[Translated article] Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature.

INTRODUCTION: There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. MATERIAL AND METHODS: A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria. RESULTS: Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive. CONCLUSIONS: Pain in response to contrast medium injection, assessed with the visual analogue pain scale ≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.

Differences in MRI measurements of lateral recesses and foramina in degenerative lumbar segments in upright versus decubitus symptomatic patients.

OBJECTIVE: To evaluate differences in measurements of the lateral recesses and foramina in degenerative lumbar segments on MR images in symptomatic patients obtained with the patient standing versus lying down and to analyze the relationship between possible differences and patients' symptoms. MATERIAL AND METHODS: We studied 207 disc levels in 175 patients aged between 17 and 75 years (median: 47 years) with low back pain. All patients underwent MRI in the decubitus position with their legs extended, followed by MRI in the standing position. We calculated the difference in the measurements of the lateral recesses (in mm) and in the foramina (area in mm2 and smallest diameter in mm) obtained in the two positions. To eliminate the effects of possible errors in measurement, we selected cases in which the difference between the measurements obtained in the two positions was ≥10%; we used Student's t-tests for paired samples to analyze the entire group and subgroups of patients according to age, sex, grade of disc degeneration, and postural predominance of symptoms. RESULTS: Overall, the measurements of the spaces were lower when patients were standing. For the lateral recesses, we observed differences ≥10% in 68 (33%) right recesses and in 65 (31.5%) left recesses; when patients were standing, decreases were much more common than increases (26% vs. 7%, respectively, on the right side and 24% vs. 7.5%, respectively, on the left side; p < 0.005). For the foramina, decreases in both the area and in the smallest diameter were also more common than increases when patients were standing: on the right side, areas decreased in 23% and increased in 4%, and smallest diameters decreased in 20% and increased 6%; on the left side, areas decreased in 24% and increased in 4%, and smallest diameters decreased in 17% and increased in 8% (p < 0.005). Considering the group of patients in whom the postural predominance of symptoms was known, we found significant differences in patients whose symptoms occurred predominantly or exclusively when standing, but not in the small group of patients whose symptoms occurred predominantly while lying. We found no differences between sexes in the changes in measurements of the recesses or foramina with standing. The differences between the measurements obtained in different positions were significant in patients aged >40 years, but not in younger groups of patients. Differences in relation to the grade of disc degeneration were significant only in intermediate grades (groups 3-6 in the Griffith classification system). CONCLUSION: MRI obtained with patients standing can show decreases in the lateral recesses and foramina related to the predominance of symptoms while standing, especially in patients aged >40 years with Griffith disc degeneration grade 3-6, thus providing additional information in the study of patients who have low back pain when standing in whom the findings on conventional studies are inconclusive or discrepant with their symptoms. Further studies are necessary to help better define the value of upright MRI studies for degenerative lumbar disease.

Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature. / Frecuencia de uso de los hallazgos de la discografía para el diagnóstico del dolor lumbar de origen discogénico. Revisión sistemática de la literatura.

INTRODUCTION: There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. MATERIAL AND METHODS: A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria. RESULTS: Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive. CONCLUSIONS: Pain in response to contrast medium injection, assessed with the visual analog pain scale≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.

Dolor lumbar en el embarazo, aspectos fisiopatológicos y tratamiento / Low back pain in pregnancy, pathophysiological aspects and treatment

INTRODUCCIÓN: El dolor lumbar es una condición de alta prevalencia en la población general. La gestación genera cambios fisiológicos que favorecen la aparición de síntomas dolorosos que pueden comprometer la calidad de vida. MÉTODO: Revisión de la literatura con términos MeSH en inglés y español en las bases de datos Embase, PubMed, Lilacs, Sage, Google Academics y Scielo desde el año 1994 hasta el año 2021. Se encontraron 74 artículos y fueron seleccionados 50, basados en su impacto clínico. RESULTADOS: El dolor lumbar afecta a más del 50% de las mujeres embarazadas. Existen antecedentes gineco-obstétricos que pueden intervenirse para disminuir el riego o la intensidad de los síntomas. El diagnóstico es clínico, pero puede asociarse a imágenes diagnósticas cuando se sospechan condiciones de riesgo. El tratamiento se basa en intervenciones no farmacológicas como ejercicio y terapia física, pero pueden utilizarse algunos medicamentos e intervenciones en dolor según su riesgo-beneficio materno y fetal. CONCLUSIONES: El dolor lumbar en el embarazo es muy frecuente y debe ser conocido, diagnosticado y tratado por los profesionales de la salud que atienden esta población, dentro de un equipo multidisciplinario de tratamiento.

INTRODUCTION: Low back pain is a condition of high prevalence in the general population. Gestation generates physiological changes that favor the appearance of painful symptoms that can compromise the quality of life. METHOD: Review of the literature with MeSH terms in English and Spanish in the databases Embase, PubMed, Lilacs, Sage, Google Academics and Scielo from the year 1994 to the year 2021. Seventy-four articles were found and 50 were selected based on their clinical impact. RESULTS: Low back pain affects more than 50% of pregnant women. There are gyneco-obstetric antecedents that can be intervened to reduce the risk or intensity of symptoms. The diagnosis of this entity is clinical, but it can be associated with diagnostic imaging when risk conditions are suspected. Treatment is based on non-pharmacological interventions such as exercise and physical therapy, but some medications and pain interventions can be used according to their risk of maternal and fetal benefit. CONCLUSIONS: Low back pain in pregnancy is very frequent, it should be known, diagnosed, and treated by health professionals who care for this population, based on a multidisciplinary treatment team.

The use of dexmedetomidine in puncture techniques for degenerative diseases of the lumbar spine / Uso de dexmedetomidina em técnicas de punção para doenças degenerativas da coluna lombar / Uso de dexmedetomidina en técnicas de punción para enfermedades degenerativas de la columna lumbar

ABSTRACT Objective To analyze the results of the use of dexmedetomidine (D) in the treatment of patients with degenerative diseases of the lumbar spine using puncture techniques. Methods The study included 77 patients who underwent surgical puncture for degenerative diseases of the lumbar spine with the use of alpha-2-adrenomimetic D: percutaneous laser denervation of the facet joints (n = 46) and posterolateral transforaminal endoscopic discectomy (n = 31). We assessed: the level of sedation using the Ramsay Sedation Scale (RSS) and the Richmond Agitation Sedation Scale (RASS); intraoperative dynamics of the cardiovascular and respiratory system parameters; the level of pain syndrome according to VAS. Results A high intraoperative level of sedation was determined, with RASS -2, -3 and Ramsay III, IV; when transferring a patient to a department (in 90 minutes) this parameter was RASS 0 and Ramsay II. There were no significant changes in central hemodynamics and respiratory depression. The minimum level of pain was determined immediately after surgery, at 30 and 60 minutes after surgery, and before transfer to the department (90 minutes): 6 (4;9); 10 (8;12); 12 (9;13); 16 (13;19) respectively. The absence of the need for additional analgesia on the first postoperative day was verified. Conclusion The use of D significantly reduces the level of pain, while maintaining the necessary verbal contact with the patient, and provides the necessary neurovegetative protection without respiratory depression or lowered hemodynamic parameters during the perioperative period. Level of evidence II; Prognostic Studies - Investigating the Effect of a Patient Characteristic on Disease Outcome. Case series, retrospective study.

RESUMO Objetivo Analisar os resultados do uso de dexmedetomidina (D) no tratamento de pacientes com doenças degenerativas da coluna lombar com técnicas de punção. Métodos O estudo incluiu 77 pacientes submetidos à punção cirúrgica em doenças degenerativas da coluna lombar com o uso de um agonista alfa-2 adrenérgico: denervação percutânea das articulações facetárias com laser (n = 46) e discectomia endoscópica transforaminal posterolateral (n = 31). Foram avaliados o nível de sedação usando a Escala de Sedação de Ramsay (RSS) e a Escala de Sedação e Agitação de Richmond (RASS); a dinâmica intraoperatória dos parâmetros dos sistemas cardiovascular e respiratório; o nível de síndrome de dor de acordo com a EVA. Resultados Determinou-se um alto nível intraoperatório de sedação pela RASS (-2, -3) e pela Ramsay (III, IV). Ao transferir um paciente para outro setor (depois de 90 minutos), esse parâmetro era 0 em RASS e II em Ramsay. Não houve alterações significativas na hemodinâmica central e na depressão respiratória. O nível mínimo de dor foi determinado imediatamente após a cirurgia, 30 e 60 minutos depois da cirurgia e antes da transferência para o outro setor (90 minutos depois): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Constatou-se que não era necessária analgesia adicional no primeiro dia pós-operatório. Conclusões O uso de D reduz significativamente o nível de dor mantendo a comunicação verbal necessária com o paciente e fornece a proteção neurovegetativa necessária sem depressão respiratória e os parâmetros hemodinâmicos reduzidos durante o período perioperatório. Nível de evidência II; Estudos prognósticos - Investigação do efeito de característica de um paciente sobre o desfecho da doença. Série de casos, Estudo retrospectivo.

RESUMEN Objetivo Analizar los resultados del uso de dexmedetomidina (D) en el tratamiento de pacientes con enfermedades degenerativas de la columna lumbar con técnicas de punción. Métodos El estudio incluyó a 77 pacientes con enfermedades degenerativas de la columna lumbar que se sometieron a punción quirúrgica mediante el uso de un agonista adrenérgico alfa-2: denervación percutánea de las articulaciones facetarias con láser (n = 46) y discectomía endoscópica transforaminal posterolateral (n = 31). Fueron evaluados el nivel de sedación mediante la Escala de Sedación de Ramsay (RSS) y la Escala de Sedación y Agitación de Richmond (RASS); la dinámica intraoperatoria de los parámetros de los sistemas cardiovascular y respiratorio; el nivel del síndrome de dolor según la EVA. Resultados Se determinó un alto nivel de sedación intraoperatoria en RASS (-2, -3) y por Ramsay (III, IV)Al transferir un paciente a otro sector (después de 90 minutos), este parámetro fue 0 en RASS y II en Ramsay. No hubo cambios significativos en la hemodinámica central y la depresión respiratoria.El nivel mínimo de dolor se determinó después de la cirugía, 30 y 60 minutos después de la cirugía y antes del traslado al otro sector (90 minutos después): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Se verificó que no era necesaria analgesia adicional el primer día postoperatorio. Conclusiones El uso de D reduce significativamente el nivel de dolor al mismo tiempo que se mantiene la necesaria comunicación verbal con el paciente y brinda la protección neurovegetativa necesaria sin depresión respiratoria y parámetros hemodinámico reducidos durante el período perioperatorio. Nivel de evidencia II; Estudios de pronóstico: Investigación del efecto de la característica de un paciente sobre el desenlace de la enfermedad. Serie de casos, Estudio retrospectivo.

Análisis biomecánico de la ligamentoplastía interespinosa con fibra de poliéster posterior a discectomía / Biomechanical analysis of interespinous ligamentoplasty with polyester fiber after discectomy

Resumen: Introducción: Existen diferentes patologías de la columna lumbar que condicionan una inestabilidad biomecánica y clínica para su tratamiento, se han efectuado diversas técnicas de estabilización que tratan de preservar el movimiento y la transmisión de carga del segmento afecto como la ligamentoplastía interespinosa con fibra Dallos®. Objetivo: Mostrar las variaciones biomecánicas de segmento funcional de columna lumbar de porcino, antes y después de realizar la discetomía y ligamentoplastía con fibra Dallos®. Material y métodos: El segmento lumbar se montó en un simulador multiaxial servo-hidráulico. Se simularon rangos de movilidad de flexión, extensión, flexiones laterales y rotaciones axiales en tres condiciones: 1) segmento natural; 2) segmento discectomizado; y 3) segmento disectomizado más ligamentoplastía con fibra Dallos®. Los rangos de movilidad se realizan hasta un torque de 7.5 N-m. La data de los torques y rangos de movilidad se recolectó en el programa del simulador y se graficaron los resultados de los cambios biomecánicos entre las tres condiciones descritas. Resultados: Se demostró que la biomecánica lumbar es afectada después de la discectomía principalmente en la flexión y la extensión. En los movimientos de flexión y rotación axial izquierdas, se comprobó una alteración del torque y los rangos de movilidad. Conclusiones: La ligamentoplastía recupera parte de la estabilidad perdida postdiscectomía, preservando parte de la altura discal sin llegar a igualar los movimientos como en el segmento natural. Posterior a la discectomía, la distribución de la fuerza sugiere que la inestabilidad residual con ligamento plastía puede representar sobrecarga facetaria.

Abstract: Introduction: There are different pathologies of the lumbar spine that condition a biomechanical and clinical instability for its treatment, various stabilization techniques have been carried out that try to preserve the movement and the transmission of load of the affected segment such as the interspinatus ligamentplasty with Dallos® fiber. Objective: To show the biomechanical variations of functional segment of lumbar spine of pigs, before and after performing the discectomy and ligamentoplasty with Dallos® fiber. Material and methods: The lumbar segment was mounted in a servo-hydraulic multiaxial simulator. Mobility ranges of flexion, extension, lateral flexion and axial rotations were simulated under three conditions: 1. Natural segment, 2. Discectomy segment, and 3. Disectomized segment plus ligamentoplasty with Dallos® fiber. The mobility ranges are made up to a torque of 7.5 N-m The data of the torques and mobility ranges was collected in the simulator program and the results of the biomechanical changes between the three conditions described were plotted. Results: It was shown that lumbar biomechanics is affected after discectomy mainly in flexion and extension. In the left axial bending and rotation movements, an alteration of torque and mobility ranges was found. Conclusions: The ligamentoplasty recovers part of the stability lost after discectomy preserving part of the disc height without reaching to equalize the movements as in the natural segment. After discectomy the distribution of force suggests that residual instability with ligament plasty may represent facet overload.

Differences in MRI measurements of lateral recesses and foramina in degenerative lumbar segments in upright versus decubitus symptomatic patients. / Cambios en recesos laterales y forámenes en segmentos degenerativos lumbares de pacientes sintomáticos estudiados mediante resonancia magnética en decúbito y bipedestación.

OBJECTIVE: To evaluate differences in measurements of the lateral recesses and foramina in degenerative lumbar segments on MR images in symptomatic patients obtained with the patient standing versus lying down and to analyze the relationship between possible differences and patients' symptoms. MATERIAL AND METHODS: We studied 207 disc levels in 175 patients aged between 17 and 75 years (median: 47 years) with low back pain. All patients underwent MRI in the decubitus position with their legs extended, followed by MRI in the standing position. We calculated the difference in the measurements of the lateral recesses (in mm) and in the foramina (area in mm2 and smallest diameter in mm) obtained in the two positions. To eliminate the effects of possible errors in measurement, we selected cases in which the difference between the measurements obtained in the two positions was ≥10%; we used Student's t-tests for paired samples to analyze the entire group and subgroups of patients according to age, sex, grade of disc degeneration, and postural predominance of symptoms. RESULTS: Overall, the measurements of the spaces were lower when patients were standing. For the lateral recesses, we observed differences ≥10% in 68 (33%) right recesses and in 65 (31.5%) left recesses; when patients were standing, decreases were much more common than increases (26% vs. 7%, respectively, on the right side and 24% vs. 7.5%, respectively, on the left side; p<0.005). For the foramina, decreases in both the area and in the smallest diameter were also more common than increases when patients were standing: on the right side, areas decreased in 23% and increased in 4%, and smallest diameters decreased in 20% and increased 6%; on the left side, areas decreased in 24% and increased in 4%, and smallest diameters decreased in 17% and increased in 8% (p<0.005). Considering the group of patients in whom the postural predominance of symptoms was known, we found significant differences in patients whose symptoms occurred predominantly or exclusively when standing, but not in the small group of patients whose symptoms occurred predominantly while lying. We found no differences between sexes in the changes in measurements of the recesses or foramina with standing. The differences between the measurements obtained in different positions were significant in patients aged>40 years, but not in younger groups of patients. Differences in relation to the grade of disc degeneration were significant only in intermediate grades (groups 3-6 in the Griffith classification system). CONCLUSION: MRI obtained with patients standing can show decreases in the lateral recesses and foramina related to the predominance of symptoms while standing, especially in patients aged>40 years with Griffith disc degeneration grade 3 to 6, thus providing additional information in the study of patients who have low back pain when standing in whom the findings on conventional studies are inconclusive or discrepant with their symptoms. Further studies are necessary to help better define the value of upright MRI studies for degenerative lumbar disease.

Foot drop after percutaneous treatment with radiopaque gelified ethanol (Discogel®) / Pie caído posterior al tratamiento percutáneo con etanol gelificado radiopaco (Discogel®)

Sciatica due to a lumbar disc herniation is a frequent symptom, between 13% and 40% of the general population will experience an episode of sciatica during their lives. Different techniques exist to treat this condition. Among them the percutaneous intradiscal Discogel®. In all the series of patients reviewed treated with Discogel®, so far, there is not any case reported with disc extrusion and significant neurological damage. We present a case of a foot drop, caused by a disc herniation after percutaneous treatment with Discogel®. We hypothesize that the pathogenic mechanism would be the increased intradiscal volume and pressure post-puncture and annulus fibrosus damage, which could produce the disc extrusion. The extrusion of Discogel® material is possible. To the best of our knowledge, this is the first reported case of this complication with this product (AU)

La ciática secundaria a una hernia discal lumbar es un síntoma frecuente; entre el 13% y el 40% de la población general experimentará un episodio de ciática durante sus vidas. Se han desarrollado diferentes técnicas para tratar esta dolencia. Entre ellas, el Discogel® intradiscal percutáneo. En todas las series revisadas de pacientes tratados con Discogel®, hasta el momento, no se ha informado ningún caso de extrusión discal ni daño neurológico importante. Presentamos un caso de pie caído, causado por una hernia de disco posterior al tratamiento percutáneo con Discogel®. Nuestro mecanismo teórico es el aumento del volumen y la presión intradiscal más el daño del anillo fibroso pospunción que podría producir una extrusión discal. La extrusión del material Discogel® es posible. Hasta donde sabemos, este es el primer caso reportado de esta complicación con este producto (AU)

Foot drop after percutaneous treatment with radiopaque gelified ethanol (Discogel®).

Sciatica due to a lumbar disc herniation is a frequent symptom, between 13% and 40% of the general population will experience an episode of sciatica during their lives. Different techniques exist to treat this condition. Among them the percutaneous intradiscal Discogel®. In all the series of patients reviewed treated with Discogel®, so far, there is not any case reported with disc extrusion and significant neurological damage. We present a case of a foot drop, caused by a disc herniation after percutaneous treatment with Discogel®. We hypothesize that the pathogenic mechanism would be the increased intradiscal volume and pressure post-puncture and annulus fibrosus damage, which could produce the disc extrusion. The extrusion of Discogel® material is possible. To the best of our knowledge, this is the first reported case of this complication with this product.

Articulación facetaria lumbar: correlación anatómica, clínica e imagenológica / Lumbar facet joint: anatomical, clinical and imaging correlation

El dolor facetario lumbar es una de las principales causas de dolor lumbar; representa alrededor del 15-56%. La articulación facetaria estabiliza la columna vertebral, tiene un rol fundamental en el soporte, distribución del peso y regulación de los movimientos rotacionales de la columna. Por ello, el conocimiento de la anatomía y de la biomecánica de esta articulación ayuda a tener una mejor comprensión de su participación en la fisiopatología del dolor lumbar y, por ende, mejora su abordaje diagnóstico y terapéutico. Nosotros revisamos aquí los conceptos actuales de embriología, anatomía, biomecánica y la correlación clínica/imagenológica de los cambios asociados a la enfermedad degenerativa facetaria de la columna lumbar.

Low back pain is a very common reason for emergency room consultation, it is found in approximately 60% of adults, and, within it, facet lumbar pain is one of the main causes, accounting for about 15-56% of low back pain cases. The facet joint stabilizes the spine, helps to distribute loads and has a fundamental role in support, weight distribution, and rotational movements regulation of the spine. Consequently, knowledge of the anatomy and biomechanics of this joint is helpful to have a better understanding of their contribution to the low back pain pathophysiology and, therefore, improving diagnostic and therapeutic approaches. This paper aims to review the current concepts of embryology, anatomy, biomechanics, and clinical/imaging correlation of the changes associated with lumbar degenerative facet disease

Paravertebral lipomatous ganglioneuroma with intraspinal extension. Case report and literature review. / Ganglioneuroma lipomatoso paravertebral con extensión intraespinal. Descripción de un caso y revisión de la literatura.

Lipomatous ganglioneuromas are a rare variant of ganglioneuromas characterized by a mature adipocytic component admixed with a conventional ganglioneuroma component. We present the case of a 34 year old patient with a paravertebral right lesion L1-L4 with intraspinal extension and secondary neurological deficit, who underwent surgery in our hospital. The pathological anatomy showed a yellowish encapsulated neoplasm, which under microscopic evaluation showed areas of ganglioneuroma admixed with areas of mature fat. In the follow up, the patient was asymptomatic, had recovered paresis in the right lower extremity and in the last image control did not present data of lesion recurrence. Fewer than 10 cases of lipomatous ganglioneuromas have been reported in the literature, being this the first paravertebral case wih intraspinal extension and with neurological deficit, hence the interest of this work.

Tophaceous Gout in the Lumbar Spine Causing Radiculopathy. / Gota tofácea en la columna lumbar causando radiculopatía.

Tophaceous deposits in lumbar spine is considered a rare condition. We report the case of a 44-year-old patient with low back pain and radiculopathy. Radiographs revealed lytic spondylolisthesis in L5. Magnetic resonance imaging showed hypointense signal on T1 and a heterogeneous signal on T2 located in the L4-L5 interspinous space and in the left facet joint that invades left neuroforamen. The left knee ultrasound showed «double contour¼ of the medial femoral condyle. Decompressive laminectomy with arthrodesis at the level of L5-S1 was performed. The histological examination revealed amorphous material with a foreign body giant cell reaction.

Spinal osteoid osteoma recurring as an aggressive osteoblastoma. / Osteoma osteoide raquídeo recidivante en forma de osteoblastoma agresivo.

We report an uncommon case of osteoid osteoma recurring as an aggressive osteoblastoma of the spine. A 15-years-old male consulted in our department with long-term painful scoliosis. The CT-scans and MRI revealed a sclerotic bone forming tumor of 7mm diameter consistent with a osteoid osteoma. A percutaneous radiofrequency ablation was performed with complete resolution of the symptoms. After 6 months, the symptoms recurred. A new CT and a MRI showed a growth of the nidus on the right L4 lamina, with a size of 15mm. Therefore, a marginal resection by laminectomy of L4 was performed. Pathology confirmed an epithelioid osteoblastoma. A year later, subsequent imaging studies showed a new recurrence with aggressive features and invasion of the spinal canal. The patient then underwent an "in block surgery" needing concurrent stabilization of the spine. Histopathology confirmed the diagnosis of epithelioid osteblastoma.

Influence of age, sex, height and lumber stenosis on the position of the conus medullaris in adults / Influencia de la edad, sexo, altura y estenosis lumbar en la posición del cono medular en adultos

Anatomical orientation of the termination level of Conus Medullaris (CM) has imperative role clinically for anesthetists and neurosurgeons which is considered as an objective guide to perform spinal anesthesia and spinal punctures circumspectly with less chance to have serious injuries. The current retrospective study was carried on to determine the location of the CM and how its termination level can be influenced by age, sex, height and lumber stenosis spine disease. The study included 462 participants that consisted of 199 men and 263 women range from 21 to 80 years of age and height range between 150-190 cm. Also, it included 150 lumber stenosis patients. The location of the CM was imaged using a series of magnetic resonance images (MRI) for the lumbosacral spine at different levels including, T12, T12-L1, L1, L1-L2, and L2. The measurements revealed inconsiderable differences in the CM termination level in relation to age, sex and height in a healthy study population. Moreover, the results showed insignificant differences in the CM termination level between men and women whether they are healthy or having lumbar spinal stenosis. In conclusion, the most common level of CM termination is at L1 followed by L1-L2. It is safe to perform a lumbar neuraxial procedures at the level of L3-L4.

La orientación anatómica del nivel de terminación del Conus medullaris (CM) tiene un importante papel clínico para los anestesistas y neurocirujanos, que se considera una guía objetiva para realizar la anestesia espinal y las punciones de la columna circunspectivamente con menos posibilidades de provocar lesiones graves. Se llevó a cabo un estudio retrospectivo para determinar la ubicación del CM y cómo su nivel de terminación puede verse afectado por la edad, el sexo, la altura y una patología de la columna vertebral, la estenosis lumbar. El estudio incluyó 462 participantes que consistían en 199 hombres y 263 mujeres de 21 a 80 años de edad y una altura de entre 150-190 cm. Además, se incluyeron 150 pacientes con estenosis lumbar. La ubicación del CM se determinó mediante una serie de imágenes de resonancia magnética (RM) de la columna lumbosacra a diferentes niveles, incluidos T12, T12-L1, L1, L1-L2 y L2. Las mediciones revelaron diferencias considerables en el nivel de terminación de CM en relación con la edad, el sexo o la altura en una población de estudio saludable. Además, los resultados mostraron diferencias poco significativas en el nivel de terminación de CM entre hombres y mujeres, sanos o con estenosis espinal lumbar. En conclusión, se encontró que el nivel más común de terminación del CM es L1 seguido de L1-L2, considerándose seguro realizar procedimientos neuroaxiales lumbares a nivel de L3-L4.

L4 erector spinal plane block after lumbar spine arthrodesi: A case-series. / Bloqueo del plano del erector espinal en L4 en cirugía de artrodesis lumbar: serie de casos.

INTRODUCTION: Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery. METHODS AND CASE SERIES: Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine. CONCLUSIONS: Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion.

Resección de quistes sinoviales por técnica tubular mínimamente invasiva. ¿Abordaje ipsilateral o contralateral? / Resection of synovial cysts by minimally invasive tubular technique. Ipsilateral or contralateral approach?

Introducción: Los quistes artrosinoviales espinales son lesiones infrecuentes que se originan principalmente en la región lumbar. Aunque el tratamiento conservador es posible, la resección quirúrgica es considerada el tratamiento de elección en pacientes sintomáticos. La inestabilidad postoperatoria es una preocupación. Las técnicas mínimamente invasivas (MISS) demostraron ser una alternativa válida que podría disminuir el riesgo de inestabilidad postoperatoria. Objetivo: Describir la importancia de la orientación facetaria en la elección del lado del abordaje (ipsilateral o contralateral) y la conservación de la unión articular en una serie de pacientes operados de quistes sinoviales lumbares por técnica tubular mínimamente invasiva. Material y métodos: Se evaluaron 8 pacientes con quistes sinoviales lumbares operados con técnica tubular mínimamente invasiva. Se analizó en RMN la relación entre la orientación de las facetas articulares y la vía de abordaje seleccionada, se evaluó además la resección de los quistes sinoviales y el grado de preservación facetaria postoperatoria. Información demográfica e intraoperatoria fue detallada. El resultado clínico fue valorado usando la Escala Visual Analógica (VAS) y los criterios de Macnab modificados para medir la satisfacción postoperatoria de los pacientes. El seguimiento mínimo fue de 6 meses. Resultados: Ocho quistes sinoviales fueron operados y resecados completamente. Cinco pacientes presentaron orientación facetaria coronal y 3 sagital los cuales fueron abordados del lado ipsilateral y contralateral respectivamente. En todos los casos se logró preservar al menos 2/3 de la unión facetaria del nivel comprometido. El tiempo promedio de cirugía fue de 110 minutos. Todos los pacientes fueron dados de alta dentro de las 24 hs. Se observó una mejoría de 6 puntos en el VAS. Según la escala de Macnab; 6 pacientes refirieron resultados excelentes, 1 bueno y 1 regular. No se registraron fístulas ni infecciones. Conclusión: La orientación de las facetas articulares definió el lado del abordaje. En facetas articulares con orientación coronal recomendamos el abordaje tubular ipsilateral y en facetas articulares con orientación sagital el abordaje contralateral. Esto permite una excelente exposición del quiste sinovial y la preservación de la articulación facetaria. Ensayos prospectivos con mayor tiempo de seguimiento y cohortes más grandes serían de utilidad para avalar nuestras recomendaciones.

Background: Spinal arthro-synovial cysts are uncommon lesions that largely originate in the lumbar area. Although conservative management is an option, surgical resection is considered the treatment of choice in symptomatic patients. Post-operative instability is of concern, however. Minimally-invasive surgery techniques have proven a valid option which might reduce post-surgical instability. The aim of this paper is to describe the importance of facet orientation in side selection for the surgical approach (ipsilateral or contralateral) and facet joint sparing in a series of patients undergoing minimally-invasive tubular surgery (MITS) for lumbar synovial cysts. Methods: Eight patients with lumbar synovial cysts undergoing MITS were assessed. Pre-operatively, magnetic resonance imaging (MRI) was performed to identify facet joint orientation and aid in surgical approach selection. Post-operatively, MRI was repeated to confirm resection of the synovial cysts and the level of post-surgical facet sparing. Demographic and intraoperative data were recorded, with post- versus pre-operative pain compared using a visual analog scale (VAS), and the modified Macnab criteria used to measure patients' post-operative satisfaction. Minimum post-operative follow-up was six months. Results: Eight synovial cysts were resected completely. Five patients had a coronal and three a sagittal orientation of their facet and were managed with an ipsilateral versus contralateral approach, respectively. In all cases, at least 2/3 of the involved facet joint was spared. Average surgical time was 110 minutes, and all patients were discharged within 24 hours. A mean 6-point improvement was observed in VAS pain severity. Using the Macnab scale, six patients reported excellent results, one a good result and one a fair result. No spinal leaks or infections were reported. Conclusions: Facet-joint orientation determines which side is used for the surgical approach. For facet joints with a coronal orientation, we recommend the ipsilateral tubular approach; while for joint facets with a sagittal orientation, the contralateral approach. This enables both excellent exposure of the synovial cyst and facet-joint sparing. Prospective trials with longer follow-up and larger cohorts are needed to validate our recommendations.

Spinal osteosarcoma in the paediatric age group: case series and literature review. / Osteosarcoma lumbar en edad pediátrica: reporte de casos y revisión de la literatura.

INTRODUCTION AND OBJECTIVE: Osteosarcoma is the most frequent malignant spinal tumour in the paediatric age group. Diagnosis and early treatment of this pathology is essential for a good prognosis. The aim of this study was to present the results of treatment of paediatric patients with lumbar osteosarcoma and conduct a literature review. MATERIAL AND METHODS: All the patients with lumbar osteosarcoma who were operated between 2012 and 2014 in the same centre were included. Demographic and radiological data (Enneking, WBB and Tomita classification), as well as anatomopathological (Broders classification) variables were analysed. All the patients were treated by surgical resection associated with adjuvant therapies (chemotherapy and radiotherapy); according to consensus with the tumour committee. The average follow-up was 62.53 months (47-70 months). RESULTS: A total of 3 patients were studied, two girls of 9 and 11, with L5 osteosarcoma, and a 15-year-old boy with L4 osteosarcoma. Two of the cases were initially treated as an osteoblastoma, supported by radiological and anatomopathological images. None of the patients had local recurrences or metastases during follow-up. CONCLUSIONS: Due to a lack of long series of cases of osteosarcoma in the mobile spine during childhood, the optimal treatment and prognosis in these patients is uncertain. Block resection improves local control of the disease, without demonstrating improvement in overall survival. Intralesional resection is associated with a higher rate of local recurrence. Oncological treatment is essential in the treatment of this pathology. A correct differential diagnosis of the tumour (osteosarcoma vs. osteoblastoma) is vital for its correct treatment.

Lumbar erector spinae plane block: Successful control of acute pain after lumbar spine surgery - A clinical report. / Bloqueo lumbar del plano del músculo erector de la columna: control exitoso del dolor agudo tras cirugía de la columna lumbar. Un caso clínico.

We report the successful clinical case of a patient scheduled for lumbar spine surgery in which we performed a bilateral single-shot erector spinae plane block as part of a multimodal analgesic strategy for pain control. Performing the block preoperatively dismissed the need for extra intraoperative opioids other than those for intubation, and enabled the use of paracetamol for analgesia only. Further, there was no need for hypotensive techniques, as the block provided satisfactory sympathetic blockade and regional vasodilation with a clear surgical field. Postoperatively, the patient had minor opioid consumption and was able to freely move without any motor impairment or pain from early on in the Post Anaesthesia Care Unit. The use of single-shot erector spinae plane block at the lumbar level for lumbar spine surgery analgesia emphasises its wide application and analgesic efficacy.

Abordaje paraespinal de Wiltse: nota técnica y revisión de sus ventajas y limitaciones / Wiltse paraspinal approach: technical note and review of its advantages and limitations

Objetivo: Describir paso a paso el abordaje paraespinal de Wiltse y resaltar las principales ventajas y limitaciones relatadas en la literatura. Material y métodos: Se realizó una descripción del abordaje de Wiltse paso a paso y detalladamente paso a paso, haciendo hincapié en algunos trucos y limitaciones adquiridos con la práctica. Se revisó la literatura disponible con una búsqueda en PubMed y Lilacs bajo los términos Mesh: "Wiltse approach", "paraspinal approach", "muscle sparing approach", "lumbar spine", para destacar ventajas y desventajas de la técnica. Se analizaron 10 trabajos que tenían relación con el objetivo de esta publicación. Ninguno de los trabajos hallados en la búsqueda describía en detalle los pasos del abordaje paraespinal. Se describió: preparación, posicionamiento, incisión, apertura fascial, disección, identificación ósea, desperiostización, descompresión, discectomía, instrumentación, artrodesis y cierre. Resultados: La mayoría de los trabajos resaltaron la utilidad del abordaje como técnica de mínima invasión, con sangrado intraoperatorio mínimo, cortas estadías hospitalarias y bajo índice de infecciones. Conclusión: El abordaje clásico descripto por Wiltse sigue los principios de cirugía de mínima invasión, respetando los planos musculares y tejidos blandos paraespinales, permitiendo amplias descompresiones, discectomías y fusiones con bajos índices de complicaciones.

Objective: To provide a step-by-step description of the Wiltse paraspinal approach, and analyze the main advantages and limitations described in the literature. Methods: We provide a detailed step-by-step description of the Wiltse approach, focusing on some of the strategies we have learned and limitations we have seen in daily clinical practice. A literature review was conducted, consisting of Pub Med and Lilacs searches using the Mesh terms: "Wiltse approach", "paraspinal approach", "muscle sparing approach", and "lumbar spine". Ten papers related to our objectives were assessed, step by step considering patient preparation and positioning, skin incisions, fascial opening, dissection, bone identification, retraction, deperiostization, decompression, discectomy, instrumentation, arthrodesis, and closure. Results: Most papers underline the usefulness of the Wiltse paraspinal approach as a minimally-invasive procedure, emphasizing the minimal intra-operative bleeding, short hospital stays, and low infection rates. However, none of the identified papers thoroughly described specific steps taken using this approach. Conclusion: The classical approach described by Wiltse observes the principles of minimally-invasive surgical procedures, sparing both the muscle planes and soft tissues, thereby allowing for ample decompression, discectomies, and spinal fusions with low complication rates.

[Impact of obesity in the pathophysiology of degenerative disk disease and in the morbidity and outcome of lumbar spine surgery]. / Impacto de la obesidad en la fisiopatología de la enfermedad degenerativa discal y en la morbilidad y resultados de la cirugía de columna lumbar.

Obesity (BMI>30Kg/m2) is a pandemic with severe medical and financial implications. There is growing evidence that relates certain metabolic processes within the adipose tissue, preferentially abdominal fat, with a low-intensity chronic inflammatory state mediated by adipokines and other substances that favor disk disease and chronic low back pain. Obesity greatly conditions both the preoperative evaluation and the spinal surgical technique itself. Some meta-analyses have confirmed an increase of complications following lumbar spine surgery (mainly infections and venous thrombosis) in obese subjects. However, functional outcomes after lumbar spine surgery are favorable although inferior to the non-obese population, acknowledging that obese patients present with worse baseline function levels and the prognosis of conservatively treated obese cohorts is much worse. The impact of preoperative weight loss in spine surgery has not been prospectively studied in these patients.