Tips and tricks for using cement augmentation of pedicle screws and vertebral body replacements - a literature review supported by two case reports.

BACKGROUND: The prevalence of osteoporosis is escalating alongside an aging global population, increasing the demand for spinal surgeries, including those necessitating cement augmentation for enhanced construct stability. OBJECTIVE: This article delves into the nuanced application of cement augmentation techniques for pedicle screws and vertebral body replacements (VBR), aimed at optimizing surgical outcomes in osteoporotic spines. METHOD: Drawing from a comprehensive literature review according to important clinical and biomechanical studies and the authors' clinical experiences, we elucidate strategies to mitigate complications and improve surgical efficacy. RESULTS: Cement augmentation has shown promise in managing vertebral fractures and in securing pedicle screws within osteoporotic vertebrae, with the advent of polymethylmethacrylate (PMMA) bone cement marking a pivotal advancement in spinal surgery. We highlight intraoperative measures like the choice between pre-injecting cement and utilizing cannulated or fenestrated screws, emphasizing the importance of controlling cement viscosity to prevent leakage and embolism. Through two case reports, we demonstrate the practical application of endplate cementation following VBR. CONCLUSION: While the use of cement augmentation poses certain risks, its judicious application-supported by evidence-based guidelines and surgical expertise-can substantially enhance the stability of spinal constructs in osteoporotic patients. This allows a reduction in instrumentation length by enhancing biomechanical stability concerning pullout, bending, and rotational forces. Furthermore, the incidence of endplate sintering following VBF can be significantly reduced. Future research, particularly on antibiotic-loaded PMMA, may further expand its utility and optimize its safety profile.

Hidden blood loss in minimally invasive surgery for osteoporotic vertebral fractures. / [Artículo traducido] Sangrado oculto intraoperatorio en cirugía mínimamente invasiva de fracturas vertebrales osteoporóticas.

INTRODUCTION AND AIM: Minimally invasive surgery (MIS) of the spine prevents the collapse of osteoporotic vertebral fractures (OVF) with lower complication and bleeding rates than open surgery. However, the possibility of hidden blood loss (HBL) has been recently described, referring to the loss of blood diffused into tissues and lost through hemolysis. This study aimed to estimate the postoperative impact of HBL in patients undergoing MIS for OVF. MATERIALS AND METHODS: This was a retrospective study of a series of patients who had MIS for OVF. A descriptive analysis of recorded variables was performed, and total blood volume, total bleeding, HBL, and hemoglobine drop were calculated. This was followed by a comparative analysis between HBL (<500ml vs. ≥500ml) and the variables of hospital stay and postoperative evolution. Binary logistic regression models were performed to rule out confounding factors. RESULTS: A total of 40 patients were included, 8 men and 32 women, with a mean age of 76.6 years. The mean HBL was 682.5ml. An HBL greater than 500ml is found to be an independent risk factor for torpid postoperative evolution (P=0.035), while it does not predict a longer hospital stay (P=0.116). In addition, a higher HBL was observed in surgeries of greater technical complexity and longer surgical time. CONCLUSIONS: Although MIS techniques have shown less intraoperative bleeding than open surgery, HBL should be diagnosed because it is associated with a torpid evolution. The use of a diagnostic and therapeutic algorithm may help minimize its impact.

Comparison of perioperative outcomes in obese and non-obese patients subjected to open lumbar spine surgery.

OBJECTIVE: Obesity is a global epidemic affecting developing countries. The relationship between obesity and perioperative outcomes during elective lumbar spine surgery remains controversial, especially in those without morbid disease. MATERIALS AND METHODS: We retrospectively revised the medical records of patients with lumbar spine degeneration subjected to elective surgery. The data retrieved included demographic and clinical characteristics, body mass index (BMI), obesity status (BMI ≥ 30), surgical interventions, estimated blood loss (EBL), operative time, length of stay (LOS), and post-operative complications. Perioperative outcomes were compared between Grade I-II obese and non-obese individuals. RESULTS: We enrolled 53 patients, 18 with Grade I-II obesity. Their median age was 51, with no differences in gender, comorbidities, laboratory parameters, and surgical procedures received between groups. No clinically relevant differences were found between grade I-II obese and non-obese participants in EBL (300 mL vs. 250 mL, p = 0.069), operative time (3.2 h vs. 3.0 h, p = 0.037), and LOS (6 days vs. 5 days, p = 0.3). Furthermore, BMI was not associated with the incidence of significant bleeding and long stay but showed a modest correlation with operative time. CONCLUSION: Grade I-II obesity does not increase surgical complexity nor perioperative complications during open lumbar spine surgery.

OBJETIVO: La obesidad es una epidemia mundial que afecta a países subdesarrollados. Su relación con los resultados de la cirugía de columna lumbar electiva sigue siendo controvertida, especialmente en obesos sin enfermedad mórbida. MÉTODOS: Se revisaron los expedientes de pacientes con degeneración de la columna lumbar sometidos a cirugía. Los datos recuperados incluyeron características demográficas y clínicas, índice de masa corporal (IMC), estado de obesidad (IMC > 30), intervenciones quirúrgicas, sangrado estimado, tiempo operatorio, tiempo de estancia y complicaciones. Los resultados se compararon entre individuos obesos grado I-II y controles. RESULTADOS: Se incluyeron 53 pacientes, 18 con obesidad de grado I-II. La edad media fue de 51 años, sin diferencias en el sexo, las comorbilidades, los parámetros de laboratorio y los procedimientos quirúrgicos recibidos entre grupos. No se encontraron diferencias relevantes entre los participantes obesos y los no obesos en sangrado (300 vs. 250 mL, p = 0.069), tiempo operatorio (3.2 vs. 3.0 horas, p = 0.037) y estancia (6 vs. 5 días, p = 0.3). El IMC no se asoció con hemorragia y larga estancia, pero mostró una correlación modesta con el tiempo operatorio. CONCLUSIONES: La obesidad grado I-II no predispone a complicaciones durante la cirugía de columna lumbar.

Hidden blood loss in minimally invasive surgery for osteoporotic vertebral fractures.

INTRODUCTION AND AIM: Minimally invasive surgery (MIS) of the spine prevents the collapse of osteoporotic vertebral fractures (OVF) with lower complication and bleeding rates than open surgery. However, the possibility of hidden blood loss (HBL) has been recently described, referring to the loss of blood diffused into tissues and lost through hemolysis. This study aimed to estimate the postoperative impact of HBL in patients undergoing MIS for OVF. MATERIALS AND METHODS: This was a retrospective study of a series of patients who had MIS for OVF. A descriptive analysis of recorded variables was performed, and total blood volume (TBV), total bleeding (TB), HBL, and Hb drop were calculated. This was followed by a comparative analysis between HBL (<500mL vs. ≥500mL) and the variables of hospital stay and postoperative evolution. Binary logistic regression models were performed to rule out confounding factors. RESULTS: A total of 40 patients were included, 8 men and 32 women, with a mean age of 76.6 years. The mean HBL was 682.5mL. An HBL greater than 500mL is found to be an independent risk factor for torpid postoperative evolution (p=0.035), while it does not predict a longer hospital stay (p=0.116). In addition, a higher HBL was observed in surgeries of greater technical complexity and longer surgical time. CONCLUSIONS: Although MIS techniques have shown less intraoperative bleeding than open surgery, HBL should be diagnosed because it is associated with a torpid evolution. The use of a diagnostic and therapeutic algorithm may help minimize its impact.

Impacto de la pandemia COVID-19 en la cirugía de columna en un centro de segundo nivel / Impact of COVID-19 pandemia on spine surgery in 2nd level hospital

Introducción: Las consecuencias de la pandemia por COVID-19, como en otros aspectos de la medicina, se han visto reflejadas también en la actividad quirúrgica de columna vertebral. Objetivos: El objetivo principal del presente estudio es cuantificar el número de intervenciones realizadas entre los años 2016 y 2021 y analizar el tiempo de espera en los pacientes intervenidos como medida indirecta del volumen de la lista de espera. Como objetivos secundarios se realiza un análisis del tiempo de estancia hospitalaria y el tiempo quirúrgico a lo largo de la serie. Métodos: Se ha realizado un estudio descriptivo retrospectivo en relación con el volumen de intervenciones y diagnósticos durante un periodo que incluye desde la etapa previa a la pandemia (2016) hasta finales del año 2021, en que la situación global llegó a una cuasi-normalización de la actividad. Se han identificado un total de 1.039 registros. Se incluyen las variables edad, género, días en lista de espera antes de la intervención, diagnóstico, tiempo de estancia hospitalaria y tiempo quirúrgico. Resultados: Se objetiva una disminución en el número total de intervenciones durante la pandemia respecto al año 2019 (32,15% menos el año 2020 y 23,5% menos el 2021). Tras el análisis de los datos, se observa un aumento en la dispersión y la mediana del tiempo de espera global y por patologías a partir de 2020, sin detectarse diferencias significativas en el tiempo de hospitalización ni en el tiempo quirúrgico. Conclusión: Durante la pandemia se ha producido una disminución del número de intervenciones debido a la necesidad de redistribuir recursos humanos y materiales para hacer frente al incremento de pacientes críticos afectados por la COVID-19. El aumento de la dispersión y de la mediana global y por patologías de la variable tiempo de espera se traduce como un aumento del tiempo de espera en las cirugías diferibles realizadas durante los años de...(AU)

Introduction: The consequences of COVID-19 pandemic, like in any other field of medicine, had such a massive effect in the activity of spine surgeons. Objectives: The main purpose of the study is quantifying the number of interventions done between 2016 and 2021 and analyze the time between the indication and the intervention as an indirect measurement of the waiting list. As secondary objectives we focused on variations of the length of stay and duration of the surgeries during this specific period. Methods: We performed a descriptive retrospective study including all the interventions and diagnosis made during a period including pre-pandemic data (starting on 2016) until 2021, when we considered the normalization of surgical activity was achieved. A total of 1039 registers were compiled. The data collected included age, gender, days in waiting list before the intervention, diagnosis, time of hospitalization and surgery duration. Results: We found that the total number of interventions during the pandemic has significantly decreased compared to 2019 (32.15% less in 2020 and 23.5% less in 2021). After data analysis, we found an increase of data dispersion, average waiting list time and for diagnosis after 2020. No differences were found regarding hospitalization time or surgical time. Conclusion: The number of surgeries decreased during pandemic due to the redistribution of human and material resources to face the raising of critical COVID-19 patients. The increase of data dispersion and median of waiting time, is the consequence of a growing waiting list for non-urgent surgeries during the pandemic as the urgent interventions also raised, those with a shorter waiting time.(AU)

[Translated article] Impact of COVID-19 pandemia on spine surgery in 2nd level hospital / Impacto de la pandemia COVID-19 en la cirugía de columna en un centro de segundo nivel

Introducción: Las consecuencias de la pandemia por COVID-19, como en otros aspectos de la medicina, se han visto reflejadas también en la actividad quirúrgica de columna vertebral. Objetivos: El objetivo principal del presente estudio es cuantificar el número de intervenciones realizadas entre los años 2016 y 2021 y analizar el tiempo de espera en los pacientes intervenidos como medida indirecta del volumen de la lista de espera. Como objetivos secundarios se realiza un análisis del tiempo de estancia hospitalaria y el tiempo quirúrgico a lo largo de la serie. Métodos: Se ha realizado un estudio descriptivo retrospectivo en relación con el volumen de intervenciones y diagnósticos durante un periodo que incluye desde la etapa previa a la pandemia (2016) hasta finales del año 2021, en que la situación global llegó a una cuasi-normalización de la actividad. Se han identificado un total de 1.039 registros. Se incluyen las variables edad, género, días en lista de espera antes de la intervención, diagnóstico, tiempo de estancia hospitalaria y tiempo quirúrgico. Resultados: Se objetiva una disminución en el número total de intervenciones durante la pandemia respecto al año 2019 (32,15% menos el año 2020 y 23,5% menos el 2021). Tras el análisis de los datos, se observa un aumento en la dispersión y la mediana del tiempo de espera global y por patologías a partir de 2020, sin detectarse diferencias significativas en el tiempo de hospitalización ni en el tiempo quirúrgico. Conclusión: Durante la pandemia se ha producido una disminución del número de intervenciones debido a la necesidad de redistribuir recursos humanos y materiales para hacer frente al incremento de pacientes críticos afectados por la COVID-19. El aumento de la dispersión y de la mediana global y por patologías de la variable tiempo de espera se traduce como un aumento del tiempo de espera en las cirugías diferibles realizadas durante los años de...(AU)

Introduction: The consequences of COVID-19 pandemic, like in any other field of medicine, had such a massive effect in the activity of spine surgeons. Objectives: The main purpose of the study is quantifying the number of interventions done between 2016 and 2021 and analyze the time between the indication and the intervention as an indirect measurement of the waiting list. As secondary objectives we focused on variations of the length of stay and duration of the surgeries during this specific period. Methods: We performed a descriptive retrospective study including all the interventions and diagnosis made during a period including pre-pandemic data (starting on 2016) until 2021, when we considered the normalization of surgical activity was achieved. A total of 1039 registers were compiled. The data collected included age, gender, days in waiting list before the intervention, diagnosis, time of hospitalization and surgery duration. Results: We found that the total number of interventions during the pandemic has significantly decreased compared to 2019 (32.15% less in 2020 and 23.5% less in 2021). After data analysis, we found an increase of data dispersion, average waiting list time and for diagnosis after 2020. No differences were found regarding hospitalization time or surgical time. Conclusion: The number of surgeries decreased during pandemic due to the redistribution of human and material resources to face the raising of critical COVID-19 patients. The increase of data dispersion and median of waiting time, is the consequence of a growing waiting list for non-urgent surgeries during the pandemic as the urgent interventions also raised, those with a shorter waiting time.(AU)

Exposición a radiación del cirujano de columna / Radiation exposure of the spine surgeon

Resumen: Introducción: en general, los cirujanos de columna buscan minimizar el daño a tejidos blandos empleando abordajes menos invasivos, lo que ocasiona que utilicen imágenes intraoperatorias de una manera mucho más habitual que el resto de las especialidades quirúrgicas; por lo tanto, están en mayor riesgo de exposición de radiación. Objetivo: el propósito del trabajo es analizar la cantidad de radiación a la cual está expuesto el cirujano de columna en diferentes escenarios. Material y métodos: estudio prospectivo con una fuente de datos descriptiva, longitudinal, no aleatorizada. Se llevó a cabo el estudio en el período del año 2015 al 2019; la protección radiológica consistió en chaleco plomado, protector de tiroides y lentes plomados; se usaron 10 dosímetros. Resultados: cuatro dosímetros fueron incluidos en el estudio, los otros seis fueron excluidos. Durante el estudio, un cirujano sufrió de cáncer de tiroides y otro de liposarcoma. En el grupo de protegidos se incluyeron dos cirujanos, en el grupo de protección aleatorizada se incluyó un cirujano y en el grupo sin protección se incluyó un cirujano. El dosímetro del grupo sin protección recibió mayor cantidad de radiación en todos los años, se realizó un análisis inferencial por año relacionado con el número de cirugías no encontrando correlación significativa, atribuimos este resultado a que no clasificamos el tipo de cirugía realizada por cada cirujano. Conclusión: el cirujano de columna debe de aplicar los métodos primarios de protección radiológica, ya que los cirujanos de columna sin equipo de protección reciben mayor cantidad de radiación en comparación con los protegidos.

Abstract: Introduction: in general, spine surgeons seek to minimize soft tissue damage by using less invasive approaches, which causes them to use intraoperative images much more frequently than other surgical specialties; therefore, they are at increased risk of radiation exposure. Objective: the aim of this work was to analyse the amount of radiation to which the spine surgeon is exposed in different scenarios. Material and methods: a prospective study with a descriptive, longitudinal non-randomized data source. We carried out this study in the period from 2015 to 2019, the radiologic protection consisted in lead apron, thyroid shield and leaded glasses, there were 10 badge dosimeters. Results: only 4 dosimeters were included in the study, the other six were excluded. During the study period one surgeon suffered thyroid cancer and other suffered of liposarcoma. In the protected group were two surgeons, in the group of aleatory exposition was one surgeon and in the unprotected group was one surgeon. In the study the dosimeter in the unprotected group received more amount of radiation in all the years, we did an inferential analysis per year related with the number of surgeries without significant correlation, we attribute this result because we didn't classified the type of surgery realized by each surgeon. Conclusion: we conclude that the spine surgeon must apply the primary methods of radiological protection and that the unprotected spine surgeon receives more amount of radiation in comparison of the protected ones.

Recomendaciones para la recuperación posquirúrgica optimizada en columna (REPOC) / Recommendations for enhanced post-surgical recovery in the spine (REPOC)

Introducción y objetivos: La recuperación posquirúrgica optimizada en columna (REPOC) constituye un enfoque multimodal, basado en la evidencia científica disponible, que consigue una mejora eficaz de la funcionalidad fisiológica del paciente, reduce el dolor e incluso disminuye los costes hospitalarios. El objetivo de este trabajo es proponer unos estándares para la aplicación de la REPOC a la cirugía de fusión lumbar. Métodos: Se constituyó ad hoc un grupo multidisciplinario de expertos que revisaron la evidencia disponible y plantearon recomendaciones consensuadas para la artrodesis lumbar, utilizando el sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Resultados: Se seleccionaron 23 recomendaciones en las fases preoperatoria, intraoperatoria y postoperatoria de la intervención quirúrgica. También se elaboró una lista de 29 ítems para la aplicación de la REPOC en cirugía de columna. Conclusiones: Este listado de recomendaciones facilitará la implementación del enfoque REPOC como herramienta segura y eficaz para la reducción de los eventos adversos en nuestro entorno.(AU)

Introduction/objectives: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. Methodology: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. Conclusions: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.(AU)

[Translated article] Recommendations for enhanced post-surgical recovery in the spine (REPOC) / Recomendaciones para la recuperación posquirúrgica optimizada en columna (REPOC)

Introducción y objetivos: La recuperación posquirúrgica optimizada en columna (REPOC) constituye un enfoque multimodal, basado en la evidencia científica disponible, que consigue una mejora eficaz de la funcionalidad fisiológica del paciente, reduce el dolor e incluso disminuye los costes hospitalarios. El objetivo de este trabajo es proponer unos estándares para la aplicación de la REPOC a la cirugía de fusión lumbar. Métodos: Se constituyó ad hoc un grupo multidisciplinario de expertos que revisaron la evidencia disponible y plantearon recomendaciones consensuadas para la artrodesis lumbar, utilizando el sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Resultados: Se seleccionaron 23 recomendaciones en las fases preoperatoria, intraoperatoria y postoperatoria de la intervención quirúrgica. También se elaboró una lista de 29 ítems para la aplicación de la REPOC en cirugía de columna. Conclusiones: Este listado de recomendaciones facilitará la implementación del enfoque REPOC como herramienta segura y eficaz para la reducción de los eventos adversos en nuestro entorno.(AU)

Introduction/objectives: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. Methodology: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. Conclusions: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.(AU)

[Translated article] Impact of COVID-19 pandemia on spine surgery in 2nd level hospital.

INTRODUCTION: The consequences of COVID-19 pandemic, like in any other field of medicine, had such a massive effect in the activity of spine surgeons. OBJECTIVES: The main purpose of the study is quantifying the number of interventions done between 2016 and 2021 and analyze the time between the indication and the intervention as an indirect measurement of the waiting list. As secondary objectives we focused on variations of the length of stay and duration of the surgeries during this specific period. METHODS: We performed a descriptive retrospective study including all the interventions and diagnosis made during a period including pre-pandemic data (starting on 2016) until 2021, when we considered the normalization of surgical activity was achieved. A total of 1039 registers were compiled. The data collected included age, gender, days in waiting list before the intervention, diagnosis, time of hospitalization and surgery duration. RESULTS: We found that the total number of interventions during the pandemic has significantly decreased compared to 2019 (32.15% less in 2020 and 23.5% less in 2021). After data analysis, we found an increase of data dispersion, average waiting list time and for diagnosis after 2020. No differences were found regarding hospitalization time or surgical time. CONCLUSION: The number of surgeries decreased during pandemic due to the redistribution of human and material resources to face the raising of critical COVID-19 patients. The increase of data dispersion and median of waiting time, is the consequence of a growing waiting list for non-urgent surgeries during the pandemic as the urgent interventions also raised, those with a shorter waiting time.

Recommendations for enhanced post-surgical recovery in the spine (REPOC). / Recomendaciones para la recuperación posquirúrgica optimizada en columna (REPOC).

INTRODUCTION/OBJECTIVES: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. METHODOLOGY: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. CONCLUSIONS: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.

[Translated article] Recommendations for enhanced post-surgical recovery in the spine (REPOC).

INTRODUCTION/OBJECTIVES: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programmes to lumbar fusion surgery, a meant benchmark we call REPOC. METHODOLOGY: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. CONCLUSIONS: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.

Impact of COVID-19 pandemia on spine surgery in 2nd level hospital. / Impacto de la pandemia COVID-19 en la cirugía de columna en un centro de segundo nivel.

INTRODUCTION: The consequences of COVID-19 pandemic, like in any other field of medicine, had such a massive effect in the activity of spine surgeons. OBJECTIVES: The main purpose of the study is quantifying the number of interventions done between 2016 and 2021 and analyze the time between the indication and the intervention as an indirect measurement of the waiting list. As secondary objectives we focused on variations of the length of stay and duration of the surgeries during this specific period. METHODS: We performed a descriptive retrospective study including all the interventions and diagnosis made during a period including pre-pandemic data (starting on 2016) until 2021, when we considered the normalization of surgical activity was achieved. A total of 1039 registers were compiled. The data collected included age, gender, days in waiting list before the intervention, diagnosis, time of hospitalization and surgery duration. RESULTS: We found that the total number of interventions during the pandemic has significantly decreased compared to 2019 (32.15% less in 2020 and 23.5% less in 2021). After data analysis, we found an increase of data dispersion, average waiting list time and for diagnosis after 2020. No differences were found regarding hospitalization time or surgical time. CONCLUSION: The number of surgeries decreased during pandemic due to the redistribution of human and material resources to face the raising of critical COVID-19 patients. The increase of data dispersion and median of waiting time, is the consequence of a growing waiting list for non-urgent surgeries during the pandemic as the urgent interventions also raised, those with a shorter waiting time.

Investigating acetazolamide effectiveness on CSF leak in adul patients after spinal surgery / Investigación de la eficacia de la acetazolamida en la fuga de LCR en pacientes adultos después de una cirugía de column

Introduction and objectives Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery. Materials and methods We conducted a single-center, double-blind, randomized-controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone(CP−A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP−A group (n=36, 50%) and CP+A group (n=36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position+dose of acetazolamide 20mg/kg/day in 3–4 divided doses for 7 days), and CP−A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide). Results Baseline characteristics between the two groups showed no significant differences: Sex (P<0.637), Age (P<0.988) and previous CNS operation at other location besides the spine (P<0.496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36(11.11%) of CP−A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081–2.748; OR=0.471; P<0.402; Adjusted P<0.247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P<0.489) and type of operation (P<0.465). Conclusion Acetazolamide has no positive effect in controlling CSF leak after dural ... (AU)

Introducción y objetivos A pesar del uso de acetazolamida en el manejo de la fuga de LCR en la mayoría de los pacientes después de cirugías del SNC, existe escasa evidencia en la literatura sobre la eficacia de este protocolo establecido entre pacientes adultos en observaciones poscirugía de columna. Investigamos el posible efecto positivo de la acetazolamida en la reducción de la fuga de LCR después de la cirugía de columna. Materiales y métodos Realizamos un ensayo controlado aleatorio, doble ciego, de un solo centro comparando acetazolamida oral más posición corporal (prona) corregida (CP + A) versus posición corporal (prona) corregida sola (CP-A) desde enero de 2014 hasta septiembre de 2015 en la sala de neurocirugía del Hospital Docente Shariati, Universidad de Ciencias Médicas de Teherán, Teherán, Irán. Setenta y dos pacientes divididos en dos grupos [grupo CP-A (n = 36, 50%) y grupo CP + A (n = 36, 50%)] fueron asignados aleatoriamente a este ensayo clínico. Grupo CP + A (mantuvo la posición lateral 3/4 + dosis de acetazolamida 20mg/kg/día en 3-4 dosis divididas durante 7 días) y grupo CP-A (grupo Control) (mantuvo la posición lateral 3/4 durante 7 días). 7 días sin acetazolamida). Resultados Las características basales entre los dos grupos no mostraron diferencias significativas: sexo (P <0,637), edad (P <0,988) y operación previa del SNC en otra ubicación además de la columna (P <0,496). Aunque informamos fuga de LCR posquirúrgica en 2/36 (5,55%) del grupo CP + A y 4/36 (11,11%) del grupo CP-A (control), no se observaron diferencias significativas entre los dos grupos (95% IC, 0,081-2,748; OR = 0,471; P <0,402; P ajustado <0,247). Además, no se observaron diferencias significativas cuando examinamos las características quirúrgicas, como el tamaño de la abertura dural (P <0,489) y el tipo de operación (P <0,465). Conclusión La acetazolamida no tiene un efecto positivo... (AU)

Estudio bibliométrico de las publicaciones en cirugía de columna en México / Publications on spine surgery in Mexico: a bibliometric study

Resumen: Introducción: el análisis bi-bliométrico es una forma útil de evaluar el pasado, el pre-sente y el futuro de las publicaciones relacionadas con un área determinada de forma cualitativa y cuantitativa. Objetivo: determinar las características de la productividad nacional en investigación escrita por autores mexicanos en el campo de cirugía de columna a través del tiempo. Material y métodos: se realizó una búsqueda exhaustiva en línea en Octubre de 2021 utilizando la base de datos Scopus desarrollada por Elsevier. La información de las publicaciones recolectadas fue la siguiente: año, título, acceso, idioma, revista, tipo de artículo, tema, objetivo, citas, autores e instituciones de afiliación. Resultados: se identificó un total de 404 publicaciones entre 1973 y 2021. El número de publicaciones entre la década 1991-2000 y 2011-2021 incrementó 68.28 veces. La mayoría de las publicaciones se realizaron en instituciones de la región centro-sur de México (66.16%), seguida de la región occidente (15.03%) y noreste (8.27%). El índice H más alto encontrado fue de revistas de origen estadounidense (102). La mayor parte de las publicaciones se realizó en la revista Coluna/Columna (15.53%), seguida de Cirugía y Cirujanos (10.52%) y de Acta Ortopédica Mexicana (8.52%). La institución con la más alta productividad fue el Instituto Nacional de Rehabilitación «Luis Guillermo Ibarra Ibarra¼ (17.57%), seguida del Centro Médico Nacional de Occidente del IMSS (6.67%) y del Centro Médico ABC (5.44%). Conclusiones: el número de artículos publicados en el campo de cirugía de columna ha incrementado rápidamente en los últimos 15 años. Las publicaciones escritas en inglés son las más citadas. La distribución geográfica de la investigación en este campo en México está centralizada, realizándose la mayor parte de las publicaciones en la región centro-sur del país (66.16%).

Abstract: Introduction: bibliometric analysis is a useful way of assessing the past, present and future publications related to a given area in a qualitative and quantitative way. Objective: to determine characteristics of national authors productivity in the field of spine surgery research across the time. Material and methods: an online research was performed using the Elsevier´s database Scopus in October, 2021. All studies were assessed for the following parameters: year, title, access, language, journal, type of article, focus of research, objective of research, cites, authors and institutions. Results: a total of 404 publications were identified between 1973 and 2021. Between 1991-2000 decade to 2011-2021 decade the number of published articles tended to increase by 68.28 times. The largest number of articles was from South-Central Region (66.16%), followed by Western (15.03%) and Northwest (8.27%). The highest h-index was found for USA journals (102). The highest number of articles was published in Coluna/Columna (15.53%), followed by Cirugía y Cirujanos (10.52%) and Acta Ortopédica Mexicana (8.52%). Instituto Nacional de Rehabilitación published the largest number of articles (17.57%), followed by Centro Médico Nacional de Occidente del IMSS (6.67%) and Centro Médico ABC (5.44%). Conclusions: the number of articles published in the field of spine surgery in Mexico has increased rapidly in the past 15 years. In terms of quality, publications written in English are the most cited. The geographical distribution of research in Mexico is centralized, the largest number of publications was from South-Central Region of Mexico.

Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery.

INTRODUCTION AND OBJECTIVES: Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery. MATERIALS AND METHODS: We conducted a single-center, double-blind, randomized -controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone (CP-A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP-A group (n = 36, 50%) and CP+A group (n = 36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position + dose of acetazolamide 20 mg/kg/day in 3-4 divided doses for 7 days), and CP-A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide). RESULTS: Baseline characteristics between the two groups showed no significant differences: Sex (P < .637), Age (P < .988) and previous CNS operation at other location besides the spine (P < .496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36 (11.11%) of CP-A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081-2.748; OR = 0.471; P < .402; Adjusted P < .247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P < .489) and type of operation (P < .465). CONCLUSION: Acetazolamide has no positive effect in controlling CSF leak after dural opening/dural tear in adult patients who undergo spinal surgery, when we considered alongside the one-week prone position. Therefore, acetazolamide administration may not be essential for postoperative spinal surgery for dural tear. Prospective studies involving a larger sample size may be needed to track long-term acetazolamide complications on patients with CSF leak.

Vertebral metastasis of renal carcinoma at diagnosis: mechanical and clinical evaluation: surgical management / Metástasis vertebral de carcinoma renal en el momento del diagnóstico: evaluación mecánica y clínica: manejo quirúrgico

Renal cell carcinoma accounts for 2-3% of all malignant neoplasms. Metastatic disease of the spine is common and 50% of bone metastases are already present at the time of primary diagnosis. Bone metastases from renal cell carcinoma are difficult to manage, especially vertebral localization.A 48-year-old woman was diagnosed with renal cell carcinoma in the context of low back pain. The patient presented two skeleton metastases at diagnosis (T11 and 5th rib). The patient received neoadjuvant treatment with cabozantinib, followed by removal of the renal tumor. Radiotherapy was administered for the lumbar lesion. In spite of the radiotherapy treatment, increased low back pain limiting mobility and ambulation. MRI showed an occupation of the spinal canal, without neurological lesion. The SINS scale revealed a score of 14 (vertebral instability). The patient's prognosis was greater than 12 months according to the Tokuhashi score. Based on clinical and mechanical criteria, surgical treatment of the vertebral lesion was decided. T11 vertebrectomy was performed, the reconstruction was made with an expandable cage, and T8 a L2 posterior spinal arthrodesis. A partial resection of the fifth rib was performed in order to remove the whole macroscopic tumor. After 3 months, she was diagnosed with a local infection, treated by irrigation, debridement and antibiotherapy, with good evolution. At 1-year follow-up, she has no low back pain or functional limitation. Follow-up chest-abdomen-pelvis computed CT scan showed absence of disease progression, furthermore, the vertebral arthrodesis shows fusion signs. At the time of this report, there are no clinical or radiological data of infection

El carcinoma de células renales representa el 2-3% de todas las neoplasias malignas. La enfermedad metastásica de la columna vertebral es frecuente y el 50% de las metástasis óseas ya están presentes en el momento del diagnóstico. Las metástasis óseas del carcinoma de células renales son difíciles de manejar, especialmente en localización vertebral.Una mujer de 48 años fue diagnosticada de carcinoma de células renales en el contexto de un dolor lumbar. La paciente presentaba dos metástasis óseas en el momento del diagnóstico (T11 y 5ª costilla). Inicialmente recibió tratamiento neoadyuvante con cabozantinib, seguido de la extirpación quirúrgica del tumor renal. Se administró radioterapia para la lesión lumbar. A pesar del tratamiento radioterápico, aumentó el dolor lumbar con limitación para la movilidad y la deambulación. La RM mostró una ocupación del canal espinal, sin lesión neurológica. La escala SINS reveló una puntuación de 14 (inestabilidad vertebral). El pronóstico de la paciente era superior a 12 meses según la puntuación de Tokuhashi. Basándose en criterios clínicos y mecánicos, se decidió el tratamiento quirúrgico de la lesión vertebral. Se realizó una vertebrectomía de T11, para la reconstrucción se usó una caja extensible, junto con una artrodesis vertebral T8-L2. Se realizó una resección parcial de la quinta costilla para eliminar todo el tumor macroscópico. A los 3 meses de la cirugía la paciente fue diagnosticada de infección local, tratada mediante irrigación, desbridamiento y antibioterapia, con buena evolución. Al año de seguimiento, no presenta dolor lumbar ni limitación funcional. La tomografía computarizada de tórax-abdomen-pelvis de seguimiento mostró ausencia de progresión de la enfermedad, además, la artrodesis vertebral muestra signos de fusión. En el momento de este informe, no hay datos clínicos ni radiológicos de infección.

How to deal with this complication: Intraoperative anterior cage migration in L5-S1 resolved with a lumbar hybrid fusion technique.

Anterior cage migration is the most infrequent and dangerous complication seen in posterior lumbar interbody fusion (PLIF) procedures. We report the case of a 74-year-old woman who underwent PLIF at the L5-S1 level. During the surgery, one of the PLIF-cages dislodged anteriorly into the abdominal cavity without vascular injury. An anterior retroperitoneal approach to remove the cage and complete the fusion was made. The patient was discharged 2 weeks later with encouraging clinical results. In a patient hemodynamically stable, removing the cage by a vascular surgeon, and complete the Anterior Lumbar Interbody Fusion could be a feasible option at L5-S1.

La migración anterior del implante para fusión lumbar es la complicación más infrecuente y peligrosa asociada a la fusión intersomática posterior (PLIF). Reportamos el caso de un paciente femenino de 74 años, operada de PLIF en L5-S1. Durante la cirugía, una de las cajas usadas migró a la cavidad abdominal, sin ocasionar lesión vascular. Para remover el implante y completar la fusión lumbar un abordaje retroperitoneal anterior fue realizado. La paciente fue egresada 2 semanas después con éxito. En un paciente hemodinamicamente estable, este abordaje puede ser una opción para revertir la complicación y completar la fusión lumbar vía anterior.

Manejo quirúrgico de ependimomas en médula cervical: A propósito de un caso clínico / Surgical management of ependymomas in the cervical spine: Apropos of a clinical case

Introducción: los ependimomas son tumores cerebrales que surgen de células ependimarias, células de soporte en el cerebro y la médula espinal. Representan entre el 2 y el 3% de todos los tumores cerebrales primarios. Son el cuarto tumor cerebral más común en los niños, donde el 90% de los mismos se localizan en la fosa posterior. En adultos, el 60% de estos tumores se encuentran en la médula espinal pudiendo presentarse a cualquier nivel de ésta; el caso a continuación reporta un ependimoma cervical. Objetivo: reportar un caso de ependimoma medular de ubicación poco frecuente, con resección total, sin recidiva porterior a 2 años de seguimiento.Descripción del caso: se reporta el caso de un paciente adulto, 44 años, masculino, con un síndrome medular cervical completo, progresivo, provocado por un ependimoma cervical. Intervención: se realizó laminectomía de dos espacios [C7 a T1], apertura dural, mielotomía posterior logrando exéresis total de la lesión con durorrafia a sello de agua y posterior cierre por planos sin complicaciones, con seguimiento de 2 años de sobrevida. Conclusiones: la resección total macroscópica de este tipo de tumores es muy importante para poder evitar residiva. El ependimoma cervical puede recidivar, sobre todo cuando existen residuales de la lesión. El manejo oportuno depende de gran manera de que los pacientes acudan tempranamente a valoración especializada; la resección guiada con monitorización neurofisiológica transoperatoria provee mayor oportunidad a los pacientes a no presentar secuelas permanentes y permite asimismo, mejores resultados de la rehabilitación neurológica postoperatoria

Introduction: ependymomas are brain tumors that arise from ependymal cells, supporting cells in the brain and spinal cord. They represent between 2 and 3% of all primary brain tumors. They are the fourth most common brain tumor in children, where 90% of them are located in the posterior fossa. In adults, 60% of these tumors are found in the spinal cord and can occur at any level of the spinal cord; the case below reports a cervical ependymoma. Objective: to report a case of medullary ependymoma of rare location, with total resection, without recurrence after 2 years of follow-up. Case description: a 44-year-old male adult patient with a progressive, complete cervical spinal cord syndrome, caused by a cervical ependymoma, is reported.Intervention: two-space laminectomy [C7 to T1], dural opening and posterior myelotomy were performed, achieving total excision of the lesion with water-seal durorrhaphy and subsequent closure by planes without complications, with a 2-year survival follow-up. Conclusions: macroscopic total resection of this type of tumor is very important to avoid residual. Cervical ependymoma can recur, especially when there is residual lesion. Timely management depends to a great extent on the patients attending early for a specialized evaluation; guided resection with intraoperative neurophysiological monitoring provides a greater opportunity for patients to not present permanent sequelae and also allows better results of postoperative neurological rehabilitation.

Infusión intravenosa de ketamina a bajas dosis durante cirugía de artrodesis de columna. Una estrategia en el manejo del dolor agudo posoperatorio / Intravenous ketamine infusión at low doses during spinal arthodesis surgery. A strategy in acute postoperative pain management

INTRODUCTION: Acute postoperative pain is a complex problem given the pathophysiological characteristics, increasing health costs and complications and hindering recovery[1],[2]. Spinal arthrodesis is one of the most painful surgical procedures, presenting intense and disabling pain[3],[4]. Multimodal analgesia has been the tool with the best results, based on opioids; however, the combined use of drugs and dependence on opiates are important consequences. Therefore, the analgesic behavior during the use of subanesthetic doses of ketamine is described in the patients undergoing this procedure. METHODOLOGY: A prospective case series study was conducted from January-December 2019, with patients undergoing spinal arthrodesis who met the inclusion criteria, at the Hernando Moncaleano Perdomo University Hospital, Neiva. A univariate statistical analysis of all the variables is performed, with a joint interpretation of the results. RESULTS: A total of 17 patients underwent surgery, one of whom was excluded due to complications related to the surgical material. 88% of the patients showed evaluations of mild or absent pain in at least 4 times, with a number of morphine rescues in 24 hours of 1-2 per patient and patient ambulation in 90% on the first day. CONCLUSIONS. Postoperative spinal arthrodesis patients receiving intravenous ketamine infusion-based analgesia at subanesthetic doses showed mild or absent pain scores at almost all times.

INTRODUCCIÓN: El dolor agudo postoperatorio es un problema complejo dada las características fisiopatológicas, aumentando los costos en salud y las complicaciones y dificultando la recuperación[1],[2]. La artrodesis de columna, es uno de los procedimientos quirúrgicos más dolorosos, presentando un dolor intenso e incapacitante[3],[4]. La analgesia multimodal ha sido la herramienta con mejores resultados, tomando como base los opioides; sin embargo, el uso combinado de fármacos y la dependencia a opiáceos son consecuencias importantes. Por lo anterior, se describe el comportamiento analgésico durante el uso de dosis subanestésicas de ketamina en los pacientes llevados a dicho procedimiento. METODOLOGÍA: Se realiza un estudio tipo serie de casos, prospectivo de enero-diciembre de 2019, con los pacientes llevados a artrodesis de columna que cumplieron con los criterios de inclusión en el Hospital Universitario Hernando Moncaleano Perdomo, Neiva. Se realiza un análisis estadístico univariado de la totalidad de las variables, con una interpretación conjunta de los resultados. RESULTADOS: Se intervinieron un total de 17 pacientes, uno de los cuales fue excluido por complicaciones relacionadas con el material quirúrgico. El 88% de los pacientes mostraron valoraciones de dolor leve o ausente en al menos 4 tiempos, con número de rescates de morfina en 24 h de 1-2 por paciente y deambulación de los pacientes en el 90% en el primer día. CONCLUSIONES: Los pacientes posoperatorios de artrodesis de columna que recibieron analgesia basada en infusión endovenosa de ketamina a dosis subanestésicas mostraron valoraciones de dolor leve o ausente, en casi todos los tiempos.