RCAAP Repository

Abstract Background: Baroreceptors act as regulators of blood pressure (BP); however, its sensitivity is impaired in hypertensive patients. Among the recommendations for BP reduction, exercise training has become an important adjuvant therapy in this population. However, there are many doubts about the effects of resistance exercise training in this population. Objective: To evaluate the effect of resistance exercise training on BP and baroreceptor sensitivity in spontaneously hypertensive rats (SHR). Method: Rats SHR (n = 16) and Wistar (n = 16) at 8 weeks of age, at the beginning of the experiment, were randomly divided into 4 groups: sedentary control (CS, n = 8); trained control (CT, n = 8); sedentary SHR (HS, n = 8) and trained SHR (HT, n = 8). Resistance exercise training was performed in a stairmaster-type equipment (1.1 × 0.18 m, 2 cm between the steps, 80° incline) with weights attached to their tails, (5 days/week, 8 weeks). Baroreceptor reflex control of heart rate (HR) was tested by loading/unloading of baroreceptors with phenylephrine and sodium nitroprusside. Results: Resistance exercise training increased the soleus muscle mass in SHR when compared to HS (HS 0.027 ± 0.002 g/mm and HT 0.056 ± 0.003 g/mm). Resistance exercise training did not alter BP. On the other hand, in relation to baroreflex sensitivity, bradycardic response was improved in the TH group when compared to HS (HS -1.3 ± 0.1 bpm/mmHg and HT -2.6 ± 0.2 bpm/mmHg) although tachycardia response was not altered by resistance exercise (CS -3.3 ± 0.2 bpm/mmHg, CT -3.3 ± 0.1 bpm/mmHg, HS -1.47 ± 0.06 bpm/mmHg and HT -1.6 ± 0.1 bpm/mmHg). Conclusion: Resistance exercise training was able to promote improvements on baroreflex sensitivity of SHR rats, through the improvement of bradycardic response, despite not having reduced BP.

Abstract Background: The hypertriglyceridemic waist (HTW) phenotype is defined as the simultaneous presence of increased waist circumference (WC) and serum triglycerides (TG) levels and it has been associated with cardiometabolic risk in children and adolescents. Objective: The objective was to evaluate the influence of HTW phenotype in the fasting glycemia and blood pressure in children and adolescents over one-year follow-up period. Methods: It is a cohort study involving 492 children and adolescents from 7 to 15 years old, both genders, who were submitted to anthropometric, biochemical and clinical evaluation at the baseline, and also after 6 and 12 months of follow-up. Generalized Estimating Equation (GEE) models were calculated to evaluate the longitudinal influence of the HTW phenotype in the glycemia and blood pressure over one-year. Results: It was observed a prevalence of 10.6% (n = 52) of HTW phenotype in the students. The GEE models identified that students with HTW phenotype had an increase of 3.87 mg/dl in the fasting glycemia mean (CI: 1.68-6.05) and of 3.67mmHg in the systolic blood pressure (SBP) mean (CI: 1.55-6.08) over one-year follow-up, after adjusting for confounding variables. Conclusions: The results of this study suggest that HTW phenotype is a risk factor for longitudinal changes in glycemia and SBP in children and adolescents over one-year follow-up period.

Abstract Background: There is growing concern about the economic impact of cardiovascular diseases (CVD) in Brazil and worldwide. Objective: To estimate the economic impact of CVD in Brazil in the last five years. Methods: The information to estimate CVD costs was taken from national databases, adding the direct costs with hospitalizations, outpatient visits and benefits granted by social security. Indirect costs were added to the calculation, such as loss of income caused by CVD morbidity or mortality. Results: CVD mortality accounts for 28% of all deaths in Brazil in the last five years and for 38% of deaths in the productive age range (18 to 65 years). The estimated costs of CVD were R$ 37.1 billion in 2015, a 17% increase in the period from 2010 to 2015. The estimated costs of premature death due to CVD represent 61% of the total cost of CVD, Direct costs with hospitalizations and consultations were 22%, and costs related to the loss of productivity related to the disease were 15% of the total. Health expenditures in Brazil are estimated at 9.5% of GDP and the average cost of CVD was estimated at 0.7% of GDP. Conclusion: CVD costs have increased significantly in the last five years. It is estimated that CVD costs increase as the Brazilian population ages and the prevalence of CVD increases.

ABSTRACT Introduction: Spinal cord trauma (SCT) is an important cause of morbidity and mortality around the world. It affects different age groups, especially young adults who are victims of high-energy trauma. The most effective way to reduce the incidence of spinal cord trauma and its consequences is through preventive campaigns and control and surveillance measures through public agencies. The objective of this study is to outline the epidemiological profile of patients with spinal cord trauma attended at a tertiary care center in the city of São Paulo. Methods: Retrospective, cross-sectional study performed at a reference center for the care of patients with spinal cord injury in the State of São Paulo. Data were collected from the medical records of patients with spinal cord trauma between 2012 and 2016. Results: Of the 515 patients with spinal trauma, 153 (29.7%) had spinal cord injury of which 131 (85.62%) were male, and 22 (14.37%) were female, in a ratio of approximately 6:1. The mean age was 39.45 years. The main cause of spinal cord trauma observed was the fall from heights, with 72 cases (47.05%), and 52.94% were classified as Frankel A. Conclusions: The results showed that the majority of the patients were young, economically active, with low educational level, exposed to accidents that could be largely avoided. Most of these patients also had severe disabling injuries, which usually bring considerable psychological sequelae and economic consequences to the individual and to society. Level of evidence: IV. Type of study: Case series.

ABSTRACT Introduction: “Mini brain” image pattern has been identified as a radiological sign for diagnosing multiple myeloma (MM) and solitary plasmacytomas in magnetic resonance imaging (MRI). However, there is still very little data on the frequency with which it can be observed, and its real diagnostic accuracy. Objetive: In this study, we present our case series, discuss sensitivity and specificity of “mini brain” in the diagnosis of multiple myeloma (MM)/plasmacytoma, and conduct a literature review. Methods: The study sample consisted of asymptomatic and/or symptomatic patients consecutively diagnosed with expansive vertebral disease. Patients were evaluated with MRI. A literature review was conducted on the relationship of the radiological sign “mini brain” and the diagnosis of multiple myeloma (MM) or plasmacytoma. Results: Forty-seven patients were evaluated consecutively. Among five patients diagnosed with multiple myeloma, four had an MRI pattern of “mini brain”. The sensitivity of “mini brain” was 80%. The specificity was 97.6%. The accuracy was 95.8%. Sensitivity and specificity were 100% when we considered differential diagnoses only with neoplastic lesions involving the spine. Conclusions: “Mini brain” is a feasible and reliable sign for the diagnosis of multiple myeloma /plasmacytoma, guiding physicians for adequate screening and treatment. Nevertheless, it should not replace pathological investigation after vertebral biopsy. Level of Evidence III; Study of case: Case-control study.

ABSTRACT Objective: To report the epidemiological profile of patients operated for treatment of spinal trauma in the UNICAMP Hospital das Clínicas. Methods: Patients older than 14 years with spinal trauma operated in the service from 2012 to 2017 with complete radiological and clinical data were evaluated. Results: A total of 143 patients were included, 120 men and 23 women, with a mean age of 37.8 years. Falls from height (32%), motorcycle (26%) and car accidents (24%) were the most common trauma mechanisms. The most affected vertebral level was C6 (11%) and most patients (55%) had some neurological deficits. The overall postoperative complication rate was 23%. Conclusions: Spinal trauma has a high socioeconomic impact due to its high morbidity and mortality, and it is necessary to study its epidemiology for the development of public policies for prevention and treatment financing. Level of Evidence: III. Type of study: Retrospective study.

ABSTRACT With the increase in the elderly population worldwide, the prevalence of degenerative diseases tends to grow, especially degenerative disc disease (DDD) in the lumbar spine. It is important to seek excellence treatments to ensure a better quality of life for patients. In this sense, the total disc replacement and the use of prostheses in the lumbar spine have been pointed out as alternative and promising treatments when compared to the standard treatment. The aim of this study is to show the results of total replacement of the intervertebral disc, through a review of the literature. The electronic search was performed in the PubMed databases, with the keywords “Total Disk Replacement”, “Low Back Pain”, and “Arthroplasty” in articles published as of 2012. We selected 16 articles. Level of Evidence: II. Type of study: Systematic reviewb of Level II studies or Level I studies with inconsistent results.

ABSTRACT Introduction: Among the primary lesions occupying the spinal space, only 1% corresponds to the epidural arachnoid cyst (EAC). This condition is usually asymptomatic, and identified accidentally in imaging tests. In symptomatic cases, total surgical resection is recommended. Objective: To describe a case of EAC refractory to clinical treatment. Methods: A 45-year-old woman had lumbar pain for six years and increased pain in the last months, with irradiation to the left lower limb (corresponding to L1). No other alterations found in the physical examination. Magnetic resonance imaging (MRI) of the spine revealed an intravertebral cystic lesion at T12-L1 level, in the left posterolateral position, causing enlargement of the foramen, and suggesting an epidural arachnoid cyst. Results: Due to failure of the initial clinical treatment, the patient underwent left T12-L1 hemilaminectomy, resection of the cyst and correction of dural failure. The patient progressed with effective pain control and MRI confirmed absence of residual lesion. Conclusion: EAC is more common in men (4:1) and may be congenital or acquired. The most common topography is thoracic (65%). Its clinical presentation is low back pain, lower limb pain and paresthesia. MRI is the method of choice for diagnosis and surgical intervention is restricted to cases that are symptomatic or refractory to clinical treatment, and the prognosis tends to be excellent. We conclude that, in addition to being a rare and commonly asymptomatic condition, an adequate therapeutic approach is essential for complete cure, avoiding intense pain and manifestations that bring about a drastic reduction of functional capacity. Level of evidence: IV. Type of study: Case series.

ABSTRACT Congenital scoliosis associated with costal malformation is well known. However, there are no reports of idiopathic scoliosis associated with the fusion of the costal arcs in the literature. This report describes a case of idiopathic scoliosis with fusion of the 1st and 2nd costal arches in a female patient and reports changes in the deformity due to scoliosis because of the treatment. The analysis was performed from a morphological and clinical point of view, and by complementary tests. Radiographs and CT scans were obtained and evaluated from the first consultation in 2012 and during the period in which the patient was followed in a private clinic, until the stabilization of the condition, in 2014. The evolution was favorable with the use of a Milwaukee vest and there was improvement of the clinical picture after the skeletal maturity, and the angle of lateral curvature, measured by the Cobb method, initially of 20 degrees, was reduced and stabilized in nine degrees, measure which is currently maintained. The analysis showed concomitant pathologies, and the fusion of costal arches did not influence the spine deformity, since there was regression with the clinical treatment. This evolution leads us to conclude that adolescent idiopathic scoliosis should be imputed as the sole responsible for the clinical picture of the patient, and that the fusion of the costal arches does not interfere with the biomechanics of the spine. Level of Evidence: IV. Type of study: Case series.

ABSTRACT Spinopelvic instability is an uncommon injury that is caused by high-energy traumas. Surgical treatment is used, in the majority of cases, to restore stability and enable early mobilization. Various stabilization techniques have been used in the treatment of spinopelvic instability, and lumbopelvic fixation (LPF) is currently the technique of choice due to its biomechanical superiority. One of its limitations is the fact that the technique does not directly address the lower sacral segment, permitting a residual kyphotic deformity. This deformity has been attributed to unsatisfactory outcomes, including late development of pelvic floor muscle defects and complications during childbirth. We report a case of a patient with spinopelvic instability due to sacral fracture, which was treated using a variation of the LPF technique, in which rods and screws originally developed for cervicothoracic fixation were adapted to correct sacral deformity in the sagittal plane. The upper sacral segment was reduced indirectly using hip extension and femoral traction manoeuvres, associated with distraction manoeuvres via rods. Bone reduction forceps were used to reduce the kyphotic deviation in the lower sacral fragment, enabling its fixation to the lumbopelvic rod and screws system. There were no complications of infection, suture dehiscence, or breakage of the implants, and at the end of the first year of follow-up, the sacral kyphosis was normal and radiographic consolidation was confirmed. Our technique provides a viable and promising alternative to traditional LPF, making it especially useful in fractures with accentuated deviations of the lower sacral fragment. Level of Evidence: 4.Type of study: Case series

ABSTRACT Objective: To determine the correlation between morbidity/mortality and the pre-surgical protocol in patients undergoing anterior cervical surgical approach. Methods: Retrospective, cross-sectional and descriptive study, in which 114 patients who underwent anterior cervical surgical approach were reviewed, divided into two groups: “Group A” Conventional Presurgical Protocol (CPP) and “Group B” Extended Presurgical Protocol (EPP). Statistical analysis used the IBM SPSS Statistics Base v.24 software. Results: We evaluated 114 patients, 35 from “Group A”, 79 from “Group B”, 83 (72.8%) with cervical myelopathy, 30 (26.3%) with cervicobrachialgia. “Group A” had 10 cases of respiratory failure, with 5 secondary to bronchial secretion, 2 secondary to cervical hematoma. “Group B” had 12 cases of respiratory failure, 3 secondary to bronchial secretion and 1 secondary to cervical hematoma. Conclusions: The extended presurgical protocol can be the answer to reduce complications by improving selection parameters of the candidate patient for a surgical procedure of the cervical spine. Level of Evidence III; Case-control studyg.

ABSTRACT Objective: To evaluate the clinical and functional results in patients with cervical spondylotic myelopathy treated surgically by anterior approach in a reference center. Methods: An observational, longitudinal, analytical study was carried out. The patients were evaluated using the JOA, Nurick and SF12v2 scales at hospital admission, at 3 and 6 months after surgery, analyzing the data with the Student's T test in the IBM SPSS Statistics version 24. Results: The male sex predominated, the mean age was 61 years; the mean JOA score before surgery, at 3 and 6 months was 8, 10.9, and 11.6, respectively. The Nurick scale obtained a presurgical score, at 3 and 6 months of 2.8, 2.2, and 1.9, respectively. Regarding the quality of life (PCS), 93.3% of the patients were found to be below the mean, 2.2% in the mean, and 4.5% above the mean, while at 6 months, 91.1% of the patients were below the mean, 6.7% in the mean, and 2.2% above the mean. In the preoperative evaluation the SF 12v2 scale, 68.9% of the patients were below the mean, 2.2% in the mean, and 28.9% above the mean, being that at 6 months, 31.1% of the patients were below the mean, 15.6% in the mean, and 53.3% above the mean. A statistically significant improvement was observed with the JOA and Nurick scales from preoperative to 3 and 6 months (p<0.05) with a statistically significant difference in the mental component of quality in the same periods. Conclusions: Anterior approach decompression gives a significant clinical improvement at 3 and 6 months. However, this improvement does not correlate with the patient's perception of his or her health condition. Level of Evidence III; Case control study.

ABSTRACT Objective: To describe the changes in the spino-pelvic parameters obtained after lumbar spine surgery. Methods: Prospective study. Results: The post-surgical pelvic parameters were found as follows: pelvic incidence of 75.75°, sacral slope 46.18°, pelvic tilt 19.68°. The sagittal balance was 30.93 mm, the postoperative lordosis was 66.06°. The surgery has significant effects on the patient's pain and posture. In our analysis, in a 12-month follow-up, we found: four patients (8.8%, two males and two females) with degeneration of the adjacent segment according to the criteria, and there was no degeneration of the underlying segment, nor any relationship with the spino-pelvic parameters. Conclusions: The degeneration of the adjacent segment does not correlate with the pelvic parameters. Level of Evidence II, Prognostic studies. Investigation of the effect of characteristics of a patient on the outcome of the disease.

ABSTRACT Objective: The objective of this longitudinal retrospective study is to assess the efficacy and safety of total lumbar disc replacement in patients with degenerative discopathy (L3-L4, L4-L5, L5-S1). Methods: One hundred and forty-three patients with low back pain, with or without radiculopathy, who met the radiographic criteria underwent anterior arthroplasty between 2000 and 2016. The Oswestry disability index (ODI), the visual analog scale (VAS), patient satisfaction, success criteria, disc height, and range of motion of the operated segment were evaluated preoperatively and at 3, 6, 12, and 24 months following surgery. Results: There were 50 men and 93 women, with an average age of 39.5 years, 13 patients (9%) with previous discectomy. The arthroplasty was performed at level L5-S1 in 97 patients (67.8%), at level L4-L5 in 45 patients (31.5%), and at level L3-L4 in 1 patient. Between the preoperative period and 24 months following surgery, the ODI decreased by 53.86%, the VAS for low back pain decreased by 63.83%, and low back pain with radiculopathy decreased by 60.20%, all statistically significant (p ≤ 0.5). Eighty-two percent of the patients were completely satisfied and 18% were satisfied. There was an average increase in disc height of 12 mm (p <0.001). The range of motion of the affected segment increased by 4° to 7° after surgery (p <0.004). Conclusions: Lumbar arthroplasty of a segment is recommended as an effective treatment for patients with degenerative disc disease with low back pain with or without a root component who meet the inclusion criteria. Level of Evidence III, Systematic reviewb of Level III studies.

ABSTRACT Objective: The objective of this study was to determine the factors associated with the persistence of pain in patients operated on for lumbar stenosis. Method: One hundred and fifty-three patients were studied, divided into two groups: 1) Patients with persistent pain in varying degrees, 2) Patients without pain. Age, sex, affected levels, comorbidities, surgical risk, and type of surgical procedure were evaluated. Results: There were 108 patients in the group with pain and 45 in the group without pain. In the group with pain, there were 28 patients with diabetes mellitus, 31 smokers, and 28 alcohol-dependent patients, with a significant difference of p = 0.001 and an RR = 1.1. A simple widening procedure was performed in 48 patients in the group with pain and 12 patients in the group without pain, with RR = 0.8, and widening plus instrumentation was performed in 7 patients in both the with and without pain groups. Conclusion: The indication of a surgical procedure in patients with spinal stenosis must take many factors into account in addition to clinical factors and the segments affected, since these factors impact patient prognosis. In the multivariate analysis, the variable most closely associated with persistent pain was the procedure performed. Level of Evidence III; Case-control study.g

ABSTRACT Objective: To determine the incidence and rate of disc degeneration adjacent to a lumbar fusion, as well as to analyze possible risk factors for its development. Methods: A retrospective study of a level of evidence IIB case series of 125 patients diagnosed with lumbar canal stenosis and spondylolisthesis, who underwent surgery from January 2011 to December 2016, with subsequent instrumentation and posterolateral fusion and outpatient follow-up in which the symptomatology and radiographic findings were evaluated to establish the diagnosis and management. Results: Twelve patients with adjacent segment disease were identified, with an incidence of 9.6%, higher both among female patients and in the seventh decade of life. The most frequent pathology was canal stenosis (42.4%), the most affected level was L4 / L5, and the procedure most associated with the prevalence of adjacent level degeneration was L4-L5 posterior transpedicular instrumentation. Conclusions: Sagittalization of the facet joint was a constant factor in all patients with involvement of the adjacent disc. The main clinical findings were treatment-resistant root pain and radiographic alterations characterized by spondylolisthesis, facet osteoarthritis and intervertebral disc herniation. Level of Evidence IIB; Retrospective study.

ABSTRACT Objective: To determine the epidemiology of orthopedic spine pathology in a national reference hospital in Mexico. Methods: Retrospective, observational and cross-sectional study, using the database and hospitalization census of the orthopedic spine service from January 2009 to December 2016. The data analysis was performed with SPSS version 22 measuring the central frequency and percentages. The demographic variables age and sex, and those related to the diagnosis, type of pathology, affected segment and degrees of affection were obtained. The sampling technique was non-probabilistic sampling by convenience of consecutive cases. Results: We analyzed 7,771 cases: 50.34% males, with a mean age of 53.51 years. The prevalence of the most frequent diseases in hospitalized patients was stenosis of the lumbar canal with 25.85% (1,834 patients), followed by lumbar disc herniation (23.12%), spondylolisthesis (22.63%), cervical spondylotic myelopathy (8.76%), lumbar pain and lumbosciatalgia (4.10%), cervical disc herniation (3.96%), primary infection (3.80%), loosening of material (3.16%), spinal tumors (2.53%) and cervical instability (2.04%). Conclusions: This is the largest series of cases of spinal pathology treated in a hospital in Latin America. The most frequent condition was the stenosis of the lumbar canal, the most affected segment was the lumbar, and the most affected age group was 51 to 60 years. The estimate is an increase in the incidence of spinal diseases, so it is necessary to identify the risk factors and the behavior of each disease for its prevention. Level of Evidence IV; Retrospective, observational and descriptive study.

ABSTRACT Objective: To compare these procedures in the treatment of osteoporotic vertebral compression fractures. Methods: Patients who underwent vertebral augmentation procedures between March 2010 and October 2016 were selected for the study. Kyphosis, anterior vertebral height, Oswestry Disability Index (ODI), Visual Analog Scale (VAS), number of portals, cement volume, and complications were recorded. The results were analyzed by difference of the means. Results: Sixty-eight patients were selected, accounting for 105 procedures. A statistically significant improvement was observed in VAS and ODI with both procedures (p<0.001) without statistically significant difference between them, regardless of the number of portals or cement applied. There was a high correlation between kyphosis correction and ODI improvement (p =0.012). Conclusions: Both vertebroplasty and kyphoplasty are effective procedures for the treatment of vertebral compression fractures. We found no significant difference between both procedures. The high correlation between improvement of kyphosis and ODI suggests that these procedures are better than conservative treatment to improve the quality of life of patients, however more studies are required to reach a final conclusion. Level of Evidence III; Retrospective comparative study.

ABSTRACT Objective: To know the clinical and radiographic results of patients with L4-L5 degenerative spondylolisthesis grade I, II, and III surgically treated with minimally invasive 360-degree arthrodesis. To determine the clinical and radiographic results according to the Oswestry Index 6 months after surgery and the percentage of postsurgical reduction in these patients. Methods: The present study was developed in the Department of Spinal Surgery of the Unidad Médica de Alta Especialidad Lomas Verdes, from October 2016 to August 2017. It is a prospective, cross-sectional, comparative observational study. We evaluated the reduction of the listhesis using pre and post-operative radiographs, as well as the Oswestry Disability Index. Results: The sample was composed of 12 patients, eight females and four males, showing a statistical significance in the Student’s t test, with p=0.05 for both variables. Conclusions: Degenerative spondylolisthesis of the 4th lumbar level is a very frequent pathology that affects groups of productive age and represents a burden not only for the patient, but also for the community. This surgical technique showed a high level of security and confidence for its resolution, showing results comparable to the literature. However, it requires certain technical resources and training to be performed. Evidence Level II; Prospective comparative study.

ABSTRACT Objective: When a lumbar fractures developes a significant deformity, the sagittal balance is altered which can lead to clinical consequences. The aim of this study was to measure and analyze the sagittal balance in patients with lumbar fractures operated with posterior instrumentation after three months and analyze their correlation with the different variables of the patient and the fracture. Methods: Sixty-three medical records of patients with lumbar fracture operated with posterior instrumentation were analyzed, excluding those with previous spinal pathology, or inability to stand upright. The parameters of pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, lumbar lordosis/pelvic incidence (LL/ PI) ratio, as well as the pre and postoperative status of segmental kyphosis and residual pain were measured. Results: Eighteen women, 44 men, with mean age of 42 years, with lumbar fractures: 29 in L1, 19 in L2, 10 in L3, 3 in L4 and 1 in L5. AOSpine Clasification: 2 type A1, 2 type A2, 37 type A3, 19 type A4, 2 type B. All patients were operated with a transpedicular polyaxial system. More than 80% of patients with spinopelvic balance within parameters considered normal. More than 70% with lumbar lordosis and LL/PI ratio within parameters. All with improvement of segmental kyphosis (average correction of 8.5°, p<.000). Final mean VAS of 1.85. Conclusions: The posterior instrumentation with a polyaxial system allows acceptable corrections of the segmental kyphosis of lumbar fractures. No statistically significant correlation was found between sagittal balance parameters, and characteristics of the patient and fracture. Level of Evidence IV; Case series.