RCAAP Repository

ABSTRACT Objective: To assess the effect of pulsed electromagnetic field (PEMF) on the consolidation of instrumented lumbar posterolateral arthrodeses in patients who have been surgically treated for degenerative spine disease. Methods: Forty cases were recruited from 163 consecutive patients undergoing lumbar arthrodesis at the same center. The patients were randomized into two groups of 20 patients: Active Group, who were exposed to PEMF for 4 hours a day for 90 days after surgery, and Inactive Group, who received an identical device, with the same instructions for use but without the ability to generate PEMF. The patients underwent computed tomography scans at 45, 90, 180 and 360 days after surgery to check for the occurrence of arthrodesis at each operated spinal level. Results: In the course of the study, two patients were excluded from each group. There were no significant differences between the groups with respect to age, gender, smoking habit, or the number of vertebral levels included in the arthrodesis. The percentage of consolidation of the vertebral levels increased at 90, 180 and 360 days compared to 45 days (p<0.001) in both groups. The Active Group had a 276% greater chance of consolidation in the vertebral levels (OR = 3.76; 95% CI: 1.39-10.20), regardless of the time of evaluation. Patients in the Active Group presented 16% more consolidation than patients in the inactive group (p=0.018). Conclusions: Post-operative exposure to PEMF following instrumented arthrodesis of the lumbar spine for degenerative spine disease increased consolidation in the first year after surgery.

ABSTRACT Objetive: Thecaloscopy is a less invasive method of exploration of the spinal subarachnoid space, using an ultra-thin, flexible endoscope and endoscopic fenestration of scars and adhesions. Thecalopscopy was used in Russian neurosurgery for the first time. Methods: Since 2009, we have operated on 32 patients with the following diagnoses: 17 - spinal adhesive arachnoiditis (8 - local forms, 9 - diffuse forms), 12 - spinal arachnoid cysts (7 - post-traumatic cysts, 5 - idiopathic cysts), and 3 - extramedullary tumors (thecaloscopic videoassistance and biopsy). In all cases, we performed exploration of subarachnoid space and pathologic lesion with endoscopic perforation of the cyst or dissection of adhesions using special instrumentation. The mean follow-up time in our group was 11.4 months. Results: Neurological improvement (mean 1.4 by the modified Frankel scale, 1.8 by the Ashworth spasticity scale) was seen in 87% of patients operated for spinal arachnopathies. Temporary neurological deterioration (mild disturbances of deep sensitivity) was seen in 9% of patients and managed successfully with conservative treatment. One patient (3.1%) was operated three times due to relapse of adhesions. There were no serious intraoperative complications (e.g. severe bleeding or dura perforation). Postoperative complications included one CSF leakage and one case of postoperative neuralgic pain. The mean hospitalization time was 7.6 days. Conclusion: According to our data, we conclude that thecaloscopy is efficient and safe method, and should be widely used for spinal arachnopathies, adhesive arachnoiditis and arachnoid cysts. Taking into account that adhesive spinal arachnoiditis is a systemic process, and that spinal arachnoid cysts may also be extended, thecaloscopy may be regarded as the most radical and less-invasive form of surgical treatment that currently exists in neurosurgery.

ABSTRACT Objectives: To evaluate thoracolumbar fractures and the complications such as adjacent disc degeneration (ADD) and post-traumatic deformity. Methods: We evaluated 32 patients divided into two equal groups, 16 in the case group (removal of the synthesis material) and 16 in the control group (not submitted to removal of the synthesis material) in order to verify if there was difference between the incidence of these complications. Results: There were no statistically significant differences between the groups regarding the progression of the ADD and the post-traumatic deformity, but both progressed during the 2-year follow-up. Conclusion: It was concluded that the removal of the synthesis material was not effective in preventing these complications after surgical fractures of the thoracolumbar spine.

ABSTRACT Objective: To analyze the epidemiological profile of patients with spinal fractures and the characteristics of the population at risk attended at a university hospital. Methods: The study population is composed of 202 patients diagnosed and treated for vertebral fracture due to trauma. The variables were correlated with each other and the correlations with p<0.05 were considered statistically significant. Results: The ratio of incidence of trauma between the sexes was 3:1 for males. The mean age was 37 years and the age group with the highest incidence was between 20 and 39 years. Traffic accidents were the most frequent mechanism (51.2%) and secondly, falls (33.2%). There was a statistical correlation between trauma mechanisms to age group and region of the spine. The first lumbar vertebra (L1) fracture alone accounted for 21.5% of all cases studied associated with the fall mechanism. Spinal cord injury was recorded in 33.7% of the individuals in the sample. A total of 57.3% of the patients were submitted to surgical treatment and 41.7% to the conservative treatment. The mean hospitalization time was 15 days. Conclusions: Spinal fractures are important determinants of morbidity and mortality in the population with a major impact on economically active individuals, especially males. They are directly associated to traffic accidents in the young population and to falls in the higher age brackets. Primary prevention of trauma is the main mechanism for change in this scenario.

ABSTRACT Objective: The aim of this study was to evaluate the success and complications rates of thoracolumbar fractures with a score equal or superior to 7 according to the load sharing classification (McCormack), surgically treated with short posterior fixation at three points. Methods: We evaluated 40 patients with thoracolumbar fractures and score by the load sharing classification greater than or equal to 7, treated exclusively by surgery by short posterior fixation. We assessed epidemiological data, increased kyphosis, loss of vertebral body height and complications at 2-year follow-up. Results: Although there was a statistically significant increase in kyphosis and a decrease in vertebral height, there was no clinical repercussion. Conclusion: We conclude that the McCormack classification is not a fundamental predictor for indication of anterior approach complementary to the short posterior fixation.

ABSTRACT Objective: The purpose of the present study was to evaluate the concordance between the Tokuhashi and Tomita scores with the prognosis of patients with vertebral metastases due to breast tumor, treated at the outpatient clinic of the Universidade Estadual de Campinas (UNICAMP). Methods: Twenty-nine patients with vertebral metastases from breast tumor were retrospectively evaluated. Twenty patients were surgically treated and received adjuvant therapy and only nine received conservative (chemotherapy/radiotherapy) or palliative/support treatment, depending on Tokuhashi and Tomita scores. Results: In this study, all selected patients were females with vertebral metastasis due to breast tumor; mean age of 57.6 years (SD = 11.8 years). The accuracy of the Tokuhashi scale was 62.1% and that of Tomita 72.4%. In addition, the Tomita scale concentrates the majority of the patients’ classifications for more than 12 months (69%), indicating a good relation with the long-term prognosis (> 12 months). None of the evaluated characteristics - age or surgery - statistically influenced the survival of patients with primary breast tumor (p > 0.05). Conclusion: The Tokuhashi and Tomita scores showed good accuracy in relation to the prognosis of patients with spinal metastasis due to breast tumor.

ABSTRACT Objective: To report two cases of multilevel cervical spondylotic myelopathy with monosegmental instability, in which we performed a minimally invasive microsurgical transmuscular approach with tubular retractors to create a single-door plate laminoplasty combined with fixation of the unstable segment with lateral mass screws. Methods: The surgical procedures were performed by the senior author. In both patients, the follow-up was performed using the Oswestry Disability Index (ODI), the Visual Analogue Scale for neck and radicular pain (radVAS, neckVAS), the Neck Disability Index (NDI) and the Short Form 36 (SF-36), in the preoperative (preop) and postoperative (postop) periods, and at 1, 3, 6, 12, 18 and 24 months. A radiological evaluation also was performed, which included AP, lateral and flexion-extension films at 6, 12 and 24 months and CT-scan at 12 months. Results: Case 1 - preop ODI: 40%, 24 months postop ODI: 4%; preop radVAS: 7, 24 months radVAS: 0; preop neckVAS: 8, postop 24 months neckVAS: 0; preopNDI: 43%, 24 months PostopNDI: 8%; SF-36 - preop Physical Functioning (PF): 40, preop Vitality (VT): 40, preop Emotional role functioning (RE): 33.3, Bodily pain (BP): 51, General Health (GH): 57, Social Functioning (SF): 75; postop PF: 95, VT: 95, RE: 100, BP: 74, GH: 87, SF: 100. Case 2 - preopODI: 46%, 24 months postopODI: 10%; preop radVAS: 7, 24m radVAS: 0; preop neckVAS: 9, postop 24 months neckVAS: 0; preopNDI: 56%, 24 months PostopNDI: 15%; SF-36 - preop PF: 39, VT: 45, RE: 33.3, BP: 50, GH: 49, SF: 70; postop PF: 90, VT: 100, RE: 100, BP: 82, GH: 87, SF: 100. No complications, cervical instability or signs of failed surgery were found trough and at final follow-up at 24 months. We found significant clinical improvement in both patients. Conclusions: Minimally invasive cervical laminoplasty combined with lateral mass screw fixation for the unstable segment is a useful technique in cases with multilevel cervical spondylotic myelopathy associated with monosegmental instability. Additional comparative studies are needed to establish its efficacy.

ABSTRACT Langerhans cell histiocytosis (LCH) is characterised by an abnormal histiocytic accumulation in tissues such as the lung, spleen, bone marrow, skin, central nervous system, liver and lymph nodes, causing focal or systemic effects. No specific clinical & radiographic presentation of LCH is described in literature. This poses a diagnostic dilemma for surgeons. The scapula is the site of 3% of bone tumours, while for LCH it is the least common site. In a 10-year-old boy with isolated lesion of the scapula with no other systemic involvement, and no specific finding in MRI or CT scan of scapula, diagnosis was confirmed on biopsy. Division into single and multi-system disease is paramount in treatment, given that it is a single system disease. The patient improved clinically on follow-up of 2 years. The scapula is one of the rarest site of LCH, and because various lesions mimic each other, a biopsy is always required, with immunohistochemistry for CD68 & S-100. This was only a single system disease, so conservative management was performed, and the patent improved clinically.

ABSTRACT Objective: To report the outcomes of non-endoscopic percutaneous cervical discectomy by anterior blunt approach for the treatment of degenerative disc disease. Methods: A review of the medical records of patients with axial cervical pain resulting from degenerative disc disease and treated with discectomy and percutaneous nucleoplasty by anterior blunt approach with radiofrequency source was carried out. The data were evaluated according to modified MacNab and pre- and postoperative VAS criteria at 3, 12 and 24 months. Results: Sixty-two procedures were performed in 48 patients between 2008 and 2014. The mean age of the population was 52.4 years. MacNab results were 84.6%, 92.3%, and 89.2% improvement (excellent and good results) at 3, 12 and 24 months, respectively. The VAS changed from 7.4 to 2.3 two years after the procedure, showing a statistically significant difference (p=0.000). There were no major complications or re-interventions related to the technique. Conclusions: Anterior non-endoscopic discectomy and nucleoplasty for the treatment of discogenic axial cervical pain may be an effective alternative to open surgery. In the two-year follow-up, our blunt technique proved to be a safe procedure with no approach-related complications, and provided outcomes comparable to those reported using the original needle technique.

ABSTRACT Objectives: To evaluate the cervical alignment after the correction of idiopathic scoliosis using high screw density and direct vertebral derotation (DVD) and to correlate it with thoracic kyphosis, spinopelvic parameters, and quality of life. Methods: Retrospective cohort study. We assessed the medical records and radiographs of patients submitted to idiopathic scoliosis surgery using high density of pedicular screws (80%) and DVD with at least 6 months of follow-up. All the radiographic parameters were evaluated in the preoperative period and in the last postoperative visit. Results: A total of 43 patients were evaluated, of which 35 (81%) were female. The mean age was 15 years (11 to 30 years) with a mean follow-up of one year and four months. Regarding Lenke’s classification, 14 were of group 1, five of group 2, 10 of group 3, eight of group 4, four of group 5 and two of group 6. Only four patients had sagittal modifier (+) and two sagittal modifier (-).There was no significant difference between pre and postoperative thoracic kyphosis. When we evaluated the groups with +, N and - thoracic modifiers, we observed hypokyphotic and normokyphotic patients (- and N) had an increase in kyphosis, whereas hyperkyphotic patients (+)had a decrease. There was no statistical difference in relation to the radiographic parameters of the cervical spine in the pre and postoperative periods. There was a significant improvement in most of the parameters of the quality of life questionnaires, but no correlation with the cervical radiographic parameters. Conclusion: Correction of idiopathic scoliosis using a high density of pedicular screws and a direct vertebral derotation technique failed to improve thoracic kyphosis or change the cervical sagittal alignment, despite promoting a significant improvement in the parameters of quality of life questionnaires.

ABSTRACT Objective: To correlate the radiographic parameters of sagittal cervical alignment with quality of life and functional capacity in patients with cervical spondylosis under conservative treatment. Methods: This is an observational and prospective study in patients with cervical spondylosis under conservative treatment and without indication for surgery. The 52 patients included were divided into three groups: axial pain, radiculopathy, and cervical myelopathy. The radiographic parameters considered were cervical lordosis (CL), cervical sagittal vertical axis (CSVA), T1 slope (TS) and the discrepancy between TS and CL (TS-CL). Quality of life and functional capacity were evaluated by the Neck Disability Index (NDI) questionnaire. Pain was assessed by the Visual Analogue Scale (VAS). The correlation between the radiographic parameters and the clinical scores was evaluated by the Pearson correlations coefficient. Results: There was no difference in cervical radiographic parameters between the three groups. In the total of the sample, the mean value of the CSVA was 17.8o (±8.3o), CL, 22.4° (± 8.8°); TS, 29.3° (±6.6°), and TS-CL, 7.0° (±7.4°). Significant inverse correlation (r= -0.3, p=0.039) was observed between NDI and CL, but there was no significant correlation between CL and VAS. CSVA (p=0.541), TS (p=0.287) and TS-CL (p=0.287) had no significantly correlated with NDI or VAS. Conclusion: Considering patients with cervical spondylosis not candidates for surgery, the only sagittal parameter that correlated with functional capacity was LC. In these patients, the correlation between cervical alignment and quality of life needs to be better characterized.

ABSTRACT Objective: This study describes the use of materials for modern cervical instrumentation, evaluating its viability in children and adolescents, and the techniques used in different cases. The efficacy of the techniques was analyzed through improvement of pain, maintenance of cervical range of motion, recovery of craniocervical stability, bone consolidation, and spinal stenosis in the postoperative follow-up. Method: Retrospective study of the clinical and radiological parameters of 27 patients aged two to 16 years with cervical spine diseases. Results: Two patients had chronic dislocation in C1-C2, one had congenital axis spondylolisthesis, two had congenital dislocation in C1-C2, three had tumors, one had kyphosis after laminectomy, one had post-infection kyphosis, one had fracture, 11 were syndromic with instabilities, and five had congenital cervical scoliosis. As to surgical approaches, two patients were transorally operated, three by anterior approach, 15 by posterior approach, two by anterior and posterior approaches, and five were treated in three stages (anterior, posterior and anterior approaches). Regarding the technique of cervical stabilization, seven patients were treated by Goel-Harms technique, two received Goel’s facet distraction, and three, Wright translaminar screws. There were complications in four cases. Two patients in the instrumentation of C1 lateral mass due to poor positioning, one with cerebrospinal fluid fistula and one with surgical wound infection. Conclusion: Modern cervical instrumentation in pediatric patients is a safe and effective technique for the treatment of cervical instability.

ABSTRACT Objective: To describe the learning curve that shows the progress of a single neurosurgeon when performing single-level MI-TLIF. Methods: We included 99 consecutive patients who underwent single-level MI-TLIF by the same neurosurgeon (JASS). Patient’s demographic characteristics were analyzed. In addition, surgical time, intraoperative blood loss and hospital stay were evaluated. The learning curves were calculated with a piecewise regression model. Results: The mean age was 54.6 years. The learning curves showed an inverse relationship between the surgical experience and the variable analyzed, reaching an inflection point for surgical time in case 43 and for blood loss in case 48. The mean surgical time was 203.3 minutes (interquartile range [IQR] 150-240 minutes), intraoperative bleeding was 97.4ml (IQR 40-100ml) and hospital stay of four days (IQR 3-5 days). Conclusions: MI-TLIF is a very frequent surgical procedure due to its effectiveness and safety, which has shown similar results to open procedure. According to this study, the required learning curve is slightly higher than for open procedures, and is reached after about 45 cases.

ABSTRACT Objective: To perform a prospective analysis of the quality of life prognostic factors in patients undergoing lumbar discectomy after two years of the procedure, relating the tools Short Form Health Survey, Roland Morris, Oswestry Disability Index, and VAS. Methods: Seventy-two patients were evaluated through the questionnaires in the preoperative, and one month, six months, one year and two years in the postoperative period, being performed lumbar discectomy after failure of conservative treatment. Results: We observed an improvement in comparative analysis during follow-up regarding baseline values. Conclusion: The domains social aspect, pain, general state, emotional aspect, mental health and vitality presented an improvement from the first month after the surgery; however, the domain functional capacity only showed significant improvement after 6 months and the physical aspects only after one year. Roland-Morris and VAS scales improved after one month after surgery, but Oswestry scale showed that for the measured aspects there was only improvement after six months of surgery.

ABSTRACT Objective: In this paper we report the clinical and radiological results of lumbar intervertebral disk (IVD) replacement with M6-L for the treatment of patients with IVD degeneration. Methods: One hundred and fifty-six patients with IVD degeneration were operated with the one level implantation of an M6-L prosthesis at three neurosurgical departments, in Irkutsk, Krasnoyarsk and Vladivostok. We assessed pain intensity (VAS), the Oswestry disability index (ODI) and outcomes by the Macnab scale up to 36 months after surgery. Instrumental data were used to assess range of motion in the operated segment and heterotopic ossification by the McAfee-Suchomel classification. Results: The average VAS before surgery was 6.9 ± 1.6 cm. After surgery, this value reduced significantly, to an average of 1.3 ± 1.2 cm (p<0.001). The average ODI before surgery was 40.2 ± 6.9%, and after IVD arthroplasty, this indictor improved to 12.3 ± 6.1% (p <0.001). Range of motion in the operated segment at baseline averaged 36.8 ± 2.6o, and within 36 months after the operation, this had increased to 41.2 ± 2.9o. During the entire follow-up period, signs of severe (13.4%, n = 21) or moderate (10.2%, n = 16) heterotopic ossification were observed. Conclusions: The use of M6-L prosthesis can significantly reduce the level of pain, improve quality of life and maintain the physiological range of motion in the operated spinal segment in patients with degenerative lesions IVD at a low level of adverse outcomes. [249 Words].

ABSTRACT Objective: To retrospectively evaluate factors that influence the return to work of patients of economically active age submitted to surgery due to spinal fractures. Methods: Patients aged between 18 and 65 years that underwent surgery after spinal fracture from 2012 to 2014 were selected. Through a specific questionnaire and review of the medical records, we identified factors that may have influenced the labor return of these patients. Results: Initially, 114 patients were allocated. After applying the inclusion criteria, 51 patients remained. Age, schooling, time to sit on the bed, and residual pain were the factors that influenced all outcomes. Other variables such as ISS (Injury Severity Score), segment of spine, number of affected vertebrae, associated lesions, and previous employment regimen had no influence. Conclusions: The rate of return to work after being submitted to surgery due to a fracture of the spine is related to age, schooling, residual pain, length of hospital stay, and the time the patient takes to be able to sit alone postoperatively. Physiotherapy positively influences the patient’s self-assessment regarding the ability to perform basic tasks. These variables can be used to identify a possible difficulty in the reallocation of these patients in the labor market.

ABSTRACT Objective: To report a new technique for extrapleural interbody release with transcorporal osteotomy of the inferior vertebral plateau (LIEPO) and to evaluate the correction potential of this technique and its complications. Method: We included patients with scoliosis with Cobb angle greater than 90° and flexibility less than 25% submitted to surgical treatment between 2012 and 2016 by the technique LIEPO at the National Institute of Traumatology and Orthopedics (INTO). Sagittal and coronal alignment, and the translation of the apical vertebra were measured and the degree of correction of the deformity was calculated through the pre and postoperative radiographs, and the complications were described. Results: Patients had an average bleed of 1,525 ml, 8.8 hours of surgical time, 123° of scoliosis in the preoperative period, and a mean correction of 66%. There was no case of permanent neurological damage and no surgical revision. Conclusion: The LIEPO technique proved to be effective and safe in the treatment of severe stiff scoliosis, reaching a correction potential close to the PEISR (Posterior extrapleural intervertebral space release) technique and superior to that of the pVCR (posterior Vertebral Column Resection) with no presence of infection and permanent neurological deficit. New studies are needed to validate this promising technique.

ABSTRACT Despite many years of dedicated research into the etiopathogenesis of adolescent idiopathic scoliosis, there is still no single distinct cause for this puzzling condition. In this overview, we attempt to link knowledge on the complex three-dimensional pathoanatomy of AIS, based on our ongoing research in this field, with etiopathogenic questions. Evidence from multiple recent cross-sectional imaging studies is provided that supports the hypothesis that AIS has an intrinsic biomechanical basis: an imbalance between the biomechanical loading of the upright human spine due to its unique sagittal configuration on the one hand, and the body’s compensating mechanisms on the other. The question that remains in the etiology of AIS, and the focus of our ongoing research, is to determine what causes or induces this imbalance.

ABSTRACT Objective: To evaluate functional results in patients submitted to lumbar arthrodesis for the treatment of degenerative disc disease. Methods: This is a retrospective study that considered patients submitted to surgery due to degenerative disc disease, with a minimum of 12 months of postoperative follow-up. The Oswestry Disability Index (ODI) and Scoliosis Research Society-22 (SRS-22) questionnaires, including total value and domains, were considered indicators of functional outcome and quality of life. Results: Sixty-one patients (mean age 60.4 years) met the inclusion criteria and had ODI and SRS-22 data recorded. Nineteen were male and 42 female. The mean of postoperative follow-up was 29 months (12-67 months). There was no statistically significant difference in any score between sexes. The mean values obtained by the questionnaires were ODI 43.4%; SRS-22 Total 2.7; Function/Activity 2.6; Pain 2.8; Appearance 2.6; Mental Health 3.0; Satisfaction 3.4. Conclusion: The values of the surgical outcome indicators were consistent with important functional disability, although the satisfaction indicator with the treatment showed satisfied patients.

ABSTRACT Objective: The objective of this study was to evaluate the association of clinical results with preoperative situation of worker compensation (WC) in patients submitted to spine surgery. Methods: This was a retrospective, comparative, single center study. Patients who underwent lumbar spine arthrodesis were included. The outcomes were pain scores (VAS), physical constraint (ODI) and quality of life (EQ-5D). Outcomes were analyzed before surgery and after surgery (minimum follow-up of six months and maximum of 12). Two groups were compared: individuals with or without WC at preoperative visit. Results: A total of 132 cases were analyzed (mean age 54 years and 51% female), 29 (22%) assigned to the WC group. The groups were matched for age, sex, and preoperative depression levels. In the preoperative period, the groups showed equal pain and physical constraint; however the CT group had lower quality of life (p=0.05). Although both groups showed improvement in clinical outcomes after surgery (p<0.05), worse scores were observed for the WC group compared to the non-WC group, respectively: VAS 4.9 vs. 3.2 (p=0.02), ODI 34.7 vs. 23.4 (p=0.002), and EQ-5D 0.56 vs. 0.75 (p=0.01). Conclusion: In this study it was possible to observe that WC is associated with worse clinical results following elective surgical treatment of the lumbar spine.