RCAAP Repository

OBJECTIVES: To investigate the reproducibility among spine surgeons in defining the treatment of vertebral metastatic lesions, taking into account the mechanical stability of injuries. METHODS: Twenty cases of isolated vertebral metastatic lesions were presented to ten experts. Their opinion was then asked about the stability of the lesion, as well as their treatment option. RESULTS: The interobserver Kappa coefficient obtained both for stability analysis as to the decision of the treatment was poor (0.334 and 0.248, respectively). CONCLUSIONS: Poor interobserver reproducibility was observed in deciding the treatment of vertebral metastatic lesions when considering the stability of the lesions.

OBJECTIVE: To evaluate the clinical and radiological outcome of minimally invasive surgical treatment of vertebral metastases using the technique of kyphoplasty. METHODS: This was a prospective observational study of patients with the diagnosis of spinal metastasis who underwent minimally invasive surgical treatment by filling the vertebral body with balloon kyphoplasty technique. Clinical evaluation included patient age at surgery, diagnosis of the tumor, biopsy results, data of the surgical procedure performed, visual pain scale (VAS) and complications related to surgery. Radiological evaluation involved the study of radiographic procedures in the anteroposterior and lateral incidences, with the analysis of vertebral body kyphosis and the occurrence of extravasation of cement. RESULTS: 22 patients with spinal metastases who were treated by balloon kyphoplasty, 8 (36%) males and 14 (64%) females were studied. The average age was 56.05 years and the mean follow-up was 8.5 months. The mean preoperative VAS was 8.73, 1.73 in the initial postoperative period, and 1.92 in the late postoperative period. CONCLUSION: Kyphoplasty proved to be a safe and effective technique for symptomatic treatment of vertebral metastases.

OBJECTIVE: To evaluate a consecutive series of patients undergoing vertebroplasty for pain control, according to results and complications in the short and medium follow-up. METHODS: Retrospective analysis of medical records of 26 patients undergoing vertebroplasty from January 2007 to December 2010. Patients were evaluated by the questionnaire of assessment of low back pain (Oswestry Index) and the visual analog pain scale (VAS) on the day before surgery, on the second day and 12 months after the procedure. RESULTS: Significant improvement of pain symptoms within 48 hours after surgery was reported in 22 patients (91.6%), two patients (8.32%) showed moderate improvement. Of the 22 patients with significant pain relief, 21 (95.4%) maintained the benefit and one (4.6%) had intense pain (new fracture in the body of L1) at a mean follow up of 12 months. Regarding the Oswestry Index, preoperative average was 52.9%. On the second day and 12 months after surgery this average was 23.6% and 24.5%, respectively; good results according to this index. Two patients were excluded from the study due to incomplete medical records. CONCLUSION: Despite the small sample size and short follow-up, the results of vertebroplasty were effective for the relief of pain symptoms and were safe as regards the risks of complications.

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Objective: To analyse changes in the range of motion (ROM) and pain after spinal manipulation of the cervical spine and thoracic spine in subjects with mechanical neck pain. Methods : Spinal manipulations were performed in the cervical and thoracic spine with the Gonstead and Diversified DTV techniques. To assess cervical ROM an inclinometer was used. Cervical pain was assessed by Visual Analogue Scale (VAS). The participation of 73 patients was obtained. Ages ranged from 18 to 63 years, with an average of 42.27 years. The subjects of this study were characterized by having mechanical neck pain and restricted cervical ROM. Results: We observed a reduction in the intensity of pain perceived by patients and increased cervical ROM. There were significant differences between pre-treatment values (first visit) and the fifth and tenth visits (p<0.01), and between the fifth and tenth visits (p<0.01) in all parameters except in the cervical extension of 70º. Conclusions: The results of this study suggest that spinal manipulation of the cervical and thoracic regions with the Gonstead and Diversified DTV techniques could subjectively reduce pain and produce considerable increase in cervical ROM in adults with mechanical neck pain.

Objective: To compare the levels of 25-hydroxyvitamin D in patients with AIS and a control group. Methods: The patients were recruited from the outpatient clinic of our institution during the year of 2013. Children diagnosed with scoliosis before 10 or after 18 years of age, and those suffering from neurological or muscular disorders, congenital malformations or genetic syndromes were excluded. The 25-OHD levels were determined by a fully automated electrochemiluminescence test. The appropriate level of 25-OHD was defined as greater than 30 ng/mL. The results were compared to a group of healthy individuals. Results: In group 1 (control) 63,3% showed abnormal vitamin D levels, while 91% of patients with AIS presented a low level of vitamin D. The mean BMI was 19.6 kg/m2 for controls and 20.3 kg/m2 for group 2. Statistical analysis showed significant difference (p<0.0001) between the levels of vitamin D. The average and minimum levels of vitamin D were respectively 27 and 13.6 ng/mL for group 1 and 18.8 and 3.13 ng/mL for AIS group. Conclusions: Patients with AIS had statistically significant lower levels of 25-OHD than healthy patients. Further research should be conducted to investigate the actual impact of serum vitamin D levels on the pathophysiology of AIS.

Objective: To present the deformities and evaluate the results of their treatment. Methods: Retrospective study of patients with deformity following surgical access to the spinal canal. Fifteen patients who met the inclusion criteria were included. Patients without complete data in medical records were excluded. Results: Fourteen patients underwent surgical treatment and one patient received conservative treatment with vest type TLSO. The average angle of kyphosis correction was 87° preoperatively to 38° postoperatively, while the associated scoliosis correction was 69° preoperatively to 23° postoperatively. Conclusions: The prevention of deformity should be emphasized to avoid laminectomy alone, while laminoplasty should be the procedure of choice for canal access in surgeries where there is no need for resection of the posterior elements.

Objective: Evaluate the impact of motor deficit (MD) on pain, disability, depression and quality of life measures of patients with LDH prior to a specific treatment. Methods: A total of 254 consecutively enrolled patients with LDH associated to neurological impairment and sciatica who have not responded to conservative treatment were evaluated. After reviewing the exclusion criteria, 168 were included. Validated instruments were used in the preoperative period to evaluate: pain, disability, quality of life, anxiety and depression. Results: Normal motor strength was observed in 57 (33.9%) patients and MD was observed in 111 (66.1%) cases. No statistically significant differences were observed between patients with and without MD regarding gender, age, level of herniation, lateralization and workers' compensation. Regarding quality of life, no difference was detected in the eight domains of SF36 and between the PCS and MCS groups. The only difference observed was a higher disability rate in the MD group, with the mean ODI difference being 7.84 (CI 95%: 1.82â€"13.87; p=0.011). Motor weakness was observed in 35.1% (n=39/111) of patients who had abnormal results at the motor evaluation, being related to severity (X²: 46.058; p<0.0001). Conclusion: In patients with LDH without prior specific treatment, the presence of MD did not modify the pain, disability, depression measures and self-reported quality of life. The MD has no discriminative power for measures of quality of life in patients with LDH.

Objective: To evaluate the results of a home rehabilitation program for patients with chronic low back pain through the evaluation of abdominal muscle strength, lumbar mobility, daily activities and improved levels of pain. A secondary objective was to evaluate the adherence of the participants to this program. Methods: We evaluated 99 patients divided into case group (69 patients with chronic low back pain without indication for surgical treatment) and control group (30 patients without low back pain), the following parameters being measured: 1) lumbar mobility, 2) strength of the abdominal muscles, 3) pain by visual analog scale (VAS), 4) limitation in daily activities (Oswestry scale). Patients received individualized guidance on home exercises to be performed during two months. For comparison of groups "control" and "case" the nonparametric Mann Whitney test was applied. For comparison of the times "before" and "after" in the group of patients who returned, the nonparametric Wilcoxon test was applied. Results: Of the 69 patients who agreed to participate, 30 completed the targeted exercises within two months and returned for the final evaluation. At baseline, there was a significant difference (p<0.05) between the case and control groups for lumbar mobility and abdominal strength. In the case group there was significant improvement in all aspects evaluated at the end of the exercise program. Conclusion: The home rehabilitation program was effective as a treatment option for low back pain. Treatment adherence was low, this being the main limiting factor.

Objectives: To study the characteristics of patients who underwent surgical treatment of degenerative spinal stenosis in the last 10 years (2000â€"2010) at the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (USP-HCFMR) and correlate the postoperative complications and preoperative comorbidities found in the study population. Methods: Retrospective review of medical records and radiographs of patients with degenerative lumbar stenosis treated surgically. Descriptive analysis of data was done with SAS 9.0. Results: 92 patients were included, 47 (51.08%) males and 45 (48.91%) females, with ages ranging from 32 to 86 years (mean age of 64.27 years). The most prevalent comorbidities were hypertension (47.82%) and diabetes mellitus (25%). Twenty-three patients (25%) had two or more comorbidities. Postoperative infection was the most common complication found in 12 cases (13%). Patients with only one preoperative comorbidity showed similar complication rates compared to the population without comorbidities. However, patients with two or more comorbid conditions had a higher incidence of postoperative complications (p<0.001). Conclusions: Comorbidities negatively influenced the outcome of surgical treatment of degenerative lumbar stenosis with higher rates of postoperative complications.

Objective: To evaluate the clinical and radiological results of treatment of patients with spondylodiscitis. Methods: Imaging exams used in this study were plain radiographs and magnetic resonance imaging of the spine. Results: Data from 33 patients, 10 (30.3%) females and 23 (69.7%) males were evaluated. The average time to diagnosis was four months and 28 days (SD ± 1 month and 28 days) and 19 patients (57.5%) presented neurological deficit. Surgical treatment was performed in 22 patients (66.6%) and three patients (9.1%) had complications from the surgery. Conclusions: Despite technological advances in complementary exams, early diagnosis of spondylodiscitis remains a challenge. However, drug treatment associated with surgery shows good results.

Objective: To identify the prevalence, clinical features and postoperative outcome of patients with spinal tuberculosis at the Instituto Mexicano del Seguro Social, in Jalisco, Mexico from 2008 to 2013. Methods: Prevalence study of patients undergoing spine surgery due to tuberculosis. Clinical, surgical pre- and postoperative parameters were evaluated by analysis of 41 medical records. Results: Seventeen (41.4%) were women and 24 (58.6%) were men with a mean age of 47.7 years. The main diagnoses were tuberculous spondylitis in 14 (34.1%) patients; discitis in 13 (31.7%); infectious spondylitis in 9 (21.9%); chronic spondylitis in four (9.7%); abscess in one patient (2.4%). Only 22% of patients were positive for epidemiological study of tuberculosis contacts. The most affected region was the lumbar spine followed by the thoracic spine and the most affected vertebrae were L3-L4. The most used surgical instrumentation was by posterior approach with drainage on 29 occasions, anterior approach with drainage in nine, and the mixed approach in three. Twenty-nine patients were independent to perform daily activities after discharge. Conclusion: The discitis or infectious spondylodiscitis should be considered in any patient with localized pain at any level of the spine. Once solved the problem of infection and stability, patients respond favorably to the surgical procedure.

Objective: Characterize victims of spinal cord injury (SCI) associated with traumatic brain injury (TBI) and risk factors. Methods: Study conducted with 52 victims of SCI associated with TBI. The variables studied were: sex; age; marital status; occupation; educational level; religion; etiology and the lesion area; neurological condition by the ASIA scale; associated injuries and potential risk factors. Results: The male (85%), aged between 21-30 years (25%), civil status stable union (56%), low level of education (69%) and the Roman Catholic religion (77%) presented the greater number of victims. Motor vehicle accidents (58%) were the main etiology. The cervical segment had higher injury risk (RR=3.48, p<0.0001). The neurological status ASIA-E (52%), the syndromic neck pain (35%) and the rate of mild TBI (65%) were the most frequent. Complications occurred in 13 patients with increased frequency of pneumonia (62%). The length of hospital stay was significantly higher (20±28 days) and 17% of patients died. Men (RR=2.14, p=0.028) and individuals exposed to motor vehicle accidents (RR=1.91, p=0.022) showed a higher risk of these lesions concurrently. Moreover, these patients had 2.48 (p<0.01) higher risk of death than victims of SCI alone. Conclusion: The SCI associated with TBI was more frequent in men, young adults, and individuals exposed to motor vehicle accidents. The cervical spine is more likely to be affected. Furthermore, the length of hospitalization is significantly higher and the subjects analyzed have higher risk of death.

Objective: To evaluate the Spine Deformity Index (SDI) and serum levels of vitamin D in patients surgically treated for proximal femur fracture and its relationship with osteoporosis. Methods: Between August and November 2013, patients older than 50 years-old with surgical fracture of the proximal femur by low-energy trauma underwent radiographic evaluation of the spine and the vitamin D levels, and enquired about diagnoses and previous treatment of osteoporosis. Results: Sixty-six patients met the inclusion criteria. The mean age was 78 years; the average level of vitamin D was 19 ng/mL. The SDI ranged between zero and 25, with a mean of 8.2. Eighty percent of these patients had never been treated for osteoporosis. Of the patients analyzed, 89.3% had insufficient levels of vitamin D. Of these, 68.1% had also SDI above 5, and only one fifth of them had any treatment for osteoporosis. Statistical significance was found between age and levels of vitamin D as well as age and SDI. Gender was not predictive of the vitamin D levels or the amount of hidden spine fractures. The season of the year had no direct influence on vitamin D levels. Conclusions: Hospitalized patients with surgical fractures of the proximal femur had a higher SDI associated with vitamin D insufficiency, with osteoporosis most often untreated, which results in delayed spinal fractures diagnosis of spinal fractures and increased risk of new fractures.

Objective: To evaluate the preliminary results of the surgical treatment through minimally invasive fixation technique in patients with thoracolumbar spinal fractures. Methods: Retrospective study of 17 patients with fractures of thoracolumbar vertebrae who underwent surgery with percutaneous fixation in the period of 2009 to 2011. The clinical evaluation of the results was performed using the SF-36 and Oswestry questionnaires. The radiographic parameters evaluated were: fracture classification according to Magerl's criteria, wedge angle of the fractured vertebrae and bisegmental Cobb angle. These measurements were made in the preoperative, immediate postoperative and 1 year after surgery. Other data such as associated injuries, neurological deficit, post-surgical infection, loosening and breakage of implants were also considered. Results: The data revealed average scores above 80% in all domains of the SF-36 questionnaire while in Oswestry Questionnaire, 79% of patients had minimal or absent physical limitations with a mean score of 12.4±11.89%. The average Cobb angle for preoperative kyphosis was 5.53º±13.80o, 2.18º±13.38o in the early postoperative period and 5.26º±13.95o one year after surgery. The average correction obtained after surgery was 3.35º and the average correction loss was 3.19º. No complications such as post-surgical infection, permanent neurological deficits and implant loosening and breakage were observed. Conclusion: The surgical treatment of fractures of thoracolumbar vertebrae using a minimally invasive technique provides satisfactory clinical and radiographic results with low complication rates.

Objectives: To analyze the clinical and radiographic outcomes in fracture of the fourth lumbar vertebra, under conservative or surgical treatment. Methods: Patients diagnosed with L4 fracture with or without neurological injury were studied and to whom conservative or surgical treatment was provided. Radiographic measurements were performed taking into account the kyphosis angle, the sagittal index, loss of vertebral body height, percentage of canal occlusion and height compression percentage. Results: Twenty-five patients were treated, five conservatively and 20 surgically. The vertebral kyphosis angle in both groups was 12°, no regional kyphosis was present, the sagittal index was 11.9 (Farcy), the loss of vertebral body height was 53.17%, the percentage of canal occlusion was 23% and the height compression percentage was 38.06%. The residual pain according to the visual analog scale was two in both groups. Conclusions: Patients with a fractured L4 have a satisfactory outcome with both treatments, the height of the vertebral body remains the same, the lordosis is preserved and therefore the sagittal balance, allowing recovering the mechanical functions of the spine as opposed to other segment fractures.

Objective: To evaluate the locomotor and histological impact on the spinal cord comparing lateral and posterior clip placement. Method: Randomized experimental trial. Twenty female Wistar rats, weighing between 250 and 300 grams and aged 12-14 weeks were randomized in two groups according to the placement of the clip: lateral group (N=10) and posterior group (N=10). After exposing the thoracic segment of the spine (T8-T10), a laminectomy was performed at the T9 level under microscopic view. The spinal cord injury was made using a 5 mm long aneurysm clip with a closing pressure of 50 grams. Locomotor behavior was evaluated by the Basso, Beattie and Bresnahan scale in days 1, 7, 14, 21, and 28 after surgery. The area of injury was assessed by histological analysis and measured by a software. Results: The histological evaluation showed a larger mean area of 4.8±1mm² of lesion (P=0.03) in the lateral group when compared with the posterior group mean area of 2.3±2mm². There was no significant difference between lateral and posterior groups with respect to locomotor scores from day 1 to 28 (P=0.361). Conclusion: The lesion area observed in the spinal cord histology after lateral placement of a clip was significantly bigger than in the posterior placement. The motor evaluation showed similar BBB scores regardless of the type of clamping method.

Objective: The BHTRM Project aims at studying the epidemiology of TRM in the city of Belo Horizonte and providing the means to monitor these patients. Method: To assess the efficacy and solvability of the project, two groups of patients treated at the João XXIII Hospital were compared in two distinct periods. Group 1 - from May 1, 2011 to July 31, 2011, months of project initiation and Group 2 - from December 1, 2012 to February 28, 2013. Results: Despite the 34% increase in the number of assisted patients, there is a 30% drop in the average number of days of hospitalization, as well as a decrease in the average days waiting for surgery of patients requiring surgical treatment, from 10.9 to 4.84, a drop of 56%. Conclusion: BHTRM Project is a useful tool in public health management. It optimizes the treatment of patients with spinal trauma by decreasing the time between admission and surgery. Also provides active monitoring of patient care and ensures better integration of rehabilitation care.

The objective of this study is to highlight the possibility of dysphagia induced by anterior cervical osteophytes. When not diagnosed early this condition may be responsible for complications such as severe dysphagia and potential lung aspiration, especially in elderly patients. Analysis of a case report of a 72-year old woman who presented cervical pain and progressive dysphagia. Imaging studies have shown anterior cervical osteophytosis and multilevel degenerative changes in the cervical spine. The patient underwent surgical excision of the cervical anterior osteophytes (C4, C5 and C6) and C5/C6 arthrodesis through anterior approach. The postoperative period was uneventful and symptoms resolved within 2 weeks. Early diagnosis and treatment led to complete resolution, avoiding late and serious complications associated with this pathology in the geriatric population, especially severe and progressive dysphagia and risk of pulmonary aspiration, and the consequent morbidity and mortality associated. A multidisciplinary approach is essential for the correct assessment of this condition

OBJECTIVE: To describe the results of surgical treatment of Scheuermann's disease by the posterior approach. METHOD: A descriptive, retrospective, longitudinal study in which patients with Scheuermann's disease, treated surgically by the posterior approach at the Hospital de Traumatologia y Ortopedia [Hospital for Traumatology and Orthopedics] "Lomas Verdes" IMSS. The Cobb method was used to measure the kyphosis in all the patients, of T5-T12. The surgical technique used was vertebral shortening by the Ponte osteotomy technique, at the apex of the deformity, accompanied by transpedicular instrumentation and posterior arthrodesis. RESULTS: Five patients were included; three men and two women, with an average age of 16.6 years. The initial average kyphosis was 76º, which was corrected to 42º after surgery. Blood loss was 590 ml, with a surgery time of 3 hours. Three patients were submitted to neurophysiological monitoring. No neurological lesion was found. There was no loss of correction at 6 months of evolution. CONCLUSIONS: The vertebral shortening technique with posterior instrumentation eliminates the use of the anterior approach to release the anterior longitudinal ligament. Osteotomies by the Ponte technique make the spine more flexible, and together with pedicular instrumentation, correct the deformity and preserve the correction over time.