiting, and early satiety. Superior mesenteric artery syndrome must be recognized early to institute an adequate treatment, which can be clinical (with gastric tube for decompression and nutritional support) or require a surgical procedure. Secondary complications related to superior mesenteric artery syndrome include delayed surgical and nutritional recovery, healing problems, and prolonged hospitalization. The present study aims to report a case of superior mesenteric artery syndrome in a patient with neuromuscular scoliosis secondary to a transverse myelitis who underwent surgical treatment for spinal deformity correction.

Resumo A compressão vascular da terceira parte do duodeno pela artéria mesentérica superior resulta no desenvolvimento de uma condição incomum de oclusão do trânsito duodenal conhecida como síndrome da artéria mesentérica superior. Este fenômeno pode acontecer após cirurgias de correção de deformidades da coluna, e sua taxa de ocorrência é de 0,5 a 4,7% dos casos. Isso ocorre em virtude da alteração do posicionamento do ponto de emergência da artéria, decorrente da mudança do comprimento do tronco após a cirurgia, e está associado a fatores de risco, como baixo índice de massa corpórea e perda ponderal. Os pacientes costumam se apresentar com um quadro de oclusão intestinal, com dor abdominal, náusea, vômito bilioso e saciedade precoce. O reconhecimento desta condição é importante para instituir o tratamento adequado, que varia do tratamento clínico, com sondagem e descompressão gástrica associados a suporte nutricional; à necessidade de abordagem cirúrgica. Complicações secundárias relacionadas à síndrome da artéria mesentérica superior incluem: recuperação cirúrgica e nutricional retardadas, problemas com a cicatrização e hospitalização prolongada. O objetivo do presente estudo é relatar um caso de síndrome da artéria mesentérica superior, ocorrido em um paciente com escoliose neuromuscular secundária a sequela de mielite transversa, submetido ao tratamento cirúrgico da deformidade da coluna.

Clinical and Radiological Results After Minimally Invasive Transpsoas Lateral Access Surgery for Degenerative Lumbar Stenosis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The lateral transpsoas access is a retroperitoneal approach for the lumbar spine to perform the lateral lumbar interbody fusion (LLIF), an intersomatic arthrodesis performed with a cage placed on the lateral borders of the epiphyseal ring. The procedure can be used to provide indirect decompression of the nervous structures through the discectomy and restoration of the disc height. The objective of the present study was to evaluate the indirect decompression following LLIF both with radiological and clinical parameters. METHODS: Prospective clinical and radiological study in a single center with 20 patients diagnosed with 1- or 2-level degenerative lumbar stenosis. Radiological analysis on magnetic resonance imaging included foramen height, canal area, canal diameter, and disc height. Clinical outcomes included visual analogue scale (VAS) and Oswestry Disability Index (ODI) collected up to 12 months. Complications and reoperations were recorded. RESULTS: In total, 25 levels were treated. No reoperation was required. Disc height was increased by an average of 25% (P < .001). The canal area increased from 109 to 149 mm2 (P < .001) and from 9.3 to 12.2 mm (P < .001) in anteroposterior diameter. The foramen area demonstrated the effect of indirect decompression on both sides (P < .001). The height of the foramen showed significant average increase of 2.8 mm (P < .001). The results from VAS and ODI questionnaires confirmed the clinical effect of indirect decompression. CONCLUSION: We observed that indirect decompression by the LLIF method is feasible both radiologically and clinically with a low rate of complications and reoperations.

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).

Four-level en bloc vertebrectomy: a novel technique and literature review / Vertebrectomia em bloco em quatro níveis: nova técnica e revisão da literatura

ABSTRACT Objective: To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction. Methods: A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital. Results: The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient. Conclusion: The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

RESUMO Objetivo: Demonstrar uma nova técnica de reconstrução por vertebrectomia em bloco multinível. Métodos: Descrição de uma reconstrução pós-vertebrectomia em bloco multinível, em paciente tratado num hospital oncológico público universitário, com indicação de ressecção curativa de sarcoma de Ewing. Resultados: O procedimento proposto foi viável para a ressecção em bloco de quatro vértebras e a reconstrução foi aceitável e satisfatória em termos de estabilidade mecânica, sem causar dano neurológico ao paciente. Conclusão: O uso de aloenxerto com parafuso intramedular bloqueado é uma solução adequada para a reconstrução da coluna anterior e medial após vertebrectomias multiníveis. Além disso, a associação de quatro parafusos intramedulares dá estabilidade à reconstrução. Benefícios imediatos da técnica são o tempo de hospitalização mais curto e a redução da morbidade cirúrgica, em comparação com outras técnicas, comumente utilizadas. Nível de Evidência V, Estudo clínico de nova técnica cirúrgica e revisão da literatura.

TRAUMATIC INJURIES OF THE CERVICAL SPINE: CURRENT EPIDEMIOLOGICAL PANORAMA.

OBJECTIVE: To collect data from patients with cervical fracture who were treated surgically in a tertiary health service, in order to better understand the current scenario of this kind of injury in our population. METHODS: This retrospective survey examined consecutive cases of patients with cervical spine trauma who received surgical treatment during 2013 and 2014. The data were subjected to descriptive statistical analysis. RESULTS: Fifty-two patients were treated with surgery during 2013 and 2014. All patients classified as Frankel A and B developed respiratory failure. Patients classified as Frankel A, B, and C had significantly higher rates for postoperative complications (p < 0.01) than patients classified as Frankel D and E, except for the rate of postoperative infections (p = 0.717). Hospitalization time was also longer in the first group (p < 0.01). CONCLUSION: Patients with cervical trauma who present with neurological deficit at hospital admission should receive special attention, since the rate of postoperative complications is higher and hospital stays are lengthier in this group. In addition, patients with Frankel A and B classification should be monitored in an intensive care unit. Level of Evidence III; Retrospective comparative study.

OBJETIVO: Levantar dados de prontuário dos pacientes com fratura cervical submetidos a tratamento cirúrgico em um serviço de saúde terciário, para melhor compreensão do cenário atual desse tipo de lesão em nosso meio. MÉTODOS: O estudo realizou o levantamento retrospectivo de casos consecutivos de pacientes com trauma da coluna cervical submetidos ao tratamento cirúrgico durante os anos de 2013 e 2014. Os dados foram submetidos à análise estatística descritiva. RESULTADOS: Cinquenta e dois pacientes foram operados neste serviço entre os anos de 2013 e 2014. Todos os pacientes classificados como Frankel A e B evoluíram com insuficiência respiratória. Quando comparados, os pacientes Frankel A, B e C e Frankel D e E, a taxa de todos os tipos de complicações pós-operatórias foi maior no primeiro grupo, com significância estatística (p < 0,01), exceto a taxa de infecções pós-operatórias (p = 0,717). Além disso, o tempo de internação foi maior no primeiro grupo (p < 0,01). CONCLUSÃO: Pacientes com trauma cervical que se apresentem com déficit neurológico na admissão hospitalar devem receber especial atenção, uma vez que a taxa de complicações pós-operatórias e os dias de internação são maiores. Além disso, pacientes Frankel A e B devem ser monitorados em ambiente de terapia intensiva. Nível de Evidência III; Estudo retrospectivo comparativo.

Traumatic injuries of the cervical spine: current epidemiological panorama / Lesões traumáticas da coluna cervical: panorama epidemiológico atual

ABSTRACT Objective: To collect data from patients with cervical fracture who were treated surgically in a tertiary health service, in order to better understand the current scenario of this kind of injury in our population. Methods: This retrospective survey examined consecutive cases of patients with cervical spine trauma who received surgical treatment during 2013 and 2014. The data were subjected to descriptive statistical analysis. Results: Fifty-two patients were treated with surgery during 2013 and 2014. All patients classified as Frankel A and B developed respiratory failure. Patients classified as Frankel A, B, and C had significantly higher rates for postoperative complications (p < 0.01) than patients classified as Frankel D and E, except for the rate of postoperative infections (p = 0.717). Hospitalization time was also longer in the first group (p < 0.01). Conclusion: Patients with cervical trauma who present with neurological deficit at hospital admission should receive special attention, since the rate of postoperative complications is higher and hospital stays are lengthier in this group. In addition, patients with Frankel A and B classification should be monitored in an intensive care unit. Level of Evidence III; Retrospective comparative study.

RESUMO Objetivo: Levantar dados de prontuário dos pacientes com fratura cervical submetidos a tratamento cirúrgico em um serviço de saúde terciário, para melhor compreensão do cenário atual desse tipo de lesão em nosso meio. Métodos: O estudo realizou o levantamento retrospectivo de casos consecutivos de pacientes com trauma da coluna cervical submetidos ao tratamento cirúrgico durante os anos de 2013 e 2014. Os dados foram submetidos à análise estatística descritiva. Resultados: Cinquenta e dois pacientes foram operados neste serviço entre os anos de 2013 e 2014. Todos os pacientes classificados como Frankel A e B evoluíram com insuficiência respiratória. Quando comparados, os pacientes Frankel A, B e C e Frankel D e E, a taxa de todos os tipos de complicações pós-operatórias foi maior no primeiro grupo, com significância estatística (p < 0,01), exceto a taxa de infecções pós-operatórias (p = 0,717). Além disso, o tempo de internação foi maior no primeiro grupo (p < 0,01). Conclusão: Pacientes com trauma cervical que se apresentem com déficit neurológico na admissão hospitalar devem receber especial atenção, uma vez que a taxa de complicações pós-operatórias e os dias de internação são maiores. Além disso, pacientes Frankel A e B devem ser monitorados em ambiente de terapia intensiva. Nível de Evidência III; Estudo retrospectivo comparativo.

Profile of spinal cord trauma victims treated at a reference unit in são paulo / Perfil das vítimas de trauma raquimedular atendidas em uma unidade de referência de são paulo / Perfil de las víctimas de trauma raquimedular atendidas en una unidad de referencia de são paulo

ABSTRACT Introduction: Spinal cord trauma (SCT) is an important cause of morbidity and mortality around the world. It affects different age groups, especially young adults who are victims of high-energy trauma. The most effective way to reduce the incidence of spinal cord trauma and its consequences is through preventive campaigns and control and surveillance measures through public agencies. The objective of this study is to outline the epidemiological profile of patients with spinal cord trauma attended at a tertiary care center in the city of São Paulo. Methods: Retrospective, cross-sectional study performed at a reference center for the care of patients with spinal cord injury in the State of São Paulo. Data were collected from the medical records of patients with spinal cord trauma between 2012 and 2016. Results: Of the 515 patients with spinal trauma, 153 (29.7%) had spinal cord injury of which 131 (85.62%) were male, and 22 (14.37%) were female, in a ratio of approximately 6:1. The mean age was 39.45 years. The main cause of spinal cord trauma observed was the fall from heights, with 72 cases (47.05%), and 52.94% were classified as Frankel A. Conclusions: The results showed that the majority of the patients were young, economically active, with low educational level, exposed to accidents that could be largely avoided. Most of these patients also had severe disabling injuries, which usually bring considerable psychological sequelae and economic consequences to the individual and to society. Level of evidence: IV. Type of study: Case series.

RESUMO Introdução: O traumatismo raquimedular (TRM) é uma importante causa de morbi-mortalidade ao redor mundo. Acomete diferentes faixas etárias, principalmente os adultos jovens vítimas de trauma de alta energia. A forma mais eficaz de diminuir a incidência do traumatismo raquimedular e suas consequências é através de campanhas preventivas e medidas de controle e fiscalização através dos órgãos públicos. O objetivo deste estudo é traçar o perfil epidemiológico dos pacientes vítimas de traumatismo raquimedular, atendidos em um centro de atendimento terciário da cidade de São Paulo. Métodos: Estudo retrospectivo, transversal, realizado em um centro de referência de atendimento de pacientes vítimas de traumatismo raquimedular do estado de São Paulo. Os dados foram colhidos dos prontuários dos pacientes vítimas de traumatismo raquimedular entre os anos de 2012 a 2016. Resultados: Dos 515 pacientes vítimas de traumatismo da coluna espinhal, 153 (29,7%) apresentaram traumatismo raquimedular. 131 (85,62%) foram do sexo masculino, 22 (14,37%) foram pacientes do sexo feminino, em uma relação de aproximadamente 6:1. A média de idade foi de 39 a 45 anos. A principal causa de trauma raquimedular observada foi a queda de altura, com 72 casos (47,05%). 52,94% dos pacientes apresentaram-se em Frankel A. Conclusão: Os resultados mostraram que a maioria dos pacientes eram de jovens, economicamente ativos, com baixo nível educacional, expostos a acidentes que, em grande parte, poderiam ser evitados. A maioria destes pacientes também apresentou lesões graves, incapacitantes, que costumam trazer sequelas psíquicas e econômicas consideráveis para o indivíduo e para a sociedade. Nível de Evidência: IV. Tipo de estudo: Série de Casos.

RESUMEN Introducción: El trauma raquimedular (TRM) es una causa importante de morbidad y mortalidad en todo el mundo. Afecta a diferentes grupos de edad, especialmente los adultos jóvenes que son víctimas de traumas de alta energía. La forma más efectiva de reducir la incidencia de traumatismos de la médula espinal y sus consecuencias es a través de campañas de prevención y medidas de control y vigilancia de agencias públicas. El objetivo de este estudio es delinear el perfil epidemiológico de los pacientes con trauma raquimedular atendidos en un centro de atención terciaria en la ciudad de São Paulo. Métodos: Estudio retrospectivo, transversal realizado en un centro de referencia para el cuidado de los pacientes con trauma raquimedular en el Estado de São Paulo. Los datos se obtuvieron de las historias clínicas de pacientes con traumatismo de la médula espinal entre 2012 y 2016. Resultados: De los 515 pacientes con trauma raquimedular, 153 (29,7%) tenían lesiones de la médula espinal, de los cuales 131 (85,62%) eran hombres y 22 (14,37%) eran mujeres, en una proporción de aproximadamente 6:1. La edad media fue de 39,45 años. La principal causa de trauma raquimedular fue la caída desde la altura, con 72 casos (47,05%), y el 52,94% se clasificó como Frankel A. Conclusiones: Los resultados mostraron que la mayoría de los pacientes eran jóvenes, económicamente activos, con un bajo nivel educativo, expuestos a accidentes que podrían evitarse en gran medida. La mayoría de estos pacientes también tenían lesiones incapacitantes severas, que a menudo traen secuelas psicológicas importantes y consecuencias económicas para el individuo y la sociedad. Nivel de evidencia: IV. Tipo de estudio: Serie de casos.

FOUR-LEVEL EN BLOC VERTEBRECTOMY: A NOVEL TECHNIQUE AND LITERATURE REVIEW.

OBJECTIVE: To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction. METHODS: A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital. RESULTS: The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient. CONCLUSION: The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

OBJETIVO: Demonstrar uma nova técnica de reconstrução por vertebrectomia em bloco multinível. MÉTODOS: Descrição de uma reconstrução pós-vertebrectomia em bloco multinível, em paciente tratado num hospital oncológico público universitário, com indicação de ressecção curativa de sarcoma de Ewing. RESULTADOS: O procedimento proposto foi viável para a ressecção em bloco de quatro vértebras e a reconstrução foi aceitável e satisfatória em termos de estabilidade mecânica, sem causar dano neurológico ao paciente. CONCLUSÃO: O uso de aloenxerto com parafuso intramedular bloqueado é uma solução adequada para a reconstrução da coluna anterior e medial após vertebrectomias multiníveis. Além disso, a associação de quatro parafusos intramedulares dá estabilidade à reconstrução. Benefícios imediatos da técnica são o tempo de hospitalização mais curto e a redução da morbidade cirúrgica, em comparação com outras técnicas, comumente utilizadas. Nível de Evidência V, Estudo clínico de nova técnica cirúrgica e revisão da literatura.

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.

Effects of estrogen on functional and neurological recovery after spinal cord injury: An experimental study with rats.

OBJECTIVES: To evaluate the functional and histological effects of estrogen as a neuroprotective agent after a standard experimentally induced spinal cord lesion. METHODS: In this experimental study, 20 male Wistar rats were divided into two groups: one group with rats undergoing spinal cord injury (SCI) at T10 and receiving estrogen therapy with 17-beta estradiol (4mg/kg) immediately following the injury and after the placement of skin sutures and a control group with rats only subjected to SCI. A moderate standard experimentally induced SCI was produced using a computerized device that dropped a weight on the rat's spine from a height of 12.5 mm. Functional recovery was verified with the Basso, Beattie and Bresnahan scale on the 2nd, 7th, 14th, 21st, 28th, 35th and 42nd days after injury and by quantifying the motor-evoked potential on the 42nd day after injury. Histopathological evaluation of the SCI area was performed after euthanasia on the 42nd day. RESULTS: The experimental group showed a significantly greater functional improvement from the 28th to the 42nd day of observation compared to the control group. The experimental group showed statistically significant improvements in the motor-evoked potential compared with the control group. The results of pathological histomorphometry evaluations showed a better neurological recovery in the experimental group, with respect to the proportion and diameter of the quantified nerve fibers. CONCLUSIONS: Estrogen administration provided benefits in neurological and functional motor recovery in rats with SCI beginning at the 28th day after injury.

Effects of estrogen on functional and neurological recovery after spinal cord injury: An experimental study with rats

OBJECTIVES:To evaluate the functional and histological effects of estrogen as a neuroprotective agent after a standard experimentally induced spinal cord lesion.METHODS:In this experimental study, 20 male Wistar rats were divided into two groups: one group with rats undergoing spinal cord injury (SCI) at T10 and receiving estrogen therapy with 17-beta estradiol (4mg/kg) immediately following the injury and after the placement of skin sutures and a control group with rats only subjected to SCI. A moderate standard experimentally induced SCI was produced using a computerized device that dropped a weight on the rat's spine from a height of 12.5 mm. Functional recovery was verified with the Basso, Beattie and Bresnahan scale on the 2nd, 7th, 14th, 21st, 28th, 35th and 42nd days after injury and by quantifying the motor-evoked potential on the 42nd day after injury. Histopathological evaluation of the SCI area was performed after euthanasia on the 42nd day.RESULTS:The experimental group showed a significantly greater functional improvement from the 28th to the 42nd day of observation compared to the control group. The experimental group showed statistically significant improvements in the motor-evoked potential compared with the control group. The results of pathological histomorphometry evaluations showed a better neurological recovery in the experimental group, with respect to the proportion and diameter of the quantified nerve fibers.CONCLUSIONS:Estrogen administration provided benefits in neurological and functional motor recovery in rats with SCI beginning at the 28th day after injury.

Subaxial cervical fracture: application and correlation of ao and SLIC / Fratura cervical subaxial: aplicação e correlação das classificações ao e SLIC / Fractura subaxial cervical: aplicación y correlación de las clasificaciones ao y SLIC

OBJECTIVE: To evaluate the AO/Magerl classification and the SLIC (Subaxial Cervical Spine Injury Classification), used in the cervical spine fractures and assess whether they are correlated to the neurological severity of patients, the choice of approach to be used, de duration of surgery an between themselves. METHOD: Retrospective analysis of medical records and radiological image files of 77 patients surgically treated of subaxial cervical fracture or dislocation from August 2010 to September 2012. RESULTS: The SLIC classification showed a strong correlation with neurological deficit and Pearson correlation value of -0.600. The AO classification was not correlated with the Frankel scale and the value of Pearson was 0.06 with a statistical significance of 0.682 (p<0.05), that is, unable to determine or suggest the severity of the deficit. When compared to each other the two classifications showed statistical correlation and the value of Pearson was 0.282 with a significance value of 0.022 (p<0.05). CONCLUSION: Among the most used classifications, the SLIC has been able to statistically define the need for surgical treatment and the severity of the neurological status, but was unable to predict the approach or the time of the surgery; the classification AO failed to predict the severity of neurological injury, surgical time, and did not help to choose the approach, just being a morphological classification.

OBJETIVO: Avaliar as classificações AO-Magerl e SLIC (Subaxial Cervical Spine Injury Classification) utilizadas em fraturas da coluna cervical e avaliar se elas apresentam correlações com a gravidade neurológica dos pacientes, com a escolha da via de acesso, a duração do ato cirúrgico e entre si mesmas. MÉTODOS: Análise retrospectiva do prontuário e acervo de imagens radiológicas dos 77 pacientes submetidos à cirurgia de fratura e ou luxação da coluna cervical subaxial, no período de agosto de 2010 a setembro de 2012. RESULTADOS: A classificação SLIC apresentou forte correlação com déficit neurológico, com valor de correlação de Pearson de -0,600. Já a classificação AO não apresentou correlação com a escala de Frankel, e o valor de Pearson foi de 0,06 com significância estatística de 0,682 (p < 0,05), ou seja, incapaz de determinar ou sugerir a gravidade do déficit. Quando comparadas entre si as duas classificações apresentaram correlação estatística e o valor de Pearson foi de 0,282 com valor de significância de 0,022 (p < 0,05). CONCLUSÃO: Entre as classificações mais utilizadas, a classificação SLIC foi estatisticamente capaz de definir necessidade de tratamento cirúrgico e a gravidade do estado neurológico, porém foi incapaz de predizer a via de acesso ou o tempo de duração da cirurgia; a classificação AO falhou em predizer a gravidade da lesão neurológica, o tempo cirúrgico e em auxiliar a escolha da via de acesso, sendo apenas uma classificação morfológica.

OBJETIVO: Evaluar las clasificaciones AO/Magerl y SLIC (Subaxial Cervical Spine Injury Classification) utilizadas en las fracturas de la columna cervical y evaluar si tienen correlación con la gravedad neurológica de los pacientes, la elección de la vía de acceso, la duración de la cirugía y si están correlacionados entre sí. MÉTODO: Análisis retrospectivo de registros médicos y colección de imágenes radiológicas de 77 pacientes tratados quirúrgicamente de fractura o dislocación de la columna cervical subaxial, desde agosto 2010 a septiembre 2012. RESULTADOS: La clasificación SLIC mostró una fuerte correlación con déficit neurológico y el valor de correlación de Pearson de -0,600. La clasificación AO no se correlacionó con la escala de Frankel y el valor de Pearson fue 0,06, con una significación estadística de 0,682 (p < 0,05), es decir, incapaz de determinar o sugerir la gravedad del déficit. Cuando se compararon entre sí, las dos clasificaciones mostraron correlación estadística y el valor de Pearson fue de 0,282, con valor de significación de 0,022 (p < 0,05). CONCLUSIÓN: Entre las clasificaciones más utilizadas, la calificación SLIC ha sido capaz de definir estadísticamente la necesidad de tratamiento quirúrgico y la gravedad del estado neurológico, pero fue incapaz de predecir la vía de acceso o la duración de la cirugía; la clasificación AO no logró predecir la gravedad de la lesión neurológica, el tiempo quirúrgico ni auxilió a elegir la vía de acceso, siendo sólo una clasificación morfológica.

Cervical disc prosthesis: 2-year follow-up / Prótese de disco cervical: 2 anos de seguimento / Prótesis de disco cervical: 2 años de seguimiento

To review the medical records of patients who underwent surgery for placement of cervical disc prosthesis after two years of postoperative follow-up, showing the basic epidemiological data, the technical aspects and the incidence of complications.

Revisar las historias clínicas de los pacientes que se sometieron a cirugía para colocación de prótesis de disco cervical después de dos años de seguimiento postoperatorio, que muestran los datos epidemiológicos básicos, los aspectos técnicos y la incidencia de complicaciones.

Revisar os prontuários de pacientes que foram submetidos à cirurgia para colocação de prótese de disco cervical, após dois anos de seguimento pós-operatório, evidenciando os dados epidemiológicos básicos, os aspectos da técnica e a incidência de complicações.

Controlled medial branch anesthetic block in the diagnosis of chronic lumbar facet joint pain: the value of a three-month follow-up.

OBJECTIVES: To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables. METHODS: Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients. RESULTS: A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05). CONCLUSION: Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives.

Controlled medial branch anesthetic block in the diagnosis of chronic lumbar facet joint pain: the value of a three-month follow-up

OBJECTIVES: To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables. METHODS: Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients. RESULTS: A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05). CONCLUSION: Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives. .

Functional assessment of patients with cervical myelopathy who underwent surgical treatment / Avaliação funcional de pacientes com mielopatia cervical submetidos a tratamento cirúrgico / Evaluación funcional de los pacientes con mielopatía cervical sometidos a tratamiento quirúrgico

OBJECTIVE: Evaluate and correlate the functional response of patients with cervical myelopathy with the current clinical scores in patients who underwent surgical treatment. METHODS: We analyzed medical records of 34 patients with cervical myelopathy who underwent four different types of surgery. All patients were evaluated preoperatively and postoperatively with the application of the JOA and Nurick questionnaires. RESULTS: Functional clinical improvement was statistically significant. The mean preoperative JOA was 8.5 ± 3.06 and 10.7 ± 3.9 in the postoperative; Nurick was 3.2 ± 1.1 preoperatively and 2.8 ± 1.3 postoperatively. CONCLUSION: There is benefit with the surgical procedure in patients with cervical myelopathy. The neurological function after surgery depends on the previous function (the higher the duration of the previous symptoms, the greater the progression of the disease and, therefore, worse the neurological function) and the age is not a relevant factor of improvement, as already shown in other series. The clinical functional improvement of patients is visible with surgical treatment, regardless of surgical technique. .

OBJETIVO: Avaliar e correlacionar a resposta funcional dos pacientes com mielopatia cervical com os escores clínicos já existentes, em pacientes que foram submetidos ao tratamento cirúrgico. MÉTODOS: Trabalho retrospectivo com análise de 34 prontuários de pacientes portadores de mielopatia cervical que foram submetidos a quatro diferentes tipos de cirurgia. Todos os pacientes foram avaliados no pré e pós-operatório com a aplicação dos questionários de JOA e Nurick. RESULTADOS: A melhora clínica funcional foi estatisticamente relevante. O JOA pré-operatório médio foi de 8,5 ± 3,06 para 10,7 ± 3,9, no pós-operatório e o Nurick foi 3,2 ± 1,1 no pré-operatório e de 2,8 ± 1,3 no pós-operatório. CONCLUSÃO: Há benefício com a realização do tratamento cirúrgico em pacientes com mielopatia cervical, a função neurológica pós-operatória depende da função prévia (quanto maior o tempo de sintomas, maior progressão e, com isso pior a função neurológica) e a idade dos pacientes não é fator relevante de melhora, como já mostrado em outras séries. A melhora funcional clínica dos pacientes, é visível com o tratamento cirúrgico, independente da técnica cirúrgica aplicada. .

OBJETIVO: Evaluar y correlacionar la respuesta funcional de los pacientes con mielopatía cervical con las puntuaciones clínicas vigentes en pacientes sometidos a tratamiento quirúrgico. MÉTODOS: Se analizaron los registros médicos de 34 pacientes con mielopatía cervical que se sometieron a cuatro diferentes tipos de cirugía. Todos los pacientes fueron evaluados antes y después de la cirugía con la aplicación de los cuestionarios JOA y Nurick. RESULTADOS: La mejoría clínica funcional fue estadísticamente significativa. El JOA preoperatorio promedio fue de 8,5 ± 3,06 y 10,7 ± 3,9 en el postoperatorio. El Nurick antes de la operación fue 3,2 ± 1,1 y 2,8 ± 1,3 después de la operación. CONCLUSIÓN: Existe beneficio con el tratamiento quirúrgico en pacientes con mielopatía cervical. La función neurológica después de la cirugía depende de la función previa (cuanto mayor sea la duración de los síntomas anteriores, mayor será la progresión de la enfermedad y, por lo tanto, peor es la función neurológica) y la edad no es un factor relevante de la mejora, como ya se ha demostrado en otras series. La mejora clínica funcional de los pacientes es visible con el tratamiento quirúrgico, independientemente de la técnica quirúrgica y esto está directamente relacionado con su condición antes de la cirugía. .

Avaliação de seis anos de fraturas cervicais subaxiais / Evaluation of six years of cervical sub-axial fractures / Evaluación de seis años de fracturas cervicales subaxiales

OBJETIVO: Avaliar retrospectivamente os fatores relacionados ao trauma cervical, segundo o tipo de fratura baseado na classificação AO. Levando-se em consideração aspectos etiológicos e epidemiológicos do evento. MÉTODOS: Foram analisados retrospectivamente prontuários de pacientes com fratura cervical, no período de 2004 a 2009. Estudou-se as fraturas subaxiais (C3-C7), por se enquadrarem em apenas uma classificação (AO). Usou-se radiografias frente e perfil, e tomografias para dividir as fraturas em A (compressão), B (distração) e C (rotação), de acordo com o padrão apresentado. Analisou-se os seguintes parâmetros: sexo, idade, classificação AO, mecanismo de trauma, presença de déficit neurológico, e tratamento cirúrgico ou conservador. RESULTADOS: Foram analisados 264 prontuários, sendo 216 pacientes do sexo masculino e 48 femininos. A média de idade destes pacientes foi de 38,55 anos. O mecanismo de trauma mais comum das fraturas cervical subaxiais foi o acidente automobilístico com 84 casos. Quanto ao tipo de fratura pela classificação AO, a mais frequente foi do tipo B. Dos casos avaliados, 136 pacientes apresentaram déficit neurológico, parcial ou completo. O tratamento cirúrgico foi realizado em 166 casos. CONCLUSÃO: Os dados apresentados demonstram que as fraturas cervicais representam um importante problema para a saúde no Brasil, pública e privada. A prevenção das fraturas cervicais apresenta a melhor relação custo benefício na abordagem destas lesões.

OBJECTIVE: Retrospectively assess the factors related to cervical trauma, according to the type of fracture based on the AO classification, taking into account etiological and epidemiological aspects of the event. METHODS: Records of patients with cervical fractures were retrospectively reviewed, from 2004 to 2009. The sub-axial fractures (C3-C7) were studied because they fit into only one classification (AO). Frontal and lateral x-rays were used as well as CTs to divide the fractures into A (compression), B (distraction) and C (rotation), in accordance with the presented pattern. The following parameters were assessed: gender, age, AO classification, trauma mechanism, presence of neurological deficit, and conservative or surgical treatment. RESULTS: The study included 264 records from the spine, where 216 patients were male and 48 female. The average age of these patients was 38.55 years. The most common mechanism of injury of the cervical sub-axial fractures was car accident with 84 cases. Regarding the type of fracture by the AO classification, the most frequent was type B. Out of the assessed cases, 136 patients presented complete or partial neurological deficit. The surgical treatment was performed in 166 cases. CONCLUSION: It is clear, based on the data presented, that cervical fractures are a major problem to the public and private health in Brazil. The prevention of the cervical fractures presents the most cost-effective approach to these injuries.

OBJETIVO: Evaluar retrospectivamente los factores relacionados al trauma cervical, según el tipo de fractura, basándose en la clasificación AO, considerandose los aspectos etiológicos y epidemiológicos del evento. MÉTODOS: Fueron analizadas retrospectivamente las historias clínicas de pacientes con fractura cervical, desde el 2004 hasta el 2009. Se estudiaron las fracturas subaxiales (C3-C7), ya que éstas se encuadran en apenas una clasificación (AO). Se utilizaron radiografías en las incidencias frontal y lateral y tomografía computarizada, para dividir las fracturas en A (compresión), B (distracción) y C (rotación), de acuerdo con el patrón de presentación. Se analizaron los siguientes parámetros: sexo, edad, clasificación AO, mecanismo de trauma, presencia de déficit neurológico y tratamiento quirúrgico o conservador. RESULTADOS: Fueron analizadas 264 historias clínicas, siendo 216 pacientes hombres e 48 mujeres. La media de edad de éstos pacientes fue de 38,55 años. El mecanismo de trauma más común de las fracturas cervicales subaxiales fue el accidente automovilístico, con 84 casos. En cuanto al tipo de fractura según la clasificación AO, la más frecuente fue el tipo B. De los casos evaluados, 136 pacientes presentaron déficit neurológico parcial o completo. El tratamiento quirúrgico fue realizado en 166 casos. CONCLUSIÓN: Queda claro que las fracturas cervicales representan un importante problema para la salud pública y privada en Brasil. La prevención de fracturas cervicales presenta la mejor relación costo beneficio en el abordaje de éstas lesiones.

Fraturas do côndilo occipital: atualização da experiência em nosso serviço e revisão da literatura / Fractures of the occipital condyle: updated experience in our service and literature review / Fracturas del cóndilo occipital: actualización de la experiencia en nuestro servicio y revisión de la literatura

Apresentamos neste trabalho a casuística de fraturas de côndilo occipital diagnosticada e tratada em nosso serviço nos últimos 10 anos. O presente estudo dá continuidade ao levantamento epidemiológico já realizado no período de 1993 a 2000. No período de 2001 a 2011, foram diagnosticados seis casos de fraturas de côndilo occipital e todos eles foram tratados de forma conservadora, exceto um, no qual se colocou um halo craniano inicialmente. Nos cinco casos tratados de modo conservador, observaram-se bons resultados, com estabilidade do segmento nas radiografias funcionais, ausência de limitação de movimento e ausência de dor. O paciente que foi tratado com halo apresentava tetraplegia parcial FRANKEL C e fraturas associadas (C5, C6, L1 e L2) e não apresentou melhora do quadro neurológico, verificando-se limitação do movimento cervical. Destacamos ainda a importância da investigação ativa de lesões na transição occipitocervical, principalmente nos casos decorrentes de trauma de alta energia, pois além das implicações clínicas da detecção precoce da fratura, o melhor emprego dos exames subsidiários tem sido um fator relevante para o aumento da incidência de fraturas do côndilo occipital. Como é historicamente relatado, o tratamento conservador ainda é eficaz e com baixo índice de complicações, e o tratamento cirúrgico deve ser indicado em casos com instabilidade definida.

We present a series of occipital condyle fractures diagnosed and treated in our hospital during the past 10 years. The present study continues an epidemiologic survey already performed in the period 1993-2000. From 2001 to 2011, six cases of fracture of the occipital condyle were diagnosed and all of them were treated conservatively, except one, in which a halo was initially placed. In the five cases treated conservatively, there were good results, with stable segment in functional radiographs, absence of limitation of motion and no pain. The patient treated with halo had FRANKEL C partial quadriplegia and associated fractures (C5, C6, L1, and L2), showing no neurological improvement, besides observing cervical motion limitation. We also highlight the importance of active research on lesions in the occipital-cervical transition, particularly in cases resulting from high-energy trauma, because in addition to the clinical implications of early detection of fracture, the best use of ancillary tests have been an important factor for the increased incidence of fractures of the occipital condyle. As is historically reported, conservative treatment is still effective and has a low rate of complications, and surgical treatment should be indicated in cases with established instability.

Presentamos en este trabajo la casuística de fracturas de cóndilo occipital diagnosticada y tratada en nuestro servicio en los últimos 10 años. El presente estudio le da continuidad al levantamiento epidemiológico ya realizado en el período de 1993 a 2000. En el período de 2001 a 2011, fueron diagnosticados seis casos de fracturas de cóndilo occipital y todos ellos fueron tratados de forma conservadora, excepto uno, en el cual se colocó un halo craneano inicialmente. En los cinco casos tratados de modo conservador, se observaron buenos resultados, con estabilidad del segmento en las radiografías funcionales, ausencia de limitación de movimiento y ausencia de dolor. El paciente que fue tratado con halo presentaba tetraplejía parcial FRANKEL C y fracturas asociadas (C5, C6, L1 y L2) y no presentó mejora del cuadro neurológico, verificándose limitación del movimiento cervical. Destacamos además la importancia de la investigación activa de lesiones en la transición occipitocervical, principalmente en los casos provenientes de trauma de alta energía, pues además de las implicaciones clínicas de la detección precoz de la fractura, el mejor empleo de los exámenes subsidiarios ha sido un factor relevante para el aumento de la incidencia de fracturas del cóndilo occipital. Como es históricamente relatado, el tratamiento conservador aún es eficaz y con bajo índice de complicaciones, y el tratamiento quirúrgico debe ser indicado en casos con inestabilidad definida.