Are the Spinal Changes in the Course of Scoliogeny Primary but Secondary?

In this opinion article, there is an analysis and discussion regarding the effects of growth on the spinal and rib cage deformities, the role of the rib cage in scoliogeny, the lateral spinal profile in adolescent idiopathic scoliosis (AIS), the genetics and epigenetics of AIS, and the interesting and novel field investigating the sleep impact at nighttime on AIS in relation to the sequence of the scoliogenetic changes in scoliotics. The expressed opinions are mainly based on the published peer-reviewed research of the author and his team of co-authors. Based on the analysis noted above, it can be postulated that the vertebral growth changes in the spine during initial idiopathic scoliosis (IS) development are not primary-intrinsic but secondary changes. The primary cause starting the deformity is not located within the vertebral bodies. Instead, the deformations seen in the vertebral bodies are the secondary effects of asymmetrical loads exerted upon them, due to muscular loads, growth, and gravity.

Neurologic pathologies of the vertebral spine.

At some institutions, musculoskeletal and general radiologists rather than neuroradiologists are responsible for reading magnetic resonance imaging (MRI) of the spine. However, neurological findings, especially intrathecal ones, can be challenging. Intrathecal neurological findings in the spine can be classified by location (epidural, intradural extramedullary, and intramedullary) or etiology (tumor, infection, inflammatory, congenital). In this paper, we provide a succinct review of the intrathecal neurological findings that can be seen on MRI of the spine, primarily by location and secondarily by etiology, in order that this may serve as a helpful guide for musculoskeletal and general radiologists when encountering intrathecal neurological pathologies.

Functional Evolution after Percutaneous Endoscopic Lumbar Discectomy, an Earlier Evaluation of 32 Cases.

Objective To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD). Methods Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks. Results All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks. Conclusion All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3 rd month.

Functional Evolution after Percutaneous Endoscopic Lumbar Discectomy, an Earlier Evaluation of 32 Cases / Evolução funcional após discectomia endoscópica lombar, uma avaliação mais precoce de 32 casos

Abstract Objective To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD). Methods Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks. Results All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks. Conclusion All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3rd month.

Resumo Objetivo Determinar o tempo de alta hospitalar e o período de melhora funcional e da dor dos pacientes submetidos a discectomia endoscópica percutânea lombar (DEPL). Métodos Avaliação retrospectiva do tempo de internação e dos questionários escala visual análoga (EVA), índice de incapacidade Oswestry (IIO), e Roland-Morris de 32 pacientes submetidos a DEPL nos períodos pré-operatório e com 2 dias, e 1, 2, 4, 6, e 12 semanas pós-operatórias. Resultados Todos os pacientes receberam alta em menos de 6 horas houve melhora estatística entre o período pré-operatório e 2 dias pós-operatório , sendo o valor médio do questionário EVA axial de 6,63 para 3,31, do EVA irradiado de 6,66 para 2,75, do IIO de 44,59% para 33,17% e do Roland-Morris de 14,03 para 10,34. Tal diferença apresentou melhora progressiva até 12 semanas em todos os questionários. O IIO atingiu valores de incapacidade mínima (19,39%) com 6 semanas de avaliação. Conclusão Todos os 32 pacientes receberam alta hospitalar em até 6 horas. Houve melhora significativa dos sintomas funcionais e de dor já com 48 horas, apresentando ainda melhora adicional significativa e progressiva até o 3º mês.

[Frequency and age distribution of combined sternovertebral injuries : Analysis of routine data from German hospitals 2005-2012]. / Häufigkeit und Altersverteilung sternovertebraler Kombinationsverletzungen : Analyse aus Routinedaten deutscher Krankenhäuser 2005­2012.

BACKGROUND: Combinations of sternal and spinal fractures often occur due to high velocity accidents and are associated with a high incidence of concomitant injuries. The anterior thoracic wall is described as the fourth column of torso stability, which is why sternovertebral injuries (SVI) present a high risk of sagittal deformation of the trunk, in particular injuries of the thoracic spine. To date, no studies have been published on the frequency distribution of the involved vertebral bodies in large patient groups. OBJECTIVES: This study was intended to elaborate a frequency distribution of vertebral fractures accompanying sternal fractures (SF) and examine the risk of a vertebral fracture accompanying a SF. MATERIAL AND METHODS: A total of 48,193 cases with the main or secondary diagnosis of a SF and 897,963 cases with vertebral fractures based on routine data of German hospitals from the years 2005-2012 were evaluated. A concomitant injury to the spinal column was examined for each vertebral body and then evaluated statistically. RESULTS AND CONCLUSIONS: Of all patients with a SF 30.96% also suffered from a vertebral fracture. Of these 3.11% were SF as the main diagnosis and 60.89% the secondary diagnosis. While vertebral fractures generally occurred most frequently in the region of the thoracolumbar transition and the second cervical vertebral body, the SVI showed a further frequency peak in the range from the lower cervical spine to the middle thoracic spine. The present study was able to show a frequency distribution of accompanying vertebral body injuries in a large and representative collective in the case of SF for the first time.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

BACKGROUND: Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants. METHODS: 11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred. RESULTS: Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years.. CONCLUSIONS: A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.

The effect of dental occlusal disturbances on the curvature of the vertebral spine in rats.

OBJECTIVE: To determine whether a unilateral increase or decrease in the bite affects the curvatures of the vertebral spine in rats. METHODS: 25 male Sprague Dawley rats were included. Five animals received no alteration on their bite. Bite was increased on 10 animals and molar teeth were extracted on 10 other animals. Frontal and lateral radiographs were taken on days 0, 7, 14 and 21. Distances from landmarks to a true vertical line were measured on both radiographs. RESULTS: Repeated measures analysis showed statistically significant differences between the amount of the curvature at the cervical and thoracic spines on frontal and lateral radiographs over time (P<0.05 and P<0.0001). One-way ANOVA computed significant differences (P<0.05) at D14 at the cervical and thoracic spines on both, increased and decreased vertical dimension. CONCLUSION: Alterations in the dental occlusion affects the normal curvatures of the vertebral spine in rats.

Alterations of the biomarker S-100B and NSE in patients with acute vertebral spine fractures.

BACKGROUND CONTEXT: Although several publications concerning the use of the biomarkers S100B and neuron-specific enolase (NSE) in vertebral spine fractures in animal experimental studies have proven their usefulness as early indicators of injury severity, there are no clinical reports on their effectiveness as indicators in patients with spinal injuries. As these biomarkers have been examined, with promising results, in patients with traumatic brain injury, there is a potential for their implementation in patients with vertebral spine fractures. PURPOSE: To investigate the early serum measurement of S100B and NSE in patients with vertebral spine fractures compared with those in patients with acute fractures of the proximal femur. STUDY DESIGN: Prospective longitudinal cohort study. PATIENT SAMPLE: A cohort of 34 patients admitted over an 18-month period to a single medical center for suspected vertebral spine trauma. Twenty-nine patients were included in the control group. OUTCOME MEASURES: S100B and NSE serum levels were assessed in different types of vertebral spine fractures. METHODS: We included patients older than 16 years with vertebral spine fractures whose injuries were sustained within 24 hours before admission to the emergency room and who had undergone a brief neurologic examination. Spinal cord injuries (SCIs) were classified as being paresthesias, incomplete paraplegias, or complete paraplegias. Blood serum was obtained from all patients within 24 hours after the time of injury. Serum levels of S100B and NSE were statistically analyzed using Wilcoxon signed-rank test. RESULTS: S100B serum levels were significantly higher in patients with vertebral spine fractures (p=.01). In these patients, the mean S100B serum level was 0.75 µg/L (standard deviation [SD] 1.44, 95% confidence interval [CI] 0.24, 1.25). The mean S100B serum level in control group patients was 0.14 µg/L (SD 0.11, 95% CI 0.10, 0.19). The 10 patients with neurologic deficits had significantly higher S100B serum levels compared with the patients with vertebral fractures but without neurologic deficits (p=.02). The mean S100B serum level in these patients was 1.18 µg/L (SD 1.96). In the 26 patients with vertebral spine fractures but without neurologic injury, the mean S100B serum level was 0.42 µg/L (SD 0.91, 95% CI 0.08, 0.76). The analysis revealed no significant difference in NSE levels. CONCLUSIONS: We observed a significant correlation not only between S100B serum levels and vertebral spine fractures but also between S100B serum levels and SCIs with neurologic deficit. These results may be meaningful in clinical practice and to future studies.

Construcciones híbridas del raquis lumbosacro: trabajo preliminar - 20 casos / Construções híbridas da coluna vertebral lombossacral: trabalho preliminar - 20 casos / Hybrid constructions of the lumbosacral spine: preliminary work - 20 cases

OBJETIVO: Presentar la filosofía utilizada y como y por qué decidimos proteger el nivel adyacente a una fusión. MÉTODOS: En el criterio de selección de 620 pacientes operados entre enero de 2007 y agosto de 2011 por patología degenerativa, inestabilidad y estenosis del conducto lumbosacro, se seleccionaron 30 pacientes con estadios de Pfirmann 3 y 4, de los cuales seis se perdieron en la consulta postoperatoria y cuatro rechazaron la terapéutica quirúrgica, quedando 20 pacientes que fueron intervenidos quirúrgicamente. La edad promedio de los pacientes fue de 46 años (rango: 22 a 71 años), siendo 11 hombres (55%) y 9 mujeres (45%). RESULTADOS: El seguimiento de los casos es de 6 meses a 2 años y hasta el momento no se evidenció empeoramiento clínicoo radiológico, ni aflojamiento de la instrumentación en ningún caso. CONCLUSIONES: Entendemos que la protección del nivel adyacente mediante el empleo de barras semirrígidas en PEEK sería una buena alternativa de protección debido a que no es necesario abordar el ligamento o los pedículos del nivel adyacente a la fusión.

OBJETIVO: Apresentar a filosofia utilizada e como e por que decidimos proteger o nível adjacente a uma fusão. MÉTODOS: No critério de seleção de 620 pacientes operados entre janeiro de 2007 e agosto de 2011 devido a patologia degenerativa, instabilidade e estenose do canal lombossacral, foram escolhidos 30 pacientes com estágios 3 e 4 de Pfirmann, dos quais seis foram perdidos na consulta pós-operatória e quatro recusaram a cirurgia, restando 20 pacientes que foram submetidos à cirurgia. A idade média dos pacientes era 46 anos (faixa: 22 a 71), sendo 11 homens (55%) e 9 mulheres (45%). RESULTADOS: O acompanhamento dos casos é de 6 meses a 2 anos e, até o momento, não se evidenciou piora clínica ou radiológica, nem afrouxamento da instrumentação em nenhum caso. CONCLUSÕES: Entendemos que a proteção do nível adjacente por meio do emprego de hastes semirrígidas em PEEK seria uma boa alternativa de proteção, devido ao fato de não ser necessário abordar o ligamento ou os pedículos do nível adjacente à fusão.

OBJECTIVE: To present the philosophy used, and demonstrate how and why we decided to protect the level adjacent to a bone union. METHODS: In the selection criteria of 620 patients who had undergone surgery between January 2007 and August 2011 due to degenerative pathology, instability and stenosis of the lumbosacral canal, 30 patients were selected with Pfirmann grades 3 and 4, from which six were lost to follow-up and four refused surgery, leaving 20 patients who underwent surgery. The mean age of the patients was 46 years (range: 22 to 71), with 11 men (55%) and 9 women (45%). RESULTS: The follow-up of the cases was 6 months to 2 years, and so far, no clinical or radiological worsening has been observed, or loosening of the instrumentation in any case. CONCLUSIONS: we understand that protection of the adjacent level through the use of semi-rigid rods in PEEK is a good alternative, as it is not necessary to approach the ligament or pedicles of the level adjacent to the union.

Terapia de presión negativa como alternativa en el manejo de la infección en cirugía de columna / Terapia com pressão negativa como alternativa no tratamento de infecção em cirurgia de coluna / Negative pressure therapy as an alternative in the management of infection in spinal surgery

Describir las indicaciones y contraindicaciones de la terapia de cicatrización asistida por presión negativa. Se realiza una revisión de la bibliografía existente en las bases de datos de OVID, PubMed, Cochrane y Medigraphic en relación a la terapia de cicatrización asistida por presión negativa. Es un sistema de cicatrización no invasivo y activo que utiliza presión negativa localizada y controlada, que consta de un apósito especializado que incluye esponja reticulada que lleva a través de un tubo el exudado a un contenedor hermético. Este conjunto forma micro deformaciones en el lecho de la herida, que han demostrado ser causa importante de mayor migración fibroblástica y por consiguiente de tejido de mayor calidad, formación de tejido de granulación y angiogénesis. En relación con la infección, el principal enfoque del tratamiento es drenar todo el material purulento, quitar los desechos, el tejido desvitalizado, los cuerpos extraños y eliminar la etiología de la infección. Las indicaciones de la TPN son: heridas agudas, crónicas, por trauma, quemaduras, úlceras por diabetes o por decúbito y abdomen abierto y se contraindica en heridas con tejido necrótico, osteomielitis no tratada, fístulas no exploradas no entéricas y no se recomienda su colocación en áreas de malignidad. Este método es eficaz para el tratamiento de las infecciones post quirúrgicas profundas de la columna vertebral, utilizándose en promedio de 1 a 4 semanas.

Descrever as indicações e contraindicações do tratamento de ferimentos com pressão negativa. Foi realizada uma revisão da literatura existente nos bancos de dados OVID, PubMed, Cochrane e Medigraphic, referente à cicatrização assistida por pressão negativa. Trata-se de um sistema de cicatrização não-invasivo e ativo, que utiliza pressão negativa controlada e localizada, e consta de compressa especializada que inclui esponja reticulada que conduz o exsudado por uma cânula, até um recipiente hermético. Esse conjunto forma microdeformações no leito da ferida, que comprovadamente são a causa importante de maior migração fibroblástica e, assim, da formação de tecido de melhor qualidade, formação de tecido de granulação e angiogênese. Com relação à infecção, o principal enfoque do tratamento é drenar todo o material purulento, remover os detritos, o tecido desvitalizado, os corpos estranhos e eliminar a etiologia da infecção. As indicações do TPN são: feridas agudas, crônicas, por trauma, queimaduras, úlceras por diabetes ou de decúbito e abdome aberto, sendo contraindicado em feridas com tecido necrótico, osteomielite não tratada, fístulas não-entéricas não exploradas e não se recomenda seu uso em áreas de doença oncológica. Esse método é eficaz no tratamento das infecções pós-cirúrgicas profundas da coluna vertebral, com tempo médio de utilização de 1 a 4 semanas.

To describe the indications and contraindications for negative pressure wound therapy (NPWT). We performed a review of the existing literature on negative pressure wound therapy on the OVID, PubMed, Cochrane and Medigraphic databases. This is a non-invasive and active healing system that uses controlled and localized negative pressure. It consists of a specialized dressing with a crosslinked sponge, and a tube through which the exudate flows into an airtight container. This system forms microdeformations on the bed of the wound, which have been demonstrated to be a major cause of fibroblast migration, resulting in the formation of better-quality tissue, granulation tissue formation, and angiogenesis. In relation to the infection, the main focus of treatment is to drain all the pus, removing debris, devitalized tissue, foreign bodies and the etiology of infection. The indications of NPWT are: acute wounds, chronic trauma, burns, diabetic ulcers, or decubitus and open abdomen. It is contraindicated in wounds with necrotic tissue, untreated osteomyelitis, and unexplored non-enteric fistulas, and its use is not recommended in areas of malignancy. This method is effective for the treatment of post-surgical infections of the vertebral spine, with an average time of use of 1 to 4 weeks.

Reducción de infecciones por autocontaminación en cirugía de columna / Redução de infecções por autocontaminação em cirurgia de coluna vertebral / Reducing infections by auto-contamination in spine surgery

OBJETIVO: Evaluar en forma prospectiva las infecciones en cirugía de columna que fueron provocadas por contaminación del cirujano o algún miembro del equipo quirúrgico. MÉTODOS: Luego de haber tenido 2 infecciones seguidas en cirugía de columna y de detectar que el germen encontrado en los cultivos de las muestras coincidía con el colonizado en la nariz de uno de los miembros del equipo, decidimos tomar una serie de medidas (en relación al lavado de manos y manejo del barbijo quirúrgico) en forma prospectiva. Evaluamos 120 pacientes que operamos de columna vertebral en forma prospectiva desde enero de 2007 a diciembre de 2009. Como criterios de inclusión fueron cirugías de columna por vía posterior realizadas por el mismo equipo quirúrgico cumpliendo las medidas que serán presentadas. Como criterios de exclusión fueron pacientes operados por vía anterior, cirugías laparoscópicas y vertebroplastías así como aquellas cirugías en que no estuvo alguno del equipo quirúrgico en estudio. RESULTADOS: De las 120 columnas operadas tuvimos infección en tres casos en los que se realizó la toilette correspondiente y el cultivo y antibiograma de la muestra y de la nariz de los miembros del equipo quirúrgico. En ninguno de los casos el germen que produjo la infección coincidió con los gérmenes hallados en las narices del equipo quirúrgico, o sea 0 por ciento de contaminación provocada por el cirujano. CONCLUSIONES: Creemos que las medidas adoptadas en quirófano, con relación al lavado de manos y manejo del barbijo, pueden reducir la infección en cirugía de columna provocada por el propio cirujano.

OBJECTIVE: To carry out a prospective evaluation of spine surgery infections caused by contamination by the surgeon or some other member of the surgical team. METHODS: After seeing two infections in a row during spine surgery, and detecting that the germ found in the sample cultures coincided with that found in the nose of one of the members of the surgical team, we decided to prospectively implement a series of measures related to scrubbing and handling the surgical mask. We carried out a prospective evaluation from January 2007 to December 2009 of 120 patients who underwent spine surgery carried out by our team. Criteria for inclusion were spine surgery by the posterior route carried out by the same surgical team complying with the measures to be presented. Criteria for exclusion were patients who underwent surgery by the anterior route, laparoscopic and vertebroplasty surgeries, and surgeries in which no member of the surgical team in question was present. RESULTS: Of the 120 spines operated on, infection occurred in three cases in which the corresponding hygiene practices and cultivation and antibiogram of the samples and noses of the members of the surgical team were carried out. In none of the cases was the germ that produced the infection the same as the germ found in the nasal sample of the members of the surgical team. In other words 0 percent of the contamination was caused by the surgeon. CONCLUSIONS: We believe that the measures adopted in the operating room in relation to scrubbing and handling the surgical mask can reduce spine surgery infections caused by the surgeon.

OBJETIVO: Avaliar prospectivamente as infecções em cirurgia de coluna que foram provocadas por contaminação do cirurgião ou algum membro da equipe cirúrgica. MÉTODOS: Depois de ter tido duas infecções seguidas em cirurgia de coluna e de detectar que o microrganismo encontrado nas culturas das amostras coincidia com o colonizado no nariz de um dos membros da equipe, decidimos tomar uma série de medidas (com relação à escovação das mãos e manipulação da máscara cirúrgica) de forma prospectiva. Avaliamos 120 pacientes nos quais operamos a coluna vertebral prospectivamente de janeiro de 2007 a dezembro de 2009. Os critérios de inclusão foram cirurgias de coluna por via posterior realizadas pela mesma equipe cirúrgica, de acordo com as medidas apresentadas a seguir. Os critérios de exclusão foram pacientes operados por via anterior, cirurgias laparoscópicas e vertebroplastias, assim como as cirurgias nas quais não havia ninguém da equipe cirúrgica em estudo. RESULTADOS: Das 120 colunas operadas houve infecção em três casos, nos quais se realizou a limpeza correspondente e a cultura e antibiograma da amostra e do nariz dos membros da equipe cirúrgica. Em nenhum dos casos, o microrganismo que produziu a infecção coincidiu com os encontrados no nariz da equipe cirúrgica, ou seja, 0 por cento de contaminação provocada pelo cirurgião. CONCLUSÕES: Acreditamos que as medidas adotadas na sala de cirurgia, a saber, escovação das mãos e manipulação da máscara cirúrgica, podem reduzir a infecção nas cirurgias de coluna provocada pelo próprio cirurgião.

Instrumentos de avaliação clínica e funcional em cirurgia da coluna vertebral / Instrumentos de evaluación clínica y funcional en cirugía de la columna vertebral / Instruments of clinical and functional evaluation in spine surgery

Alguns dos indivíduos submetidos à cirurgia de coluna vertebral terão desfechos pós-operatório desfavoráveis, independente do êxito técnico. Esse insucesso gera aumento da morbidade e dos custos socioeconômicos. Sabe-se que fatores psicossociais interferem na impressão do sujeito. Com o propósito de identificá-los, tem-se estimulado a busca de preditores prognósticos por meio de instrumentos de triagem. Porém, a eleição do mais adequado pode ser difícil, já que existe um grande número de questionários. Entre os aspectos abordados por eles, podemos citar: incapacidade funcional, qualidade de vida, satisfação, dor, depressão, distúrbios do humor e atividade funcional. O trabalho objetiva revisar as particularidades, indicações e limitações dos instrumentos de avaliação do paciente com doença na coluna vertebral.

Some individuals submitted to spine surgery will have unfavorable postoperative outcomes, regardless of the success of the technical procedure. This failure leads to an increase in morbidity and socioeconomic costs. Also, it is known that psychosocial factors influence the subject's impression. In order to identify these factors, the search for prognostic predictors through screening instruments has been stimulated. However, selecting the most appropriate one may be difficult, as a large number of questionnaires already exist. The aspects addressed by these questionnaires include: functional incapacity, quality of life, satisfaction, pain, depression, mood swings and functional activity. This work reviews the special characteristics, indications and limitations of the instruments used to evaluate patients with spine disease.

Algunos individuos, sometidos a la cirugía de columna vertebral, tendrán resultados posoperatorios desfavorables, independientemente del éxito técnico. Esta falla causa aumento de la morbilidad y de los costos socioeconómicos. Se sabe que factores psicosociales interfieren en las impresiones del sujeto. Con la finalidad de identificarlos, se ha estimulado la búsqueda de predictores pronosticadores mediante instrumentos de selección. Sin embargo, elegir el más adecuado puede ser difícil, ya que existe un gran número de cuestionarios. Entre los aspectos abarcados por estos, podemos citar: incapacidad funcional, calidad de vida, satisfacción, dolor, depresión, disturbios del humor y actividad funcional. El trabajo tiene el objetivo de revisar las particularidades, indicaciones y limitaciones de los instrumentos de evaluación del paciente con enfermedad en la columna vertebral.

Opção minimamente invasiva lateral para artrodese intersomática tóraco-lombar / Minimally invasive lateral option for thoracic-lumbar intersomatic arthrodesis / Opción mínimamente invasiva lateral para artrodesis intersomática toracolumbar

OBJETIVO: O objetivo deste artigo é mostrar resultados clínicos e radiográficos do acesso lateral transpoas na experiência brasileira em condições degenerativas do disco intervertebral. MÉTODOS: 46 pacientes foram submetidos à fusão intersomática lombar por via lateral. Dentre os casos, 18 eram do sexo masculino e 28 do sexo feminino, com idade média de 57,3 (84-32 anos) e média de IMC de 25,9 ± 3,1. Todos os pacientes completaram um ano de acompanhamento. Foram coletados exames radiológicos, como raio X e tomografia computadorizada, exame neurológico e resultados clínicos usando os questionários ODI e VAS (costas e membros inferiores). RESULTADOS: Os procedimentos foram realizados, sem ocorrência de complicações intra-operatórias importantes, em uma média de 103,9 ± 105,5 minutos e com menos de 50cc de perda sanguínea. Em oito dos 46 procedimentos (17,4 por cento) foi utilizada suplementação por parafusos pediculares percutâneos por apresentarem instabilidade segmentar. Foram tratados 80 níveis (de um a cinco níveis) tóraco-lombares (de T12-L1 a L4-L5). Os resultados clínicos avaliados pelos questionários revelaram melhora significante de dor logo após uma semana da cirurgia e da função física após seis semanas. A lordose lombar foi de 36,5 ± 14,7 no pré-operatório para 43,4 ± 12,4 no seguimento de 12 meses. Todos os pacientes apresentaram formação óssea após 12 meses da cirurgia. Sete casos foram revisados (15,2 por cento), ainda de forma minimamente invasiva devido à estenose persistente (três casos; 6,5 por cento), afundamento do espaçador (três casos; 6,5 por cento) ou mal-alinhamento de barra da suplementação (um caso; 2,8 por cento). CONCLUSÕES: Com melhora de parâmetros clínicos e radiológicos, a técnica se mostrou segura e eficaz no tratamento de condições degenerativas da coluna lombar.

OBJECTIVE: The purpose of this article is to show clinical and radiological results of lateral transpsoas approach for degenerative conditions of intervertebral disc in Brazilian practice. METHODS: 46 patients have undergone lateral lumbar intersomatic fusion. Eighteen patients were male and 28 female. The mean age was 57.3 years (32 to 84 years), and mean BMI was 25.9 ± 3.1. All patients were followed up during one year. Radiology tests, such as X-ray and CT, and neurological tests were performed. The clinical results were obtained using ODI and VAS (back and leg) questionnaires. RESULTS: The procedures were performed during an average time of 103.9 ± 105.5 minutes, and less than 50 mL of blood loss occurred. Also, no significant intraoperative complication occurred. Supplementation with percutaneous pedicle screws due to segmental instability was used in eight of the 46 procedures (17.4 percent). Eighty thoracic-lumbar (from T12-L1 to L4-L5) levels (from one to five) were treated. According to the questionnaires, the clinical results showed significant pain and physical function improvement after one week and six weeks of surgery, respectively. The lumbar lordosis changed from 36.5 ± 14.7 before surgery to 43.4 ± 12.4 during one year follow-up. All patients showed bone formation 12 months after surgery. Seven cases were revised (15.2 percent), using minimally invasive approach due to persistent stenosis (three cases, 6.5 percent), depressed spacer (three cases, 6.5 percent), and malalignment of supplemental rod (one case, 2.8 percent). CONCLUSIONS: This technique showed to be a safe and efficacious treatment for degenerative diseases of lumbar spine as demonstrated by the improvement of clinical and radiological parameters.

OBJETIVO: El objetivo de este artículo es mostrar resultados clínicos y radiográficos del acceso lateral transpolar, en la experiencia brasileña, en condiciones degenerativas del disco intervertebral. MÉTODOS: 46 pacientes fueron sometidos a fusión intersomática lumbar por vía lateral. Dentro de los casos, 18 eran del sexo masculino y 28 del sexo femenino, con edad promedio de 57,3 años (84-32) y promedio de IMC de 25,9 ± 3,1. Todos los pacientes completaron un año de acompañamiento. Fueron realizados exámenes radiológicos, como rayos X y tomografía computadorizada, examen neurológico y se obtuvieron resultados clínicos usando los cuestionarios ODI y VAS (espaldas y miembros inferiores). RESULTADOS: Los procedimientos fueron realizados, sin ocurrencia de importantes complicaciones intraoperatorias, en un promedio de 103,9 ± 105,5 minutos y con menos de 50 cc de pérdida sanguínea. En ocho de los 46 procedimientos (17,4 por ciento) se utilizó suplementación mediante tornillos pediculares percutáneos porque se presentaba instabilidad de segmento. Se trataron 80 niveles (de uno a cinco niveles) toracolumbares (de T12-L1 a L4-L5). Los resultados clínicos, a los que se tuvo acceso por los cuestionarios, revelaron mejoría significativa del dolor, luego después de una semana de la cirugía y mejor función física después de 12 meses. La lordosis lumbar fue 36,5 ± 14,7 en el preoperatorio yendo para 43,4 ± 12,4 durante el seguimiento de 12 meses. Todos los pacientes presentaron formación ósea después de 12 meses de la cirugía. Siete casos tuvieron nueva intervención (15,2 por ciento), aunque de manera mínimamente invasiva, debido a la estenosis persistente (tres casos; 6,5 por ciento), hundimiento del espaciador (tres casos; 6,5 por ciento) o mala alineación de la barra de suplementación (un caso; 2,8 por ciento). CONCLUSIONES: con mejora de parámetros clínicos y radiológicos, la técnica se mostró segura y eficaz en el tratamiento de condiciones degenerativas de la columna lumbar.

Estudo experimental do sequenciamento das manobras da ligamentotaxia na descompressão do canal vertebral / Experimental study of ligamentotaxis maneuvers sequencing in vertebral canal decompression

A descompressão do canal vertebral, para aliviar as estruturas nervosas, pode ser realizada por meio da ligamentotaxia. O objetivo foi analisar a influência da seqüência de realização da ligamentotaxia sobre a descompressão do canal vertebral. Foram utilizados segmentos de vértebras de suínos (Landrace). Um equipamento especialmente desenvolvido foi utilizado para produção de fratura do tipo explosão. Após a tomografia computadorizada, 10 espécimes que melhores apresentavam fraturas do tipo explosão foram fixados com fixador interno (Synthes). Foram formados dois grupos. No primeiro (n=5) foi realizada a lordose e depois a distração. Posteriormente, foram submetidos à nova compressão por meio de morsa até o retorno da fratura à posição inicial, a seguir foram novamente submetidos à distração e lordose. No segundo grupo (n=5) foi realizada a distração e depois a lordose. Após cada manobra era realizado o exame tomográfico para medir o diâmetro do canal vertebral. Os deslocamentos dos fragmentos dos corpos vertebrais fraturados foram mensurados e comparados utilizando t de Student (p<0,05). Comparando os deslocamentos entre os grupos, não foram observadas diferenças estatísticas (p<0,06). Esse resultado é próximo ao nível de significância adotado, sugerindo uma forte tendência que demonstra a eficácia superior da manobra iniciada pela realização da lordose.

Vertebral canal decompression, intended to provide relief to nervous structures, may be performed by means of legamentotaxis. The objective of this study was to assess the influence of the ligamentotaxis sequence on vertebral canal decompression. Vertebral segments of Landrace swine specimens were used. A device especially developed for producing a burst-type fracture was employed. Subsequently to the computerized tomography scan, 10 specimens that best showed a burst-type fracture were fixated with internal fixator (Synthes). Two groups were formed. On the first group (n=5), lordosis followed by distraction were performed. Then, they were submitted to distraction and lordosis. On the second group (n=5), distraction was provided first, and then lordosis was performed. After each maneuver, vertebral canal was measured by tomography scan. Fractured vertebral body fragments were measured and compared using the Student's t test (p<0,05). By comparing dislocations between groups, no statistical differences were found (p<0,06). This result is close to the significance level adopted, suggesting a strong trend towards a better effectiveness of the maneuver started with lordosis.