Follow-up of a new titaniumcoated polyetheretherketone cage for the cervical spine.

Poly-ether-ether-ketone (PEEK) cages have lower modulus of elasticity when compared with Titanium (TTN) cages. This suggests that PEEK-cages could show a lower rate of subsidence after anterior cervical discectomy-fusion (ACDF) and might lead to a lower loss of correction. We investigated the one to five year-results of standalone PEEK-TTN-porous coated cages in a patient cohort from 2014 to 2017. The patients underwent single-level ACDF for disc herniation and degenerative discopathy. Clinical and radiological outcome were assessed in 50 eligible patients after a mean of 27 months. Results: Solid arthrodesis was found in 84%. Neck disability index (NDI), and visual analogue scale (VAS) of neck and arm show comparable results to the literature. Conclusions: Clinical and radiological outcomes of ACDF with PEEK-body-cages with a porous coated surface show good bony integration. The modulus of elasticity, design, shape, size, cage surface architecture, as well as bone density, endplate preparation, radical microdiscectomy and distraction during surgery should be considered as important factors influencing the clinical results. One main advantage, over titanium cages, is the absence of MRI artifacts, allowing an excellent postoperative follow-up.

Monitorización neurofisiológica intraoperatoria en cirugía raquimedular. Aspectos clínicos y médico-legales / Neurophysiological monitoring during spine and spinal cord surgery. Clinical and medico-legal issues

El objetivo de la monitorización neurofisiológica intraoperatoria es la detección de daño o alteración funcional en el sistema nervioso lo más precozmente posible, asegurando la funcionalidad medular, evitando las complicaciones neurológicas. Sin embargo, la falta de estandarización en la metodología, junto con cierta inconsistencia en los estudios sobre su utilidad, limita el establecimiento de unas recomendaciones universales para su utilización. El presente trabajo pretende revisar los procedimientos de monitorización neurofisiológica, sus fortalezas y debilidades, así como la conveniencia de su empleo en cirugía espinal. Concluimos que, con carácter general, su falta de uso en dicha cirugía no contraviene la «lex artis», pues no existe evidencia de que pueda ayudar en revertir el daño neurológico. Sin embargo, puede emplearse como elemento de prueba tanto para detectar el momento y el tipo de daño neurológico como para aumentar la defensibilidad. Se requieren protocolos de uso, bien por las sociedades científicas o por los propios centros hospitalarios

The purpose of neurophysiological monitoring during surgery is to identify damage or functional neurological disturbances as soon as possible, ensuring spinal cord functionality and avoiding neurological complications. However, the lack of standardisation of the methodology, together with some inconsistencies in the studies on its usefulness, limit the establishment of universal recommendations for its use. The present paper intends to review neurophysiological monitoring procedures during surgery, including their strength and weaknesses, as well as to assess the convenience of their use during spinal surgery. It is concluded that, in general, the lack of its use in this surgery does not legally contravene the standard of care, as there is no evidence it could result in reverting neurological damage. Nevertheless, it can be used as evidence both in detecting the time and kind of neurological injury, and for increasing the defensibility. Protocols of use, provided either by scientific societies or hospitals themselves, are required

Primer programa español de donación corporal virtual. Aspectos médico-legales e interés en docencia, asistencia e investigación / First Spanish program of virtual body donation. Medico-legal issues and academic, clinical care and research interest

La donación corporal es la base de los programas de trasplantes, cuya regulación se fundamenta en los derechos del donante y receptor. Sin embargo, si su objetivo no es asistencial, la normativa difiere tanto en vivos como en fallecidos. Las llamadas «técnicas de imagen» permiten obtener ficheros digitales con el cuerpo virtual del paciente, lo que brinda una nueva posibilidad: la donación corporal virtual, no regulada en España y tampoco ajustada a la normativa del resto de las donaciones. Presentamos un programa de donación corporal, analizando sus características, aspectos médico-legales, clínicos, de organización y funcionamiento. Contar con un número ilimitado de especímenes virtuales impulsa una nueva forma de docencia e investigación. Tiene, además, ventajas para la formación de los profesionales en técnicas de autopsia virtual. Creemos que este programa, pionero en España, puede servir para extender iniciativas similares de utilidad ilimitada en docencia e investigación en ciencias forenses, morfológicas y afines

Body donation is in the basis of transplantation programs, founded on receptor and donor rights. Nevertheless, if the purpose is not directed to healthcare, the regulation is different both in live or deceased individuals. "Imaging techniques" generates digital files containing the «virtual body» of the patient, raising a new possibility: virtual body donation, which is not regulated in Spain and would not be compliant with legal requirements for other ways of donation. A pioneer program for virtual body donation is presented, analysing its characteristics, medico-legal issues, organisation and functioning. Having an unlimited number of virtual specimens (normal and pathological) could support a new way for teaching and research. These resources would also have the advantage of learning virtual biopsy (virtopsy). It is thought that these programs, pioneers in Spain, could be useful for introducing similar initiatives that would have unlimited applications in teaching and research both in forensic and morphological sciences

Delay in diagnosis of thoracolumbar fractures.

The time interval between the date of trauma and the diagnosis of vertebral column fractures hinders management and increases liability. We have examined the features and implications of this delay. 585 consecutive thoracolumbar fractures (2005-2016), were considered; 382 (65.30%) were males and 203 (34.70%) females. Mean age was 51 yr. Fall from a height (187; 31.97%), simple fall (147; 25.13%) and road accidents (111; 18.97%) were the most frequent causes of trauma. Physical exertion caused 8.38% (N=49). 142 patients (24.27%) were not diagnosed on the injury day (mean = 3.2 days). Delay was longer in females (mean = 5.5 vs. 2.7 days) and shorter in falls from a height (mean = 2.3) or road accidents (2.8). Mean age of diagnosed on the injury day differed from those diagnosed in the first month (49.2 vs 60.1). Plain X-ray signs were found in 7 misdiagnosed cases (46.6%). Delay was more frequent in low mineralization cases. Diagnostic delay of spine fractures is frequent. Some risk profiles can help to reduce it. Careful emergency X-ray examination is encouraged, as well as early magnetic resonance imaging in risk profiles.

Lesión medular con normalidad radiológica. Etiología, diagnóstico y problemática médico-legal / Spinal cord injury and normal neuroimaging. Aetiology, diagnosis and medico-legal issues

La objetivación de las lesiones espinales o medulares en accidentes es un tema clásico de discusión tanto en Medicina Asistencial como en Medicina Forense. Un problema particular son los pacientes con daño medular sintomático y neuroimagen normal. Estos casos se denominan con los acrónimos SCIWORA («spinal cord injury without radiographic abnormality»), SCIWNA («spinal cord injury without neuroimaging abnormality») y SCIWORET («spinal cord injury without radiologic evidence of trauma»). Nuestro propósito es revisar los aspectos clínicos, radiológicos y médico-legales de estos cuadros, desconocidos muchas veces para quien no trata habitualmente lesionados medulares. El objetivo principal está centrado en los aspectos médico-legales de estos cuadros. Nuestros resultados cuestionan algunos aspectos del reciente sistema para la valoración de los daños y perjuicios causados a las personas en accidentes de circulación (Ley 35/2015), en los llamados traumatismos cervicales menores. En consecuencia, el tratamiento que la reciente legislación española da a dichos traumatismos podría necesitar ser revisada (AU)

The objective demonstration of minor spinal and spinal-cord lesions following accidents is a classic discussion issue in both Clinical and Forensic Medicine. Particular problems are the patients with symptomatic spinal cord damage and normal neuroimaging. These situations are usually named with acronyms: SCIWORA ("spinal cord injury without radiographic abnormality"), SCIWNA ("apinal cord injury without neuroimaging abnormality"), and SCIWORET ("spinal cord injury without radiological evidence of trauma"). Our purpose is to review the main clinical, radiological, and medico-legal features of these conditions, often unknown by those who are not used to treating spinal cord lesions. The main objective is focused on the medico-legal problems of these conditions. The results of our review places under question some aspects of the recent 35/2015 Spanish Law on accidents compensation, in particular when dealing with minor spinal injuries. Therefore, a review of the recent Spanish law's statements about spinal minor injuries compensation is required (AU)

Are Modic Changes Able to Help Us in Our Clinical Practice? A Study of the Modic Changes in Young Adults During Working Age.

STUDY DESIGN: Modic changes [vertebral endplate spinal changes (VESC)] have been related to degenerative disk disease, and in past decades it was thought that their presence justified the surgical treatment, in particular spinal fusion. OBJECTIVE: The aim of the present study is to investigate its prevalence and features in a population of young workers suffering from low back pain, and explore the eventual relationship with the treatment applied in each case. BACKGROUND DATA: We conducted a retrospectively review of 450 magnetic resonance images from our hospital, in patients with low back pain or sciatica and age below 40. MATERIALS AND METHODS: Age, sex, symptoms predominance, concurrence with other spine disease, VESC type, evolution, level/s of involvement and placement, affected disk location and extent of the disease, disk height, and status of the endplate were recorded. The applied treatment was divided in groups according to the degree of invasiveness of the procedure. RESULTS: Prevalence of VESC was 13.05% predominant in patients over 30 years, and 100% associated to disk degenerative changes. Most frequent features were: type I (54%), lower lumbar region (98%), along with a decreased disk height (68%), and distortion of the disk endplates (98%, P<0.01). The patients with VESC presented a favorable outcome with conservative treatment, but were more frequently associated with invasive treatment, compared with non-VESC patients (P<0.024). CONCLUSIONS: VESC prevalence increases with age, underlying the degenerative causative etiology. Surgical indication should not be stated on the basis of the VESC findings alone, the main factor for indicating surgery depends more on other associated degenerative spinal changes.

Dispositivos interespinosos y hernia discal. Estudio morfogeométrico y clínico de 71 casos tratados con microdiscectomía L4-L5 asociada a colocación de espaciador / Interspinous spacers and disc herniation. Geomorphometric and clinical study of 71 cases treated by L4-L5 microdiscectomy associated to spacer placement

Objetivo: Una indicación controvertida de los espaciadores interespinosos es su utilización complementaria a la discectomía. Actualmente, no existen evidencias sólidas de la eficacia de dicha asociación, lo que podría derivar de la variabilidad en la colocación del espaciador, limitando su labor biomecánica. El presente trabajo busca identificar y analizar la variabilidad de emplazamiento de un espaciador interespinoso, y determinar su relación con el resultado clínico. Material y método: Se estudiaron 71 casos de hernia discal L4-L5 intervenidos en nuestro hospital mediante discectomía y colocación de espaciador interespinoso. Se utilizaron técnicas de morfometría geométrica: análisis procrustes y componentes principales. Se comparan los resultados morfológicos con la lordotización, distracción quirúrgica, así como con variables clínicas (índice de Herron y Turner). Resultados: Se identificó significativa variabilidad morfológica tanto en forma de traslación cráneo-caudal como rotación horaria-antihoraria en la posición del implante. Esta variación no se correlacionó con el resultado clínico, pero sí con variables anatómicas (grado de lordosis), y con aspectos quirúrgicos (distracción adicional del implante). Se detectó, igualmente, un emplazamiento ligeramente diferente en los casos con recidiva. Conclusiones: La morfometría geométrica permite objetivar una elevada variabilidad morfológica en el emplazamiento de los espaciadores interespinosos, que, sin embargo, no parece influir en el resultado clínico, dependiendo más bien del grado de lordosis y distracción. Se apreciaron diferencias de emplazamiento en los casos que recidivaron. Para valorar la eficacia de los espaciadores como complemento de la cirugía discal se requieren estudios con mayor número de casos, que necesariamente deben incluir análisis de variables morfológicas

Objective: A controversial indication of interspinous spacers is their use as a complement to discectomy. At the present time, there is no solid clinical evidence of effectiveness of that association, which might result from variability in spacer positioning, restricting its correct biomechanical actions. In this study our goal was to identify and analyse the variability in the placement of an interspinous spacer, and to investigate its relationship with the clinical results. Materials and methods. We performed a retrospective study on X-ray films from 71 patients suffering from disc herniation in L4-L5 who underwent surgery in our hospital, consisting of: microdiscectomy and biomed interspinous spacer implantation. The geomorphometric techniques used to analyse the data were procrustes superimposition and principal components analysis. We compared the clinical results (using the Herron and Turner scale), segmental lordosis and surgical distraction with the geomorphometric parameters. Results. Significant morphological variability was found in the implant position showing cephalo-caudal translation and clockwise-counterclockwise rotations. This variability did not correlate with clinical results. A relationship with anatomical features (lordosis) and additional surgical distraction was identified. A different morphology of implant-segment configuration was identified in cases with recurrence of disc herniation. Conclusions: Geometric morphometrics allowed identifying high variability in the final placement of interspinous spacers. Nevertheless, it seems not to be related to the clinical outcome, depending rather on the degree of lordosis and distraction. Some differences in segment-implant morphology were identified in cases with recurrences. To assess the effectiveness of spacers, larger studies including morphological and clinical variables are required

[Interspinous spacers and disc herniation. Geomorphometric and clinical study of 71 cases treated by L4-L5 microdiscectomy associated to spacer placement]. / Dispositivos interespinosos y hernia discal. Estudio morfogeométrico y clínico de 71 casos tratados con microdiscectomía L4-L5 asociada a colocación de espaciador.

OBJECTIVE: A controversial indication of interspinous spacers is their use as a complement to discectomy. At the present time, there is no solid clinical evidence of effectiveness of that association, which might result from variability in spacer positioning, restricting its correct biomechanical actions. In this study our goal was to identify and analyse the variability in the placement of an interspinous spacer, and to investigate its relationship with the clinical results. MATERIALS AND METHODS: We performed a retrospective study on X-ray films from 71 patients suffering from disc herniation in L4-L5 who underwent surgery in our hospital, consisting of: microdiscectomy and biomed interspinous spacer implantation. The geomorphometric techniques used to analyse the data were procrustes superimposition and principal components analysis. We compared the clinical results (using the Herron and Turner scale), segmental lordosis and surgical distraction with the geomorphometric parameters. RESULTS: Significant morphological variability was found in the implant position showing cephalo-caudal translation and clockwise-counterclockwise rotations. This variability did not correlate with clinical results. A relationship with anatomical features (lordosis) and additional surgical distraction was identified. A different morphology of implant-segment configuration was identified in cases with recurrence of disc herniation. CONCLUSIONS: Geometric morphometrics allowed identifying high variability in the final placement of interspinous spacers. Nevertheless, it seems not to be related to the clinical outcome, depending rather on the degree of lordosis and distraction. Some differences in segment-implant morphology were identified in cases with recurrences. To assess the effectiveness of spacers, larger studies including morphological and clinical variables are required.

Estudio preliminar de casos y controles de la morfología axial L4-L5 en la hernia de disco / Preliminary case-control study of axial L4- L5 morphology in disc herniation

Una de las cuestiones discutidas es el papel de los factores genéticos y adquiridos en la etiologia de la hernia de disco. Como expresión genómica, el estudio de la morfología podría clarificar dicho papel. Las recientes técnicas de morfometría geométrica (análisis Procrustes generalizado y estudio de componentes principales, entre otras) permiten analizar la forma desde un enfoque no euclidiano, brindando una nueva via de investigación que puede ser aplicada en el raquis. En el presente trabajo empleamos técnicas de morfometría geométrica para analizar la forma axial L4-L5 en pacientes con hernia de disco (n = 69) y controles sanos (n = 87). Se observó una variabilidad de forma a modo de expansión-contracción coronal, a partir del centro del canal medular. Se hallaron diferencias morfológicas entre los controles y las hernias: potenciales factores de riesgo que afectaron principalmente a las láminas y la orientación interapofisaria, condicionando cambios en la morfología del canal. Los resultados apoyan un origen genético de la variabilidad morfológica, con un importante dimorfismo sexual. No obstante, el cambio más relevante para la discriminación la presencia y la ausencia de hernia fue el tamaño del disco, que varió significativamente con el peso. Nuestros hallazgos contribuyen a mejorar el conocimiento morfológico espinal, y a entender el papel de la forma en la hernia de disco, como expresión de la genética, frente a otros factores etiológicos adquiridos. Las técnicas de morfometría geométrica ofrecen una prometedora vía para la investigación de la columna, recomendándose un mayor uso dada la escasez de publicaciones al respecto...