Repositório RCAAP

ABSTRACT Objective: To identify the incidence and type of postoperative hospital complications in patients with cervical spondylotic myelopathy (CSM) treated by anterior approach, and to describe comorbidities present in patients who had complications. Methods: Retrospective, observational, descriptive cohort study of secondary sources (medical records), over a period of 3 years. We included 180 cases treated by anterior approach, excluding revision surgeries. Results: There was an incidence of complications of 11.11% (20 cases), with no statistically significant difference between sexes. The main complication was pneumonia (50%), associated to prolonged intubation (40%), followed by neurological impairment (20%). In the hospital outcome he was found most often to another hospital discharge (65%, 13 cases). The main comorbidity was systemic arterial hypertension (31.58%, p = 0.46), followed by smoking (26.32%, p 0.10). Conclusions: The highest hospital incidence of postoperative complications was found in patients with CSM treated by anterior approach in relation to that reported in the literature. There was a high incidence of airway complications not correlated with soft tissue edema or hematoma in more than half of the cases. The incidence of airway complications shows an area of opportunity to improve extubation protocols and management of the airways in post-surgical special care unit. Level of Evidence III. SIRELCIS Registry: R-2014-3401-5. Study conducted without commercial support.

ABSTRACT Introduction: Cervical myelopathy is a degenerative pathology of spinal and/or root involvement. Caused by hypertrophy of the yellow ligament, osteophytes in the medullary canal and disc herniation. It affects the upper and lower motor neurons. The treatment of myelopathy diagnosed by magnetic resonance and electromyography consists of decompression by corpectomy. Methods: Autologous graft integration with cervical plate placement was evaluated in 31 patients, from January 1, 2013 to December 31, 2015. The procedure consisted of a Smith Robinson approach, anterior corpectomy, iliac crest autograft, anterior stabilization with cervical plate (Vectra, Synthes). Statistical analysis was performed with EPIINFO 3.5.1. Results: Age 64.6% (45-65 years), Sex: 41.9% (women), 58.1% (men). Segments treated: 38.7% (C5-C6), 35.5% (C4-C5), graft separation in sections <0.5 cm, sagittal, and <0.5 cm, axial at 12 months. Bleeding 61.3% (100-500 ml), 32.3% (501-100 ml), 6.5% (1,001-1,500 ml). Time 32.3% (> 249 min), 32.3% (121-180 min), 32.3% (181-240 min), 3.2% (91-120 min). Discussion: In this series, Querétaro is similar to other cities in the world with respect to sex, age, levels affected, number of complications, surgical time and bleeding, as well as graft integration in the evaluation at 12 months. Conclusions: Increased frequency in adult men, C4-C6 affected levels; Complications: recurrent laryngeal nerve injury, bleeding greater than 500 ml.

ABSTRACT Objective: To analyze the functional outcome of surgical treatment of cervical spondylotic myelopathy. Methods: A retrospective study involving 34 patients with CSM, operated from January 2014 to June 2015. The neurological status was assessed using the Nurick and modified Japanese Orthopedic Association (mJOA) scales preoperatively and at 12 months. Sex, age, time of evolution, affected cervical levels, surgical approach and T2-weighted magnetic resonance hyperintense signal were also evaluated. Results: A total of 14 men and 20 women participated. The mean age was 58.12 years. The average progression time was 12.38 months. The preoperative neurological state by mJOA was mild in 2 patients, moderate in 16 and severe in 16, with a mean of 11.44 points. The preoperative Nurick was grade II in 14 patients, grade III in 8, grade IV in 10 and grade V in 2. The T2-weighted hyperintense signal was documented in 18 patients (52.9%). The functional outcome according to the mJOA recovery rate was good in 15 patients (44.1%) and poor in 19 (55.9%). The degree of Nurick recovery was good in 20 (58.8%) and poor in 14 (41.2%). Conclusions: Decompressive surgery of the spinal cord has been shown to be effective in the treatment of cervical spondylotic myelopathy in well-selected patients. Although it is suggested that there are certain factors that correlate with functional outcome, we believe that more prospective randomized studies should be conducted to clarify this hypothesis.

ABSTRACT Objective: This study aims to evaluate the outcome of surgical treatment of congenital torticollis in our hospital. Methods: We collected the medical records of all patients diagnosed with congenital torticollis in the last 3 years at Shriners Hospital, Mexico City. The cases of congenital torticollis treated with surgery were selected and we evaluated the type of surgical technique, bleeding, time of surgery and complications, as well as the associated diagnoses of hip dysplasia. Results: We found 11 patients, of whom 7 met the inclusion criteria. Three women and four men with mean age of 10.7 years, five of whom had right, and two left side affections. All were surgically treated, five with unipolar and two with bipolar release. The surgery time was similar in both techniques and no complications were found in any of the groups. In two cases there were associated diagnoses, Klippel-Feil syndrome and congenital talipes equinovarus (CTEV) in one and psychomotor retardation in another. No association was found with hip dysplasia. All patients had improved range of movement and head tilt. There were no complications related to the surgical procedure or need for reintervention in our patients. Conclusions: Surgical treatment of congenital torticollis by uni- or bipolar release is an effective and safe method for these patients, presenting aesthetic and functional benefits.

ABSTRACT Objective: To determine the morphology of the vertebral foramen and its distance to the midline. Methods: Twenty cervical CT scans from the radiographic record of 12 men and 8 women, 18 to 74 years old, of C1 to C6 segments were evaluated, measuring the foramen diameter and its distance to the midline. We look for anomalies of vertebral foramen morphology, using Philips Ingenuity CT equipment with Philips IntelliSpace Portal software. Results: The mean age was 47 years; the segment with the most anomalies was C1, with 10% (increase in foramen diameter), followed by C2 and C6, with 5% (vertebral foramen hypotrophy); the mean diameter of the C1 to C6 segment was 6.081 mm, and the median distance from the midline to the vertebral foramen of C2 to C6 was 13.215 mm. The largest diameter of the vertebral foramen was C2, with a mean of 6.67 mm and the smallest was C4, with a mean of 5.75 mm; the greatest distance from the midline to the vertebral foramen was C1, with a mean of 22.59 mm and the shortest was C4, with a mean of 12.13 mm. Conclusions: The mean diameter of the vertebral foramen and its distance to the midline was determined, setting a safety region for procedures. In our city, there is no study that determines the means of the vertebral foramina diameters, the distance from the midline and its anomalies. It is necessary to rely on CT scans and to make a preoperative plan to avoid complications associated with morphological alterations.

ABSTRACT Surgical treatment of intervertebral disc degeneration aims to restore the height of the disc space and the release of involved neurological structures. Like any surgical treatment in orthopedics, the success or failure of the lumbar procedure involves the possibility of performing an adequate planning of each particular event. In the case of lumbar stabilization surgery with interbody fusion, it is essential to know the ideal height of the disc space for the fusion to be successful. Objective: To demonstrate that the ideal height of the disc space corresponds approximately to one third of the height of the vertebral body. Methods: X-ray images were taken in AP and lateral views of hospital residents to measure L4-L5 vertebral bodies as well as the disc space. The rule of three was used to check the height of the disc and vertebral bodies. Results: It was verified that the disc space corresponds to 31% of the size of the vertebral body, taking 0.31 as the constant. Conclusions: The size of the disc corresponds to one third of the vertebral body, taking 0.31 as the constant. The multiplication of the constant by the height of the vertebral body results in the exact height of the disc. Thus, in the presence of degeneration of the intervertebral disc, it is possible to know the size of the disc and, therefore, the size of the interbody cage.

ABSTRACT Objective: To analyze the possibility of using cadavers of pigs for training in endoscopic interlaminar discectomy. Methods: Five young pigs were used. The necessary instruments and equipment were used, and the endoscopic transforaminal and interlaminar percutaneous approach was performed at the L7-S1 level. A specialist surgeon performed the procedure. The points of entry, needle angulation, and subjective technical difficulties indicated by the surgeon were analyzed. Results: The mean weight of pigs was 42.2 kg. The posterolateral (transforaminal) entry point was, on average, 6.28 cm from the midline at an angulation of 32.8°. The posterior (interlaminar) entry point was on average 1.82 cm. Full-endoscopic interlaminar discectomy was possible in all animals of the sample. The structures described in the literature were visible endoscopically in 100% of the models. Conclusions: The demonstrated benefits and increased indications of endoscopic lumbar surgery created the need to establish safer and more efficient training processes. The authors raise the possibility of using experimental models to develop technical skills in endoscopy via interlaminar approach. The use of teaching tools such as animal models constitutes a new learning technique and give more confidence to surgeons. The use of cadavers of pigs, obtained according to ethics, avoids the use of human cadavers, and minimizes the development of the learning curve on patients.

ABSTRACT Objective: To determine the epidemiology of spine trauma in patients with polytrauma. Methods: The database of the service of polyfractured patients was reviewed from January to December 2015, 334 patients in total. Among them, 56 had spinal injury, of which 38 patients were included in the study. Results: Of the patients with polytraumatism, 16.77% had spinal cord injury. Mechanism of injury: fall 63.16%, traffic accidents 21.05%, running over 10.53%. Injury conditions: occupational 36.84%, at home 23.68%, traffic accident 15.79%, public road 13.16%, motorcycle accident 5.26%, of which 13.16% had consumed alcoholic beverages. Total with neurological injury 23.68%, incomplete lesion 18.42%. Injured vertebral segment: lumbar 76.32%, thoracic 31.58%, and cervical 7.89%. Associated injuries: upper limbs 47.37%, lower limbs 42.11%, pelvis 36.84%, thorax 34.21%, craniofacial 31.58%, abdomen 21.05%. Treatment: instrumentation 71.05%, orthoses 26.32%. Infection rate of 22.22%. Conclusions: The most common mechanism of injury was falls in the working environment, almost one fourth presented neurological damage, the most affected segment was the lumbar associated with injury of the lower limbs in 50%, with one fourth of patients that undergone intervention presenting infection. It is in the workplace, at home and in the transit where preventive measures must be reinforced to reduce the incidence of injuries in working age patients.

ABSTRACT Objective: To identify the category of evidence and the strength of recommendation for the conservative treatment of thoracolumbar spine burst fractures. Method: A systematic review was conducted from April 2014 to June 2015, selecting articles according to their prospective design, related to thoracolumbar spine burst fractures and their treatment. These studies were published in the electronic bibliographic databases from January 2009 to January 2015. Results: A total of 9,504 articles were found in a free search, of which 7 met the selection criteria and were included for analysis in a study of a total of 435 patients, of whom 72 underwent surgical treatment and 363 received some type of conservative treatment, showing predominantly level of evidence "1b", with strength of recommendation type "A". Conclusions: According to the evidence obtained, the conservative treatment is a choice for patients with stable burst fracture in a single level of thoracolumbar spine and with no neurological injury.

ABSTRACT Objective: The thoracolumbar spine trauma represents 30% of spinal diseases. To compare the minimally invasive technique with the open technique in lumbar fractures. Method: A prospective, cross-sectional, comparative observational study, which evaluated the following variables: surgery time, length of hospital stay, transoperative bleeding, postoperative pain, analyzed by SPSS software using Student's t test with statistical significance of p ≥ 0.05, with 24 patients with single-level thoracolumbar fractures, randomly treated with percutaneous pedicle screws and by open technique with a transpedicular system. Results: The surgery time was 90 minutes for the minimally invasive technique and 60 minutes for the open technique, the bleeding was on average 50 cm3 vs. 400 cm3. The mean visual analogue scale for pain at 24 hours of surgery was 5 for the minimally invasive group vs. 8 for the open group. The number of fluoroscopic projections of pedicle screws was 220 in the minimally invasive technique vs. 100 in the traditional technique. Quantified bleeding was minimal for percutaneous access vs. 340 cm3 for the traditional system. The hospital discharge for the minimally invasive group was at 24 hours and at 72 hours for those treated with open surgery. Conclusions: It is a technique that requires longer surgical time, with reports of less bleeding, less postoperative pain and less time for hospital discharge, reasons why it is supposed to be a procedure that requires a learning curve, statistical significance with respect to bleeding, visual analogue scale for pain and showed no significant difference in the variables of surgical time.

ABSTRACT Objective: The objective of this study was to analyze the pressure pain threshold (PPT) of the sternocleidomastoid (SCM), suboccipital (SO) and upper trapezius (UT) muscles and the craniocervical posture in individuals with episodic tension-type headache (ETTH). Methods: This study was a cross-sectional, non-randomized study with 60 young adults (77% female) comprising both sexes and an age range of 18-27 years. Individuals were distributed into a control group (G1) and individuals with ETTH (G2). The frequency of headaches per month was recorded. A pressure dynamometer was used to evaluate the PPT. Photogrammetry was used to evaluate the cervical lordosis (CL) and cephalic protrusion (CP). The data were statistically analyzed. Results: There were differences in the PPT, where the UT, SO and SCM muscles presented lower sensitivity to pain, respectively. The SCM muscle presented a lower PPT in G2. The CL and CP angles were significantly lower in G2. Conclusion: Individuals with ETTH exhibited a significantly lower PPT in the SCM and SO muscles than in the UT muscle. Nevertheless, individuals with ETTH presented with the SCM muscle being more sensitive to pain as well as higher CL and CP than individuals without symptomatology.

ABSTRACT Objective: To compare radiation exposure to the surgeon, patient and radiation technician during percutaneous access of the vertebral pedicle, using three different fluoroscopic imaging set up. Methods: Percutaneous access in pedicle T9-L5 of nine adult male cadavers using three different fluoroscopic set ups: standard C-arm, C-arm with L-arm, and the biplanar technique. The radiation dose exposure of the surgeon, radiation technician, and cadaver were measured using dosimeter in each procedure and in real time. Results: The radiation dose absorbed by the surgeon was higher when using the standard C-arm fluoroscopic technique than when using the C-arm with L-arm or the biplanar technique. Conclusions: The use of the C-arm with L-arm, or the biplanar fluoroscopic technique, for percutaneous access to the vertebral pedicle, reduces the radiation exposure of the surgeon compared to the standard C-arm fluoroscopic technique.

ABSTRACT Objective: To determine the amount of loss of function after spinal cord transection of varying extents, and whether magnetic iron oxide nanoparticles, in combination with an external magnetic field, improve the rate of subsequent functional recovery in rats. Methods: The animals were divided into groups with 50%, 80% and complete spinal cord transection. The animals of all three study groups were administered magnetic iron oxide nanoparticle suspension to the area of injury. The three control groups were not administered magnetic nanoparticles, but had corresponding transection levels. All animals were exposed to a magnetic field for 4 weeks. Loss of postoperative function and subsequent recovery were assessed using the BBB motor function scale and somatosensory evoked potential monitoring on the first day after surgery, and then weekly. Terminal histological analysis was also conducted in all the groups. Results: The animals in the control or complete transection groups did not demonstrate statistically significant improvement in either the BBB scores or evoked potential amplitude over the four-week period. In the group with 50% transection, however, a statistically significant increase in evoked potential amplitude and BBB scores was observed four weeks after surgery, with the highest increase during the second week of the study. In the group with 80% transection, only improvement in evoked potential amplitude was statistically significant, although less pronounced than in the 50% transection group. Conclusion: The use of magnetic iron oxide nanoparticles in combination with a magnetic field leads to higher rates of functional recovery after spinal cord injury in laboratory animals. The mechanism of this functional improvement needs further investigation.

ABSTRACT Objective: Lumbar disc herniation is a common indication for surgical treatment of the spine. Open microdiscectomy is the gold standard. New surgical techniques have emerged, such as spinal endoscopy. We compared and evaluated two endoscopic techniques: the transforaminal and the interlaminar. Methods: Fifty-five patients underwent endoscopic technique and were assessed by VAS and ODI in the preoperative period, and in the first and sixth month after the procedure. Results: We had 89.1% of good results and 10.9% of complications. Conclusion: We conclude that endoscopic techniques are safe and effective for the surgical treatment of lumbar disc herniation.

ABSTRACT Objective: To determine the efficacy of PEEK (Poly-ether-ether-ketone) cage without plate for the treatment of single-level cervical spondylosis. Methods: Ten patients with cervical myelopathy data, with a single-level root condition, seen at the outpatient clinic of the Neurosurgery Service, operated in 2016, mean age 53 years, 6 (60%) female, 4 (40%) obese, 3 (30%) smokers. The Cloward technique was used by anterior approach, discectomy, and PEEK cage placement. Results: At six months of surgery, 100% of the patients had increased intervertebral space, with a 100% reduction in osteophytes; only one patient had dysphagia, no patient had lesion of the adjacent segment and 10% had persistent root pathology. Cervical lordosis was observed in 90% of the patients and arthrodesis in 100% of the cases. Conclusions: Anterior approach arthrodesis using PEEK cage without cervical plate is effective as a treatment of cervical myelopathy in a single level.

ABSTRACT Objective: To investigate the relationship between preoperative vitamin D and albumin levels and postoperative quality of life in patients undergoing spinal surgery. Methods: Patients undergoing thoracic and lumbar spine surgery were evaluated in this prospective study. Their vitamin D and albumin levels were assessed before surgery and quality of life was measured by two questionnaires, Oswestry Disability Index (ODI) and Scoliosis Research Society - 22 (SRS-22), one year after the procedure. Data on infection occurrence and healing time were collected. Preoperative nutritional values and patients’ quality of life were analyzed using the chi-square test and ANOVA for albumin and vitamin D, respectively. The relationship among nutritional status, healing time, and the occurrence of infection was evaluated by the Pearson correlation coefficient. Results: Forty-six patients were included and their mean nutritional values were 19.1 (6.6) ng/mL for vitamin D and 3.9 (0.6) g/dL for albumin [mean (standard deviation)]. No association was found between vitamin D and quality of life of patients measured by ODI (p=0.534) and SRS-22 (p=0.739) questionnaires. There was also no association between albumin levels and quality of life measured by ODI (p=0.259) and SRS-22 (p=0.076) questionnaires. No correlation was found between the healing time or occurrence of infection and nutritional values. Conclusions: There was no association between vitamin D and albumin levels and the surgical result, according to the patient’s perception, besides the occurrence of complications with the surgical wound.

ABSTRACT Objective: To evaluate the postoperative analgesic efficacy in patients undergoing lumbar canal decompression using epidural morphine and clonidine at the Hospital Santa Casa de Vitória - ES, Brazil. Methods: Prospective, randomized study of 60 patients with stenosis of the lumbar canal up to two levels with surgical indication, in which decompression of the canal was performed in association with lumbar arthrodesis. In group 1 we performed conventional postoperative analgesia and in group 2, in addition to conventional analgesia, we associated epidural morphine and clonidine. We used VAS as a means of analyzing pain intensity at 1, 12, and 36 hours after surgery. The statistical analysis was performed using Microsoft Office/Excel and the software GraphPad Prism (San Diego, CA, USA). Results: The mean age of patients was 47 years, and 52% were female. The mean VAS in the first hour, 12th, and 36th hours after surgery in the control group was 5.44, 2.13, and 0.55 respectively. In the morphine-clonidine group it was 6.96; 2.21 and 0.60. Comparing one group with another in its absolute values through the Mann-Whitney test, as well as comparing the pain variations between the 1st and 12th hour (1h X 12h) and between the 12th hour and 36th hour (12h x 36h ) through Student’s t test it became clear that there was no statistical difference between groups (p > 0.05). Conclusions: The addition of epidural morphine and clonidine to conventional analgesia is not beneficial to reduce postoperative pain in patients undergoing lumbar canal decompression.

ABSTRACT Objective: To evaluate the efficacy of acute chiropractic adjustment in individuals who practice CrossFit with regard to complaints of low back pain and the joint range of motion in this region. Methods: A randomized clinical trial comprised of CrossFit practitioners from a box in Novo Hamburgo-RS, of both sexes and aged 18 to 40 years who had low back pain at the time of the study. The following tools were used: Semi-structured Anamnesis Questionnaire, Visual Analog Scale, McGill Pain Questionnaire, and SF-36 Quality of Life Questionnaire. Individuals in the control group answered the questionnaires before and after CrossFit training. The chiropractic group performed the same procedure, plus pre-training chiropractic adjustment and joint range of motion (ROM) before and after lumbar adjustment. Results: There was a significant increase in pain in the control group, and a significant decrease in pain in the chiropractic group, including one day after the chiropractic adjustment. In the chiropractic group, the joint ranges of motion had a significant increase in flexion and extension of the lumbar spine after chiropractic adjustment. Conclusion: The chiropractic group achieved a significant improvement in pain level and joint range of motion, suggesting that acute chiropractic adjustment was effective in reducing low back pain.

ABSTRACT Objective: To identify the prevalence and distribution of cases of self-reported spinal disorders by persons who are 18 years or older living in Brazil according to sociodemographic variables. Methods: We used the Pesquisa Nacional de Saúde (PNS, national health research), developed by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health. The data obtained from the website of IBGE System of Automatic Recovery - SIDRA were analyzed using the SPSS Statistics software version 20.0, IBM. Results: In Brazil 19% of the adult population report chronic spinal pain, 15.26% (± 4.56) men and 20.08% (+/- 4.11) women. After the age of 60, the prevalence is higher. Regarding skin color 18.26% (± 3.53) are white, 17.27% (± 6.65) are black and 17.93% (± 4.05) are brown, with no statistical difference. As for education, 23.55% (±5.70) had low or absent schooling (p < 0.001). The southern region of Brazil has the highest percentage (23.3%) of adults with chronic problems in the spine, and the state with the highest percentage is Paraná, with 26%. Conclusions: The results showed that there is a relationship between spinal pain and sociodemographic characteristics, pointing to the southern region as the most affected by spinal disorders when compared to other regions of the country.

ABSTRACT Objective: The development of minimally invasive spine surgery leads us to reflect on the efficiency of new methods compared with older ones. In the case of endoscopic spine surgery, we always seek to compare our results using new techniques with the results of older and trusted microsurgical techniques. Unfortunately, there are few reliable studies measuring endoscopic and microsurgical approaches. We therefore decided to compare our treatment results with those of what are, in our opinion, the best and most thorough studies found. Furthermore, we found no illustrated experience in the usability of endoscopic methods. We therefore analyzed each step of the technique used, according to the practical experience with microsurgical discectomy. Methods: We compared our two-year experience of treatment of 183 patients with lumbar disc herniations using the endoscopic technique, with data reported in the literature on microsurgical minimally invasive methods. Results: Our group achieved good to excellent results in 92.9% of cases (170 patients) compared to 90% reported in the literature. We compared the capabilities of endoscopic discectomy with microsurgical methods, and concluded that the endoscopic method is sufficient to perform any movement inside the surgical field that is microscopically possible. It is also possible to perform any type of spinal cord decompression, with better visualization provided by the endoscope. Conclusions: We conclude that endoscopic microdiscectomy is a good and reliable alternative, with better outcomes and more efficient usage of the approach space.