Deformity correction from the convexity of the curve in neuromuscular scoliosis.

Background: "Convex Pedicle Screw Technique" reduces the theoretical risk of neurovascular injury. Our aim is to evaluate the efficacy of this technique in patients with neuromuscular scoliosis (NMS). Methods: Retrospective study of 12 patients who underwent a Convex Pedicle Screw Technique and were diagnosed with NMS. Patients who had undergone previous spinal surgery were excluded. The minimum follow-up required was 24 months. Demographic data, intraoperative data, neurovascular complications and neurophysiological events requiring implant repositioning, as well as pre- and postoperative radiological variables were collected. Results: Twelve patients diagnosed with NMS underwent surgery. The median operative time was 217 minutes. Mean blood loss was 3.8±1.1 g/dL hemoglobin (Hb). The median postoperative stay was 8.8±4 days. A reduction of the Cobb angle in primary curve of 49.1% (from 52.8°±18° to 26.5°±12.6°; P<0.001) and in secondary curve of 25.2% (from 27.8°±18.9° to 18.3°±13.3°; P=0.10) was achieved. Coronal balance improved by 69.4% (7.5±46.2 vs. 2.3±20.9 mm; P=0.72) and sagittal balance by 75% (from -14.1±71.8 vs. -3.5±48.6 mm; P=0.50). There were no neurovascular complications. There were no intraoperative neurophysiological events requiring implant repositioning, nor during reduction maneuvers. No infections were reported. Conclusions: The correction of the deformity from convexity in NMS achieves similar results to other techniques, and a very low complication rate.

Ruminococcus gnavus, an unusual cause of surgical site infection following vertebral posterior instrumentation: a case report.

Background: Ruminococcus gnavus (R. Gnavus) is an anaerobic Gram-positive coccus, common commensal of the gastrointestinal tract of animals and humans. Anaerobic organisms as etiologic agents of bone and joint infections (BJI) are uncommon and frequently underestimated. New technologies, such as mass spectrometry techniques and molecular techniques like 16S rRNA, allow for more efficient diagnosis of these anaerobic bacteria. We present the first case report of deep surgical site infection (SSI) due to R. Gnavus, following spinal surgery. Case Description: We report the case of a deep SSI caused by R. Gnavus following posterior spinal instrumentation in an 81-year-old woman. The patient underwent extension of her previous fusion L2-L5, due to adjacent segment disease (ASD). We performed a T10 to S2-alar-iliac instrumentation. During the postoperative period, the patient presented with a paralytic ileus that required the placement of a nasogastric tube followed by gastrointestinal bleeding and two gastroscopies. Subsequently the patient showed signs of deep SSI. We performed surgical irrigation and debridement. All six cultures in anaerobic media showed short Gram-positive diplococci, using matrix-assisted laser desorption/ionization time of flight mass spectrometry (Maldi-TOF MS) all six strains were identified as R. Gnavus. The patient was treated with amoxicilin 1 g/8 h and ciprofloxacin 750 mg/12 h for 4 weeks. Six months postoperative, she was asymptomatic. Conclusions: As is the case with our patient, all previously described cases of R. Gnavus infection had a history of intestinal disease or immunosupression. We believe the isolation of R. Gnavus should raise the possibility of intestinal injury. Immunosuppression is also an important risk factor for the development of R. Gnavus infection.

Abducens nerve palsy associated with pseudomeningocele after cervical spine surgery: a case report.

Background: Cerebrospinal fluid leakage can cause abducens nerve palsy (ANP) secondary to downward brain traction, caused by intracranial hypotension. We present the first case after cervical fixation and fusion with spinal cord decompression. Case Description: We present a 65-year-old male, who undergone C5-C6 decompression by laminectomy and C3-T2 fixation and fusion, without intraoperative complications. Two months later, the patient referred a 2-week history of diplopia, with no other accompanying symptom. Clinical examination revealed a lack of lateral gaze of the left eye. Cervical MRI disclosed findings compatible with pseudomeningocele. Given the time of evolution, the subacute clinical findings and the absence of image or clinical data of infection or intracranial hypotension, we decided to perform conservative treatment. We submitted the patient to periodic clinical examinations and we confirmed progressive clinical improvement of diplopia, in association with neurologic and ophthalmologic specialists. At this time, six months after surgery, the patient is asymptomatic. The swelling has significantly decreased in size. Control MRI revealed no growth of the pseudomeningocele. Conclusions: ANP secondary to intracranial hypotension after cervical spine surgery requires immediate imaging tests and clinical evaluation from neurology and ophthalmology specialists. Management can be conservative, as long as diplopia is the only clinical and radiological finding and wound does not show signs of infection.

Scoliosis induced by costotransversectomy in minipigs model.

Aim To validate surgical costotransversectomy as a technique for creating a scoliosis model in minipigs and to assess whether differences in approach (posterior medial approach, posterior paramedial approach and anterior approach by video-assisted thoracoscopy) lead to differences in the production of spinal deformity. Creation of disease models in experimental animals, specifically in minipigs, is controversial, as no appropriate technique has been reported. Methods Surgical costotransversectomy was performed in 11 minipigs using 3 different approaches: posterior medial approach (4 animals, group I), posterior paramedial approach (3 animals, group II) and anterior approach by videothoracoscopy (4 animals, group III). A conventional x-ray study was performed in the immediate postoperative period. Follow-up lasted for 4 months. Specimens were humanely killed according to current protocols, and a second x-ray study was performed. A deformation was measured using the Cobb angle and direct observation of the rotational component. Results Data from group I revealed a scoliosis deformation of 27º-41º (mean 34.5º) with a macroscopic rotational component. No deformity (<10º) or rotational component was observed in groups II and III. Only a posterior medial costotransversectomy produced a significant deformity in minipigs and established a valid model for studying scoliosis in these animals. Conclusion Only a posterior medial costotransversectomy produces a significant deformity in minipigs and establish a valid model for studying scoliosis in these animals. A tensegrity model would elucidate such results and harmonize disparate conclusions. Further investigation is needed to demonstrate the reliability of tensegrity principles for spinal biomechanics.

Uso de toxina botulínica paravertebral para detener la progresión de escoliosis en pollos pinealectomizados: la columna vertebral como sistema de tensegridad / Use of paravertebral injection of botulinum toxin to control scoliosis progression in pinealectomized chicken: the spine as a tensegrity system

Antecedentes y Objetivos. La escoliosis idiopática infantil no tiene un tratamiento satisfactorio que permita reducir la importante morbilidad y mortalidad asociada a los casos más severos y progresivos de la enfermedad. El desarrollo de procedimientos que puedan ralentizar la progresión de la enfermedad durante el desarrollo del niño puede influir favorablemente en el crecimiento y retrasar el tratamiento definitivo de la deformidad al momento de la madurez músculoesquelética. Presentamos un estudio sobre la influencia de la toxina botulínica en el desarrollo de deformidad en un modelo animal de escoliosis progresiva. Material y Método. Utilizamos 52 pollos Broiler hembra, en los que se practicó pinealectomía para producir escoliosis. Comparamos la evolución de la deformidad entre un grupo control y un grupo intervención asignado a recibir toxina botulínica paravertebral en la concavidad de la curva, bajo control electromiográfico. Realizamos estudios radiográficos y anatomopatológicos de los animales para evaluar los resultados. El grado de escoliosis se midió utilizando el método del ángulo de Cobb. Resultados. Cinco animales no sobrevivieron al estudio (1 en el grupo control y 4 en el de intervención). En el grupo control observamos una deformidad media de 32.9º (n= 25) y en el grupo intervención de 18.8º (n=22), encontrando diferencias estadísticamente significativas (p<0.05). Por tanto, la aplicación de toxina botulínica en la concavidad de la deformidad de pollos pinealectomizados frena la progresión de escoliosis. Conclusiones. La consideración de la columna vertebral y sus tejidos blandos asociados como una estructura de tensegridad puede explicar el fenómeno mediante el desequilibrio generado entre los componentes de tensión (músculos y ligamentos) y compresión (vértebras) que conforman el sistema. Estos resultados justifican nuevos estudios en investigación clínica para explorar una nueva alternativa para el tratamiento de la escoliosis idiopática infantil (AU)

Background and Objectives. Severe and progressive adolescent idiopathic scoliosis has no satisfactory treatment since high rates of morbidity and mortality are associated. Development of procedures that might slow down the progression of the deformity in the growing children may postpone definitive surgery to the end of musculoskeletal maturity period. A study about the influence of botulinum toxin in the development of deformity in a progressive scoliosis animal model is reported. Methods. Surgical pinealectomy was performed in 52 Broiler chickens to induce progressive scoliosis. Scoliosis progression among a control group and an intervention group assigned to paravertebral injection of botulinum toxin in curve´s concavity electromyographycally assisted is compared. Conventional x-ray and anatomopathologic studies were conducted to evaluate results. Cobb angle method was used to measure spine deformation. Results. Five animals died (1 in the control group and 4 in the intervention group). Mean scoliosis values observed were 32.9 degrees (n= 25) and 18.8 degrees (n= 22) for control and intervention groups respectively (p<0.05). Therefore, the use of botulinum toxin in the deformity´s concavity restrains scoliosis progression in pinealectomized chickens. Conclusions. The assumption of the spine and its associated soft tissues as a tensegrity structure may explain these results, through the induced imbalance between the tension (muscles and ligaments) and compression (vertebrae) components that shape the system. Further studies are necessary to determine clinical applications of this therapy in adolescent idiopathic scoliosis (AU)

[Orthopedic surgery and traumatology]. / Cirugía ortopédica y traumatología.

Terrorist explosions cause destruction of material goods and human injury on such a scale that the provision of healthcare in available centers can be compromised. In the last few years we have witnessed terrible terrorist attacks that affect us increasingly closely. The authors describe the intervention of the Department of Traumatology of a university hospital in response to a terrorist attack that left nearly 2,000 persons wounded and 191 dead. As usually occurs in these attacks, the victims' lesions were characterized by the severity and extension of the tissue damage, including penetrating wounds, blast injuries and burns. Critical analysis of previous disasters described by our colleagues in the medical literature is useful to avoid future errors.

Cirugía Ortopédica y Traumatología / Orthopedic Surgery and Traumatology

Una catástrofe supone, además de la destrucción de bienes materiales, un daño sobre personas de tal magnitud que se puede comprometer la correcta asistencia sanitaria de los centros disponibles. En los últimos años hemos observado terribles atentados terroristas que cada vez nos afectan de una forma más cercana. A continuación se describe y analiza la actuación de un departamento de traumatología de un hospital universitario ante un ataque terrorista que ocasionó cerca de 2.000 heridos y 191 muertos. Las lesiones de las víctimas del atentado se caracterizaron, como es habitual, por la gravedad y extensión del compromiso tisular, e incluyeron heridas penetrantes, lesiones por estallido y quemaduras. El análisis crítico de catástrofes previas, descritas por colegas nuestros en la bibliografía, puede sernos útil para evitar errores futuros (AU)

Terrorist explosions cause destruction of material goods and human injury on such a scale that the provision of healthcare in available centers can be compromised. In the last few years we have witnessed terrible terrorist attacks that affect us increasingly closely. The authors describe the intervention of the Department of Traumatology of a university hospital in response to a terrorist attack that left nearly 2,000 persons wounded and 191 dead. As usually occurs in these attacks, the victims' lesions were characterized by the severity and extension of the tissue damage, including penetrating wounds, blast injuries and burns. Critical analysis of previous disasters described by our colleagues in the medical literature is useful to avoid future errors (AU)