Management of incidental durotomies in an integrated Orthopaedic and Neurosurgical Spinal Unit.

Introduction: Incidental durotomy (ID) is an intraoperative event associated to prolonged bed rest and hospital stay, antibiotic use, higher patient dissatisfaction, and leg pain among other complications of its postoperative course. Several repair techniques and postsurgical care have been proposed for its management. This study was designed to develop an agreed protocol in cases of ID among Orthopaedic Surgeons (OS) and Neurosurgeons (NS) integrated into a Spinal Surgery Unit. Research question: Incidental durotomies management protocol. Materials and methods: From 997 eligible cases operated in Hospital del Mar (Barcelona, Spain) from April 2018 to March 2022, demographic, clinical, surgical and postoperative data was collected for statistical analysis from the morbidity and mortality database, with 79 identified IDs. Redo procedures were significantly associated to OS, and cervical and anterior/lateral approaches to NS, both groups were not comparable. Results: ID occurred in 7.9% of cases, more frequently after the lockdown (p=0.03), in females (p=0.04), during posterior approaches (p=0.003), and less frequently in the cervical spine (p=0.009). IDs were linked to postoperative infections (p< 0.001) and nerve root damage (p< 0.001). Patients without ID evolved more satisfactorily during the postoperative period (p=0.002), and those with CSF leak (20/79) spent on bed rest more than twice the time as those without (p<0.001). Multivariable logistic regression showed strong association between posterior approaches and ID, between complicated postoperative courses and ID. Discussion and conclusions: ID is linked to an adverse postoperative recovery, and it should be primarily repaired under microscope, with early mobilization of patients after surgery.

Polymorphisms and haplotypes across the osteoprotegerin gene associated with bone mineral density and osteoporotic fractures.

UNLABELLED: Osteoprotegerin plays a key role in bone remodelling. We studied the association between 24 polymorphisms and haplotypes on the OPG gene and bone mineral density and fractures. After multiple-testing correction, one SNP and two block-haplotypes were significantly associated with FN BMD. Two other block-haplotypes were associated with fracture. INTRODUCTION AND HYPOTHESIS: Osteoprotegerin (OPG) plays a key role in bone remodelling. Here we studied the association between polymorphisms and haplotypes on the OPG gene and bone mineral density (BMD) and fractures. METHODS: Twenty-four single nucleotide polymorphisms (SNPs) were selected to cover six haplotypic blocks and were genotyped in 964 postmenopausal Spanish women. Haplotypes were established with HaploStats. Association was analysed by GLM (for BMD) and logistic regression (for fractures) both at single SNP and haplotype levels. RESULTS: Upon adjustment for multiple testing (p < 0.0073), one of the SNPs (SNP #17, rs1032129) remained significantly associated with FN BMD (p = 0.001). Four block-haplotypes stood multiple-testing correction. Two remained associated with FN BMD and two with fracture. The association of block-4 haplotype "AC" (of SNPs #18 and #17) with FN BMD (p = 0.0002) was stronger than that of SNP#17 alone and was the best result overall. A global assessment of the results indicated that all the alleles and haplotypes with a protective effect, at p < 0.05, belonged to a frequent long-range haplotype. CONCLUSIONS: In conclusion, these results provide a detailed picture of the involvement of common variants and haplotypes of the OPG gene in bone phenotypes.

Fiabilidad, sensibilidad, especificidad y seguridad de la biopsia vertebral percutánea guiada por tomografía axial computarizada / Reliability, sensitivity, specificity and safety of computed tomography-guided

Objetivo. Estudio retrospectivo de la biopsia vertebral percutánea (BVP) guiada por tomografía axial computarizada (TC) en el estudio de las lesiones focales de la columna vertebral (CV) con el objetivo de analizar la suficiencia de la muestra, adecuación de la biopsia, sensibilidad y especificidad del diagnóstico y finalmente seguridad del procedimiento. Material y método. Criterios de inclusión: presunción diagnóstica de neoplasia o infección, lesión focal de la CV, la realización de BVP guiada por TC (ELSCINT modelo 2400 Elect, año de adquisición 1993) y el seguimiento clínico-radiológico del paciente, por un periodo mínimo de un año después de la punción. Entre febrero de 1993 y febrero de 2001 (8 años) se ha practicado BVP guiada por TC en 236 pacientes consecutivos. Rechazados por diferentes motivos: 14 (n = 222). Edad: 57,9 años (r: 6-8);119 varones (54%) y 103 mujeres (46%). Localización: 82% columna toracolumbar, 11% sacro y 7% columna cervical. Resultados. Sensibilidad 86%, especificidad 100%, valor predictivo positivo 100%, valor predictivo negativo 14,3% y exactitud diagnóstica 84,2%. En 217 pacientes (98%) se obtuvo material histológico; en 207 (93%) el material fue adecuado para el diagnóstico y en 5 (2,2%) no existía material valorable. En 187 pacientes (84,2%) existió coincidencia entre el resultado de la BVP y el diagnóstico final, y en 30 no (13,5%). En 5 pacientes (2,2%) no se llegó a ningún diagnóstico. Los diagnósticos más frecuentes fueron metástasis vertebral (69; 31%) e infección con cultivo positivo (51; 23%). En 150 casos (68%) la BVP resultó ser el elemento básico en el diagnóstico. En ninguno de los 222 se ha producido complicación mayor o grave relacionada con la BVP. Las complicaciones menores se clasificaron en relación al paciente: 4 reacciones vagales, un hematoma subcutáneo y una reacción alérgica, y en relación con la técnica: 3 roturas de aguja (con extracción posible en los 3 casos). Se practicó un análisis del dolor post-punción mediante llamada telefónica a las 24-48 h en 40 pacientes consecutivos sin mostrar repercusiones valorables. Conclusión. La BVP guiada por TC es una técnica fiable, sensible, específica y segura para el diagnóstico de las lesiones focales de la CV

Purpose. This is a retrospective study of the role played by computed tomography (CT)-guided percutaneous vertebral biopsy (PVB) in the study of focal spinal cord lesions. The aim was to analyze sample size sufficiency, adequacy of the biopsy, sensitivity and specificity of the diagnosis and last but not least the safety of the procedure. Materials and methods. Inclusion criteria: diagnostic presumption of neoplasm or infection, focal spinal cord lesion, performance of a CT-guided PVB (ELSCINT 2400 Elect scanner purchased in 1993) and clinical/radiological follow-up for at least one year post puncture. Between February 1993 and February 2001 (8 years) CT-guided PVB was carried out in 236 consecutive patients, 14 of whom were rejected for various reasons (n = 222). Mean age was 57.9 years (range:6-8);119 were male (54%) and 103 female (46%). Location: 82% thoracolumbar spine, 11% sacrum and 7% cervical spine. Results. Sensitivity: 86%, specificity: 100%, positive predictive value: 100%, negative predictive value: 14.3%, diagnostic accuracy: 84.2%. Histological material was obtained for 217 patients (98%); in 207 of these (93%) the material was adequate for diagnosis and in 5 (2.2%) assessment was impossible. In 187 patients (84.2%) the final diagnosis matched the result of PVB and in 30 (13.5%) this was not the case. In 5 patients (2,2%) no diagnosis was reached .The most frequent diagnoses were vertebral metastasis (69 patients, 31%) and culture-positive infection (51 patients, 23%). In 150 cases (68%) PVB turned out to be the key diagnostic factor. None of the 222 patients had a major or severe complication resulting from PVB. Minor complications were of two kinds: a) patient-related (4 vagal reactions, one subcutaneous hematoma and an allergic reaction, and b) technique-related (3 instances of needle breakage, with extraction being possible in all cases). A telephone-call based post-puncture pain evaluation was conducted in 40 consecutive patients at 24-48 hours. No significant repercussions were reported. Conclusion. CT-scan guided PVB is a reliable, sensitive, specific and safe technique for diagnosing focal spinal cord lesions (AU)

Comportamiento biomecánico del injerto anterior en la cirugía del raquis lumbar. Estudio comparativo mediante un modelo de elementos finitos / Biomechanical performance of the anterior graft in lumbar spine surgery. Comparative finite-element analysis

Objetivo. Investigar el comportamiento biomecánico de diversos aloinjertos y el efecto del tratamiento del platillo vertebral en un modelo de corporectomía lumbar. Método. Se utiliza un modelo modificado no lineal de elementos finitos en tres dimensiones de la columna lumbar al que se adaptó un instrumental transpedicular. Se modelaron por elementos finitos un fragmento diafisario de fémur, uno de tibia y uno de peroné. Se investigaron cuatro configuraciones: con fémur, con tibia, con tres peronés y con seis peronés. Se evaluaron cuatro superficies sobre las cuales se sustentaba el injerto en función de la resección de los distintos componentes. Se aplicaron fuerzas de compresión de 1.000 N, flexión, extensión y rotación de 15 Nm respectivamente. Se calcularon las tensiones y desplazamientos generados. Resultados. La resección completa de cartílago y hueso subcondral es la configuración que menos altera las tensiones dentro de las vértebras adyacentes. El uso de fragmentos de peroné modifica en mayor medida las tensiones en las vértebras adyacentes. El uso de tibia genera una asimetría en los campos de desplazamiento debido a la forma de dicho injerto. Los resultados con fémur modifican en menor medida los estreses en las vértebras adyacentes, configurando un montaje más fisiológico. Conclusiones. La preservación del hueso cortical del platillo vertebral no ofrece ninguna ventaja biomecánica en la reconstrucción de la columna anterior. El aloinjerto de fémur es el más adecuado para la sustitución del cuerpo vertebral, comparado con tibia y peroné

Methods. A modified non-lineal tri-dimensional finite-element model of the lumbar spine was used, to which a set of transpedicular instruments was adapted. By means of a finite-element analysis, modeling was carried out of diaphyseal fragments of the femur, the tibia and the fibula. Four configurations were analyzed: with one femur, with one tibia, with three fibulas and with six fibulas. Four surfaces were evaluated that gave support to the graft according to the resection of the various components. Compression loads of 1,000 N were applied, as well as flexion, extension and rotation of 15 Nm respectively. The stresses and displacements caused were calculated. Results. Full cartilage and subchondral bone resection is the configuration that least disrupts stresses within the adjacent vertebrae whereas the use of fibular fragments causes the greatest disruption. The use of the tibial bone gives rise to an asymmetry in the displacement area because of the shape of the said graft. The femur does not bring about a significant disruption of stresses in the adjacent vertebrae thereby constituting a more physiological construct. Conclusions. Preservation of the endplate's cortical bone does not lead to any biomechanical advantage in the reconstruction of the anterior spine. Femoral allografts are the most appropriate ones to replace the vertebral body, compared with the tibia or the fibula

The effect of bone graft geometry on spinal fusion vertebral stresses.

Spinal fusion is a frequent surgical technique in which the success is uncertain due to post-operative changes in the biomechanics of the spine. Bone grafts are good candidates for disc and vertebra substitutes due to their similar bone properties and their good osteogenic properties. However, the effect of the anatomic harvest location of the bone graft on the load transfer is unknown. A physiologic three-dimensional (3D) finite element model of a lumbar spine was modified to model spinal fusion with a fixator and a bone graft. Bone grafts were taken either from the femur, the tibia, or from the fibula in a configuration of three or six fragments. The configurations were submitted to physiological loadings, and strain and stress distributions were calculated within the vertebrae, the fixator and the bone grafts. Quantitative differences were found from one type of bone graft to another. It was found that fibula bone grafts provided better stability by carrying a large part of the load. However, femoral and tibial bone grafts provided a more similar strain distribution within the vertebrae compared to the physiologic model. For tibial bone grafts, load transfer was found to be sensitive to the orientation used during the surgery. The use of a femoral bone graft to replace one vertebra and two intervertebral discs was found to give a better biomechanical function than using a tibial or fibula bone graft. This surgical technique is proposed to be beneficial in the case of severe spinal trauma providing good interface is obtained between the bone graft and the vertebrae.

[Lobectomy versus limited resection to treat non-small cell lung cancer in stage I: a study of 78 cases]. / Lobectomía frente a resección limitada en el tratamiento del cáncer pulmonar no microcítico en estadio I. Estudio de 78 casos.

OBJECTIVE: To compare mortality and loco-regional recurrence rates in patients treated surgically for stage I non-small cell lung cancer by either lobectomy or sublobar lung resection (pulmonary wedge) from 1994 to 1998. PATIENTS AND METHODS: Seventy-eight patients who underwent lung resection for stage I non-small cell lung cancer from January 1994 to December 1998 were reviewed retrospectively. Fifty patients underwent lobectomy and 28 limited resection (pulmonary wedge). We reviewed oncologic history, tumor histology, loco-regional recurrence and tumor-related mortality during the follow-up period. RESULTS: Histology, lobectomies: 36 (72%) squamous cell carcinomas, 12 (24%) adenocarcinomas and 2 (4%) large cell carcinomas. Histology, wedge resection: 12 (42.8%) squamous cell carcinomas and 16 (57.2%) adenocarcinomas. Staging, lobectomies: 15 Ia (30%) and 35 Ib (70%). Staging, wedge resections: 16 Ia (57.2%) and 12 Ib (42.8%). Loco-regional recurrence: lobectomies 9 (18%) and wedge resections 4 (14.3%) plus 1 remote metastasis (3.6%). Mortality during follow-up: lobectomies 8 (16%) and wedge resections 4 (14.3%). Accumulated survival rate (in months): lobectomies 62.38 and wedge resections 63.92. The rates of loco-regional recurrence and accumulated survival in the two groups were not significantly different. CONCLUSIONS: The rates of loco-regional recurrence and accumulated survival in this study agree with those from other retrospective studies. We found no statistically significant differences between patients undergoing lobectomy and those undergoing sublobar resection. Wedge resection is an appropriate technique for patients with stage I non-small cell lung cancer who can not tolerate lobectomy.

Lobectomía frente a resección limitada en eltratamiento del cáncer pulmonar no microcíticoen estadio I. Estudio de 78 casos / Lobectomy versus limited resection to treat non-small cell lung cancer in stage I: a study of 78 cases

OBJETIVO: Comparar la tasa de mortalidad y recidiva locorregional de nuestra serie de pacientes intervenidos por un cáncer pulmonar no microcítico en estadio I durante el período 1994-1998, divididos en dos grupos: a) intervenidos de lobectomía, y b) intervenidos de resección pulmonar sublobar (cuña pulmonar).PACIENTES Y MÉTODOS: Se han revisado retrospectivamente 78 casos de resección pulmonar por cáncer pulmonar no microcítico en estadio I realizada entre enero de 1994 y diciembre de 1998: 50 sometidos a lobectomía y 28 a resección sublobar (cuña pulmonar). Se recogieron antecedentes oncológicos, histología de los tumores, recidiva locorregional y mortalidad relacionada con el tumor durante el período de seguimiento. RESULTADOS: El estudio histológico de las lobectomías evidenció 36 carcinomas escamosos (72 por ciento), 12 adenocarcinomas (24 por ciento) y dos carcinomas de células grandes (4 por ciento). En el caso de las cuñas puso de manifiesto 12 carcinomas escamosos (42,8 por ciento) y 16 adenocarcinomas (57,2 por ciento). En cuanto a los estadios, en las lobectomías, en 15 (30 por ciento) era Ia y en 35 (70 por ciento) Ib, y en las cuñas, en 16 (57,2 por ciento) era Ia y en 12 (42,8 por ciento), Ib. Hubo recidiva locorregional en 9 lobectomías (18 por ciento) y en 4 cuñas (14,3 por ciento), más un caso de metástasis a distancia (3,6 por ciento).En cuanto a la mortalidad durante el seguimiento, fallecieron 8 pacientes (16 por ciento) sometidos a lobectomías y 4 (14,3 por ciento) sometidos a cuñas. La tasa de supervivencia acumulada (en meses) fue de 62,38 y 63,92 en lobectomías y cuñas, respectivamente. Los datos obtenidos no presentaron diferencias estadísticamente significativas en lo que se refiere a recidiva locorregional y supervivencia acumulada entre ambos grupos. CONCLUSIONES: En este trabajo las tasas de recidiva locorregional y supervivencia acumulada son concordantes con las de otros estudios retrospectivos. En nuestra serie no hallamos diferencias estadísticamente significativas entre los pacientes sometidos a lobectomía y los sometidos a resección sublobar. La resección en cuña resulta una técnica adecuada para aquellos pacientes con un carcinoma pulmonar no microcítico en estadio I que no pueden tolerar una lobectomía. (AU)

[Spontaneous pneumothorax: pleurodesis with an iodo-povidone hydroalcoholic solution]. / Neumotórax espontáneo: sínfisis pleural con solución hidroalcohólica de povidona yodada.

OBJECTIVE: To analyze the efficacy of an iodo-povidone hydroalcoholic solution for the chemical pleurodesis of spontaneous pneumothorax. MATERIAL AND METHOD: A descriptive, retrospective study of 81 patients with spontaneous pneumothorax. The patients were treated by video-assisted thoracoscopy and chemical pleurodesis with an iodo-povidone hydroalcoholic solution at the thoracic surgery unit of Hospital de la Santa Creu i Sant Pau in Barcelona (Spain) between January 1993 and December 1999. RESULTS: Eighty-one patients, 59 men (73%) and 22 women (27%), between 14 and 82 years old (mean age 33 years) were treated. Pneumothorax was most often on the right side (43 cases, 53%). The main indications for surgery were recurrence (52 cases, 64%) and persistent air leaks (25 cases, 31%). All were treated by video-assisted thoracoscopy, with resection of the pulmonary parenchyma in 30 cases (37%) and pleural instillation of the iodo-povidone hydroalcoholic solution as the irritant in all cases. Air leaks were observed during early postoperative recovery in 10 patients (12.3%), self-limited fever in 5 (6.1%) and infection of drainage openings in 2 (2.4%). During the postoperative follow-up period of 6 to 67 months (mean 24 months), 5 recurrences (6.1%) were seen. CONCLUSIONS: An iodo-povidone hydroalcoholic solution is easy to apply by video-assisted thoracoscopy and is highly effective for pleurodesis in cases of spontaneous pneumothorax.

Neumotórax espontáneo: sínfisis pleural con soluciónhidroalcohólica de povidona yodada / Spontaneous pneumothorax: pleurodesis with an iodo-povidone hydroalcoholic solution

OBJETIVO: Analizar la eficacia de una solución hidroalcohólica de povidona yodada como agente químico sinfisante, en el tratamiento del neumotórax espontáneo. MATERIAL Y MÉTODO: Estudio descriptivo y retrospectivo de 81 pacientes con diagnóstico de neumotórax espontáneo, tratados mediante videotoracoscopia y pleurodesis química con una solución hidroalcohólica de povidona yodada, en el Servicio de Cirugía Torácica del Hospital de la Santa Creu i Sant Pau de Barcelona, desde enero de 1993 a diciembre de 1999.RESULTADOS: Se trata de 81 pacientes, 59 varones (73 por ciento) y 22 mujeres (27 por ciento) con edades comprendidas entre los 14 y los 82 años (media de 33 años). El hemitórax afectado con mayor frecuencia fue el derecho, en 43 casos (53 por ciento).Las principales indicaciones de tratamiento quirúrgico fueron: recidivas en 52 casos (64 por ciento) y fugas aéreas persistentes en 25 (31 por ciento).Todos fueron tratados por videotoracoscopia, se realizó resección del parénquima pulmonar en 30 casos (37 por ciento) e instilación pleural de solución hidroalcohólica de povidona yodada como agente químico sinfisante en todos los casos. Durante el postoperatorio inmediato presentaron fugas aéreas 10 pacientes (12,3 por ciento), fiebre autolimitada 5 pacientes (6,1 por ciento) y hubo dos infecciones en los orificios de los drenajes (2,4 por ciento). Durante un período de seguimiento postoperatorio de 6 a 67 meses (media de 24 meses) hemos constatado 5 recidivas (6,1 por ciento). CONCLUSIONES: La solución hidroalcohólica de povidona yodada es un agente químico sinfisante de fácil aplicación por videotoracoscopia y de gran eficacia en el tratamiento del neumotórax espontáneo (AU)

[Traumatic diaphragm injuries: a review of 8 cases]. / Lesión diafragmática traumática. Revisión de 8 casos.

Traumatic rupture of the diaphragm is a rare event that is usually found in polytrauma cases or after violent attacks. Patients are usually males between 20 and 50 years old, and car accidents are the main causes. Diagnosis can be difficult and injuries may go unnoticed, leading to serious delayed complications. We present 8 cases from 1991 through 2000. All patients came to the emergency department of our hospital with a diagnosis of traumatic rupture of the diaphragm. We analyze the reasons for admission, signs and symptoms, diagnostic approach, associated lesions, treatment and course, comparing our experience with reports in the literature.

Lesión diafragmática traumática. Revisión de 8 casos / Traumatic diaphragm injuries: a review of 8 cases

La rotura diafragmática traumática es una lesión poco frecuente, que aparece en politraumatismos o agresiones. Predomina en los varones entre los 20 y los 50 años de edad, siendo en Europa la principal causa los accidentes de tráfico. Su diagnóstico puede resultar dificultoso y pasar desapercibido, lo que puede provocar graves complicaciones tardías. Presentamos 8 casos correspondientes al período 19912000. Todos los pacientes ingresaron en el servicio de urgencias de nuestro centro con el diagnóstico de politraumatismo con posible rotura de diafragma. Analizamos el motivo de ingreso, la clínica, las formas de diagnóstico, las lesiones asociadas, el tratamiento y la evolución, contrastando la bibliografía existente con nuestra experiencia (AU)

Osteoid osteoma of the coracoid process.

Osteoid osteoma is a small, benign, and painful tumor most commonly affecting the extra-articular portions of the long bones, especially the femur or tibia. Osteoid osteoma of the coracoid process is so rare that we have found only three previously reported cases in the international literature. We describe our experience in managing a case of osteoid osteoma in this unusual location.

[Spontaneous pneumothorax. Apropos 2507 cases]. / Neumotórax espontáneo. A propósito de 2.507 casos.

This retrospective study of 2,507 cases of spontaneous pneumothorax (SP) involves 1,873 patients treated at our hospital over nearly 20 years. Men represented 92.4% and most patients were between 16 and 30 years old (56.2%). Presenting more than one episode were 29.7%. The treatment of choice was placement of a pleural drain whenever SP had led to lung collapse amounting to more than 10% of volume. Thoracotomy was performed when the patient had experienced three or more episodes of SP; when a pleural drain had not resolved the condition 10 days after placement; in hemo-SP with severe hemorrhage; and in 2 cases in which SP was bilateral. A total of 419 thoracotomies were performed on 384 patients (20.7%). All episodes were resolved and complications were few. Six patients died (0.32%), three following thoracotomy. All of these had antecedents of chronic obstructive lung disease and all were over 70, excepting one who was 56.