RCAAP Repository

Objective: This study investigates whether the thickening of the ligamentum flavum (LF) is correlated with disc degeneration. Methods: This retrospective study was conducted with 98 patients with chronic low back pain treated in a spinal surgery service between January 2012 and January 2013. All patients underwent magnetic resonance imaging (MRI) and the images were evaluated by a spinal surgeon to measure the thickness of the LF and evaluate the degree of disc degeneration by the Pfirrmann grading system, according to the spinal levels (L3 -L4, L4-L5, L5-S1). An association was sought between LF hypertrophy and disc degeneration, age, sex and disc height. Results: The mean age of the patients was 53.6 years, and the majority were women (59.2%). The thickness of the LF and disc height varied according to the spinal level, the greatest LF thickness being found between L4-L5, and the greatest disc height at L5-S1. Women had statistically thicker ligaments in L3/L4 than men. The degree of disc degeneration was inversely correlated with the height at all the levels evaluated, i.e., the greater the degree of degeneration, the lower the disc height. Conclusions: The thickening of LF is not related to disc height or degree of disc degeneration. Therefore, there is no deformation of the LF within the spinal canal secondary to disc degeneration.

Objective: To determine the level of knowledge and attitudes of physicians in Tijuana based on Clinical Practice Guidelines (CPG) for the prevention, diagnosis and treatment of Nonspecific Low Back Pain (NLBP). Methods: Prospective, cross-sectional, descriptive study. Data were obtained from doctors who practice in clinics, private surgeries, and/or government institutions. Results: Of a total of 56 doctors surveyed, 37 were men and 19 women. None of the doctors said they had not seen a patient with Back Pain. 49% knew the GPC, and 51% did not know of its existence. Conclusions: Although some physicians reported knowledge of the GPC, according to the results, there was a lack of full knowledge of, and adherence to these guidelines. Not knowing the GPC did not make it impossible to complete the questionnaire. The doctors felt more connected to the health system, but with less confidence in the management of cases of NLBP.

Objective: To demonstrate the safety of soccer for adolescents in terms of chronic lesions of the lumbar spine, particularly spondylolysis. Methods: 54 young players underwent a pre-season assessment. The athletes were submitted to radiography of the lumbosacral spine. Players complaining of chronic low back pain were later submitted to more specific tests. Results: only 1 athlete (1.85 % of our sample) had complaints of chronic low back pain. In this case, the radiograph showed olisthesis grade I spondylolysis at the L5 level. Conclusion: Soccer proved to be a very safe sport in terms of the risk of developing chronic lesions of the lumbosacral spine. However, the actual incidence of spondylolysis in these athletes was not determined because only plain radiographs were used in this study.

Objective: To compare clinical outcomes in laborers who have undergone open transforaminal interbody fusion (TLIF) and minimally invasive transforaminal interbody fusion (MIS TLIF). Methods: 78 patients were submitted to lumbar arthrodesis by the same two spine surgeons partners from January 2008 to December 2012. Forty-one were submitted to traditional open arthrodesis and 37 to the minimally invasive procedure. Three patients were not included because they had already retired from work. The analyzed variables were length of hospitalization, length of follow-up, type of access (TILF or MIS TLIF), need for blood transfusion, percentage of improvement or worsening after surgery, pre- and postoperative VAS scale, time off work, pre-and postoperative Oswestry disability index, and general aspects of the laborers such as age, education, profession, working time, amount of daily weight carried at work, and use or not of personal protective equipment. Results: Time off work was longer in the TLIF group (average of 9.84 months) compared with the MIS TLIF group (average of 3.20 months). Significant improvement in postoperative VAS and Oswestry was achieved in both groups. Average length of hospitalization was 5.73 days for the TLIF group and 2.76 days for the MIS TLIF group. Conclusions: Minimally invasive transforaminal lumbar interbody fusion presents similar results when compared to open TLIF, but has the benefits of less postoperative morbidity, shorter hospitalization times, and faster rehabilitation in laborer patients.

Objective: To introduce a new minimally invasive surgical approach to anterior and lateral craniocervical junction diseases, preserving the midline posterior cervical spine stabilizing elements and reducing the inherent morbidity risk associated with traditional approaches. Methods: We describe a novel surgical technique in four cases of extra-medullary anterolateral compressive lesions located in the occipito-cervical junction, including infections and intra- and/or extradural tumor lesions. We used a paramedian trasmuscular approach through an anatomical muscle corridor using a micro MaXcess(r) surgical expandable retractor, with the purpose of reducing morbidity and preserving the posterior muscle and ligamentous tension band. Results: This type of surgical approach provides adequate visualization and microsurgical resection of lesions and reduces muscle manipulation and devascularisation, preserving the tension of the ligament complex. There was minimal blood loss and a decrease in postoperative pain, with rapid start of rehabilitation and shorter hospitalization times. There were no intraoperative complications, and all patients recovered from their pre-operative symptoms. Conclusions: This novel surgical technique is feasible and adequate for the occipito-atlanto-axial complex, with better results than traditional procedures.

Objective: This study evaluates the manual and digital reliability and reproducibility of five methods of measuring deformity (kyphosis) in thoracolumbar burst fractures. Method: Ninety (90) tomographic images were evaluated and, in each case, kyphotic deformity was measured, both manually and digitally, through the five most relevant methods described in the literature. For the assessment of intraobserver error, 20 cases were measured again. Results: The results show that all five methods are highly reliable and digitally reproducible, with estimated error near or lower than that indicated in the intraobserver error analysis. Cobb's method had the highest concordance (96%) while the sagittal index had the lowest concordance (75%). It is also suggested that digital assessment is more reliable then the manual method. Conclusion: All tested methods are highly reliable and digitally reproducible.

Objectives: To analyze the epidemiological profile of patients undergoing surgery at a referral hospital in a small, country town. Methods: A retrospective study was carried out between February 2009 and May 2010, in a Regional Referral unit, with a total of 24 patients. The cases study included all patients undergoing surgery for spinal trauma during this period, with or without neurological deficits. The data analyzed were: sex, age, location and degree of the injury, and mechanism of the injury. Results: The medianage of the patients was 35.8 years, and 75% were male. The mechanisms of the injury were motorcycle accidents in 37.5%, falls in 33.3%, automobile accidents in 25%, and diving into shallow water in 4.2%. The vertebral level affected was the cervical spine in 44%, the thoracic spine in 36%, and the thoracolumbar level in 20%. The neurological damage, classified according ASIA (American Spinal Injury Association) was complete, or category A in 37.5%, incomplete, or category B in 4.2%, incomplete, or category C in 12.5%, incomplete, or category D in 8.3%, and incomplete, or category E in 37.5%. In terms of access route, 64% of the procedures were performed with posterior access and 36% with anterior access. Conclusion: The epidemiological profile maintains the trend towards a prevalence of injuries among young men, affecting the cervical level, with the presence of spinal cord lesion. However, accidents involving motorcycles and fallings from heights are factors that can be modified by safety measures on the roads and in the workplace, which can reverse the high prevalence of these accidents.

Objective: To analyze individuals with spinal cord injury who developed secondary clinical complications, and the variables that can influence the prognosis. Methods: A prospective study of 321 patients with spinal cord injury. The variables were collected: age, sex, cause of the accident, anatomical distribution, neurological status, associated injuries, in-hospital complications, and mortality only in patients who developed complications. Results: A total of 72 patients were analyzed (85% male) with a mean age of 44.72±19.19 years. The individuals with spinal cord injury who developed clinical complications were mostly male, over 50 years of age, and the main cause was accidental falls. These patients had longer hospitalization times and a higher risk of progressing to death. Pneumonia was the main clinical complication. With regard to the variables that can influence the prognosis of these patients, it was observed that spinal cord injury to the cervical segment with syndromic quadriplegia, and neurological status ASIA-A, have a higher risk of developing pneumonia, the most common complication, as well as increased mortality. Conclusion: Clinical complications secondary to spinal cord injury are influenced by demographic factors, as well as characteristics of the injury contributing to an increase in mortality.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) present a high incidence after surgery, posing a high risk in surgical practice. Although a consensus does exist on thromboprophylaxis in orthopedic surgery, this topic remains controversial in regard to spinal surgery. In this current paper, we review and discuss the different forms of prophyilaxis presented in literature, in order to develop guidelines on prophylactic measures in spinal surgery, improving patient´s outcomes and reducing any medical/legal problems that could arise from a thrombotic complication.

Spinal angiolipoma is an uncommon form of benign tumor. There are 142 reported cases and only one of acute paraplegia. We describe a case of a 39 year old male with acute spinal paraplegia angiolipoma in T4-T5 with surgical resolution three weeks after the onset of the neurological syndrome. Postoperative neurologic recovery was complete. The angiolipoma consists of mature fat cells and abnormal blood vessels. There are 2 types: non-infiltrating and infiltrating. Its clinical course is slow and progressive, it can be accelerated by vascular phenomena, intratumoral abscess, and pregnancy. There is just one report of spontaneous intratumoral hemorrhage and acute paraplegia, coinciding with our case. There is no consensus as to treatment, and release and complete resection are suggested, as it is a disease with good prognosis. Angiolipoma spinal epidural is a rare form of benign tumor, and the treatment of this pathology continues to be release and resection of the tumor, with a favorable prognosis, despite the delay in surgery, as in the case reported. Intratumoral bleeding should be considered a cause of acute spinal compression syndrome, as ocurred in our patient.

We present a case of a 73-year-old male patient with progressive dysphagia, and hoarseness (irritability in the throat). He was studied with the appropriate imaging techniques, and esophagoscopy led to a diagnosis of extrinsic esophageal dysphagia for osteophyte obstruction of the cervical spine due to the arthrosis. A surgical resection was performed, without complications. Some considerations are given on this theme.

Report of a rare complication - fracture of the pedicles - in a patient with total disc replacement of L5-S1, a surgical resolution, and a biomechanical explanation. To the authors' knowledge, there is only one previous report of bilateral fracture of the pedicles in the literature, as a complication in total disc replacement of the lumbar spine. In this case, no direct repair was made to the fracture site; instead intersomatic fusion was performed by the anterior approach. A 40-year-old male, a martial arts practitioner who had undergone L5-S1 (ProDisc(r)) disc replacement nine months earlier, with complete resolution of the preoperative symptoms and no complications, sudden pain during physical activity, without neurological symptoms. Computed axial tomography showed a fracture of the L5 pedicles and anterior luxation of the polyethylene insert. Surgery was performed by the posterior approach, with direct repair of the fractures and posterolateral fusion of L5-S1 with transpedicular screws (Schanz) and USS(r) internal fixator. A follow-up axial CT scan at 6 months after surgery showed complete consolidation of the fractures, and the patient was asymptomatic. Due to the alteration in weight transmission through the anterior part of the spine in the total replacement of the lumbar disc, which preserves the movement but not the absorption of forces, the pedicle becomes more susceptible to fracture. It is important to bear this complication in patients submitted to this procedure.

OBJECTIVE: To evaluate the complications of anterior approach to the cervical spine in patients who underwent cervical arthrodesis with instrumentation. METHODS: Prospective and descriptive study was conducted from January 2009 to April 2010. All patients who underwent arthrodesis of the cervical spine by anterior approach were included, regardless the diagnosis. Access was made by the anterior approach on the right side. We evaluated the number of operated levels (1, 2 or 3 levels) and, the type of procedure performed: discectomy and placement of cage and plate (D+C+P), discectomy with placement of a cage (D+C) or corpectomy with placement of cage and plate (C+C+P). All complications related to surgical approach were reported. RESULTS: We studied 34 patients, 70% male. The average age was 50 years and mean follow-up was 8 months. Eighteen percent of patients had complications, distributed as follows: dysphasia (33%) and dysphonic (67%). Among patients who developed complications, most underwent to D+C+P (83%) and no complications were found in patients where no cervical plate was used. Regarding levels, both complications were identified in patients operated to one or two levels. However, in patients operated on three levels, only dysphonia was identified. CONCLUSION: The most frequent complication was dysphonia. Patients who presented more complications were those undergoing discectomy and fusion with cage and anterior cervical plate. All cases of dysphonia were in this group. The number of accessible levels does not seem to have affected the incidence of complications.

OBJECTIVE: Retrospective analyses of 216 patients undergoing foraminal decompression with transcorporeal approach and review of the surgical technique. METHOD: 216 patients with minimum follow-up of 2 years and an average of 41.8 months were included in the study. The clinical records of these patients were reviewed for complications, NDI (neck disability index) and VAS (visual analogue scale). Pre and post-operative radiographs were used to evaluate the disc height. RESULTS: At the end of follow-up patients had significant clinical improvement with reduction of NDI of 88.3% and 86.5% and 68.3% of the VAS for neck and upper limb, respectively (p<0.05). A reduction of 8.8% of the disc height was observed without other complications associated (p<0.05). CONCLUSION: Radicular decompression through a transcorporeal approach is an alternative that provides good clinical results without the need for a fusion and with few complications.

OBJECTIVE: To quantify the mobility of the lower cervical spine after seven years of total cervical disc replacement at two levels. METHOD: This clinical study was designed randomly and prospectively at the spine surgery center at the Hospital Nossa Senhora das Graças, in Canoas, RS-Brazil and at the Hospital Don João Becker, in Gravataí, RS-Brazil. Seventeen patients were included in the study that was designed to compare the data obtained from annual and sequential manner until the end of seven years. A comparison was made with the prior range of motion (ROM) of each patient. All patients were diagnosed with not tractable symptomatic cervical degenerative disc disease with two adjacent levels between C-3 and C-7. RESULTS: A total of patients underwent TDR in two levels and at the end of seven years, only one patient was lost to follow-up. The pre and postoperative ROM was the same in the first three years however after the fourth year there was a gradual decline with a loss of 12% of preoperative ROM in flexion, 21% in extension and 23% in the right and left lateral bending at the end of seven years. CONCLUSIONS: The clinical outcome of this study is evidence level IV in evaluating the ROM for Moby-C(r) for TDR in two adjacent levels at the lower cervical spine. These results show that the ROM is maintained during the first three years, gradually declining after that.

OBJECTIVE: To analyze the clinical and radiographic changes in patients with postural rounded upper back. METHODS: 30 patients diagnosed with postural rounded upper back were studied, being 22 male and eight female, aged between 10 and 20 years, referred by the outpatient clinic of the Grupo de Cirurgia da Coluna of the Irmandade da Santa Casa de Misericórdia de São Paulo, SP, Brazil. Patients underwent assessment of posture, special tests to check for muscle retractions and radiographic examination to measure the curvatures of spine using the Cobb method. RESULTS/CONCLUSION: It is concluded that in the postural roundback there is a moderate increase of the thoracic kyphosis; the lumbar and cervical curvatures do not increase as a compensatory mechanism; the head appears anteriorized and the shoulder is also anteriorized and medially rotated; muscle retractions are present in the hamstrings, hip flexors, pectoralis minor and adductors of the shoulder muscles; the mobility of the lumbar spine is preserved and there is no relationship between the magnitude of thoracic curvature and the retraction of the hamstring muscles.

OBJECTIVE: To evaluate bone mineral density in patients with neuromuscular scoliosis secondary to spastic quadriplegic cerebral palsy. METHODS: A prospective descriptive study in which, in addition to bone densitometry, the anthropometric data of the patients were assessed. As inclusion criterion we adopted patients with spastic quadriplegic cerebral palsy, wheelchair users, aged between 10 and 20 years and with neuromuscular scoliosis. RESULTS: We evaluated 31 patients, 20 female, whose average age was 14.2 years. The mean bone density was -3.2 standard deviation (Z-score), with mean biceps circumference of 19.4 cm, calf circumference 18.6 cm and BMI of 13.6 kg/m². CONCLUSION: There is a high incidence of osteoporosis in patients with neuromuscular scoliosis secondary to spastic quadriplegic cerebral palsy.

OBJECTIVE: To assess in a cross-sectional study whether there are changes in sagittal balance in patients with adolescent idiopathic scoliosis Lenke types 1 and 5 compared with patients without pathology of the spine and compare the values of the parameters of normal subjects with the parameters found in the literature. METHODS: We measured the values of the parameters of sagittal balance of 21 patients with scoliosis and 14 patients without scoliosis in panoramic radiographs or simply collected data previously measured from the medical records. We compared the mean values of normal subjects, the mean values found in the literature, and the means between normal subjects and patients with scoliosis. For this, we used the Student t test. RESULTS: Using a confidence interval of 5% (p < 0.05) and the Student t test we obtained statistical significance in the comparison of two parameters of sagittal balance between normal subjects and patients with scoliosis. We observed similarities in the measurements of the average parameters of normal subjects with regard to the work already published. CONCLUSIONS: The adolescent idiopathic scoliosis causes changes in two parameters of sagittal balance with statistical significance but suggests changes in all other parameters. As for comparison with previously published work, the results were similar.

OBJECTIVE: To compare X-rays usually performed in supine with lateralization with those in lateral decubitus with fulcrum at the apex of the primary curve caused by cushion, in order to monitor the achievement of improvement patterns of correction in preestablished deformities for the preoperative surgical planning. METHODS: Comparison of radiographic studies in the preoperative supine with lateralization and lateral decubitus with cushion performing fulcrum at the apex of the major curve in patients with adolescent idiopathic scoliosis. RESULTS: Curves varied in AP between 76° e 40° and were corrected in supine with lateralization to the average of 21° observing that when carried out with fulcrum with cushion in lateral decubitus the curves were corrected to 15° on average with higher discrepancy in values among the most rigid curves. CONCLUSIONS: It was verified that on flexible curves the cushions did not produce satisfactory corrections in primary curves. In more rigid curves and in collaborative patients, greater effectiveness on the correction of deformity in main curves was obtained with cushions producing local fulcrum for a better preoperative planning on correction of deformities.

OBJECTIVE: To evaluate the relationship of sex and age with Modic and Pfirrmann classifications and verify the relationship between the two classifications in the group of patients studied. METHODS: 300 magnetic resonance scans (MRI) of the lumbar segment of the patients were evaluated; each lumbar segment (L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1) was assessed according to Modic and Pfirrmann classifications. RESULTS: The type III of Pfirrmann was the most prevalent, whereas Modic was absent on most levels analyzed. The Modic signal was present mainly in the lower levels (L4-L5 and L5-S1) and in females. CONCLUSION: There is a strong correlation between the changes of the endplate and intervertebral discs, evidenced by changes in MRI. The relationship between Pfirrmann and Modic classifications is statistically higher the greater the disc degeneration.