Diário da Espinha

Background: Micro endoscopic decompression of stenosis and micro endoscopic discectomy has been shown to be safe and effective. Minimally invasive techniques are associated with decreased soft tissue injury, less pain, and quicker patient recovery. The obese population can pose unique peri-operative challenges. We explored the role of obesity on self-reported outcomes, blood loss, operative time, length of stay, and complications following minimally invasive lumbar decompression.

Methods: A retrospective review of outcomes on 60 obese patients (BMI ≥30 kg/m2) who underwent minimally invasive micro endoscopic decompression of stenosis or micro endoscopic discectomy, compared to 51 normalweight patients (BMI 18.5 kg/m2-24.9 kg/m2), undergoing the same procedures. Outcomes analyzed included the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI).

Results: In 51 normal-weight patients, the mean age was 55.0 years and average BMI was 23.2 ± 0.4 kg/m2. In 60 obese patients, the mean age was 58.0 years and average BMI 34.2 ± 0.6 kg/m2. Mean operative time was 99 ± 4 minutes, and LOS was 9.8 ± 2.7 hours for the normal-weight group. For obese patients, the mean operative time was significantly longer with 117 ± 5 minutes; LOS was 16.1 ± 5.1 hours. BMI significantly correlated with operative time (p= 0.002). Obese patients had a statistically significant (p=0.04) increased estimated blood loss (26.7 cc) compared to normal-weight patients (19.5 cc). Improvements in VAS-back, VAS-leg, and ODI were seen within each cohort. There were no statistically significant differences between the obese and normal groups at the last follow-up. The obese group had more complications (8.33%) compared to normal controls (3.92%), but was not statistically significant.

Conclusion: Microendscopic decompression of stenosis and micro endoscopic discectomy are effective surgical options for the obese population. Obesity did not have an impact on self-reported outcomes or length of stay. Obesity was associated with an increase in average operative time, estimated blood loss, and subsequent return to surgery

Purpose: “Pilates” is known to be a gentle technique of strength training with an emphasis on the deep trunk muscle layers. Positive influences on spinal form parameters are assumed.

Methods: Spinal form parameters of 24 female volunteers (10 Pilates / 14 controls) were measured before and after a definite Pilates program (12 units, 60 minutes each, once a week) by means of video raster stereography (Formetric®-system), and analyzed using 2-way ANOVA.

Results: We found significant (p<0.05) spine shape changes in the form of spinal erection (decreasing thoracic angle, increasing spinal length) after Pilates-based training exercises.

Conclusions: We consider the controlled spinal shape adaptations – apparent in an erection of spinal alignment in the sagittal plane – to be valid and specifically exercise-induced, supporting a basic idea of the Pilates training concept.

Summary of Background Data: Anterior cervical discectomy and fusion (ACDF) is the gold standard surgical intervention for cervical degenerative disc disease (DDD). Cervical disc arthroplasty (CDA) has been introduced as an alternative. CDA offers the potential advantage of preserving intersegmental motion and preventing adjacent segment degeneration. Although a number of trials demonstrated non-inferiority of CDA compared to ACDF in terms of symptom/function related outcomes, little data is available comparing perioperative outcomes.

Methods: The Natiowide Inpatient Sample (NIS) database was queried for ACDFs or CDAs between 2005 and 2010. Univariate analyses was used comparing the two procedures in terms of patient demographics, comorbidities, perioperative complications, length of stay (LOS), total hospital charges, and mortality. Complications rates that were significant on univariate analysis were analyzed via logistic regression models that account for age, gender, and overall comorbidity burden. National estimates of annual total number of procedures were calculated.

Results: An estimated 9,910 CDAs and 699,289 ACDFs were performed in the United States between 2005 and 2010. The CDA cohort was younger and with less comorbidities than the ACDF cohort. The CDA cohort experienced less post-operative dysphagia, hematoma, acute anemia secondary to intraoperative blood loss, or ARDS. ACDF was associated with less cardiac complications, peripheral vascular, and device related complications. All complications remained statistically significant in logistic regression models. CDA had a lower average LOS (1.56 versus 2.23 days, p<.0001) and was associated with less total charges ($39,563 versus $43,477, p<.0001). Mortality was lower after CDA (0.10% versus 0.22%, p=.01).

Conclusions: This data suggests that CDA may be safer, associated with lower mortality, lower hospital charges and shorter LOS compared to ACDF. However, baseline differences between the two cohorts, including age and comorbidity burden, may play a confounding role in these findings. This information could be important in developing an evidence-based paradigm for surgical management of cervical DDD.

Summary of Background Data: The high prevalence of chronic persistent neck pain not only leads to disability but also has a significant economic, societal, and health impact. Among multiple modalities of treatments prescribed in the management of neck and upper extremity pain, surgical, interventional and conservative modalities have been described. Cervical epidural injections are also common modalities of treatments provided in managing neck and upper extremity pain. They are administered by either an interlaminar approach or transforaminal approach. Objectives: To determine the long-term efficacy of cervical interlaminar and transforaminal epidural injections in the treatment of cervical disc herniation, spinal stenosis, discogenic pain without facet joint pain, and post-surgery syndrome. Materials and Methods: The literature search was performed from 1966 to April 2014 utilizing data from PubMed, Cochrane Library, US National Guideline Clearinghouse, previous systematic reviews, and crossreferences. The evidence was assessed based on best evidence synthesis with Level I to Level V. Results: There were 7 manuscripts meeting inclusion criteria. Of these, 4 assessed the role of interlaminar epidural injections for managing disc herniation or radiculitis, and 3 assessed these injections for managing central spinal stenosis, discogenic pain without facet joint pain, and post surgery syndrome. There were 4 high quality manuscripts. A qualitative synthesis of evidence showed there is Level II evidence for each etiology category. The evidence is based on one relevant, high quality trial supporting the efficacy of cervical interlaminar epidural injections for each particular etiology. There were no randomized trials available assessing the efficacy of cervical transforaminal epidural injections. Conclusion: This systematic review with qualitative best evidence synthesis shows Level II evidence for the efficacy of cervical interlaminar epidural injections with local anesthetic with or without steroids, based on at least one high-quality relevant randomized control trial in each category for disc herniation, discogenic pain without facet joint pain, central spinal stenosis, and post-surgery syndrome.

Study background: There is still controversy on the effectiveness of conservative treatment and the need for surgical intervention in thoracolumbar burst fractures. The aim of the study was to prospectively evaluate the results of a cohort of patients with acute thoracolumbar fractures comparing surgical and conservative treatment.

Methods: Forty-five patients were included. Treatment was decided upon fracture stability and clinical involvement. Two groups were made: surgical (S-group) and conservative (Cgroup). Radiological variables at initial presentation, 1-month, 6-months and at 2-years follow-up were analyzed. Local and regional kyphosis, SF-36 and Oswestry Disability Index (ODI) results, and complications were compared.

Results: 54.8% were type A2-A3 fractures, and 45.2% were type B1-B2 fractures. L1 was the most often affected level, mean age was 40.3±13.2 years, and both groups were homogeneous except for type of fracture according to the AO classification. Group C had mostly A types, group S had mostly B types. Statistically significant differences (p<0.05) were found for local initial kyphosis (C: 12.4º ± 3.6 vs S: 17.5º ± 6); local and regional kyphosis at 1 and 6 months; and final local kyphosis (C: 14.8º ± 6.2 vs S: 7.3º ± 4.6). At the end of follow-up, patients undergoing conservative management showed a +2.6º ± 4.1 increase in local kyphosis, whereas those with surgical treatment showed a -10.3º ± 5.6 improvement (p=0.000). At two years there was a non-significant trend favoring conservative treatment in all SF-36 domains except emotional role. Patients who underwent conservative treatment showed less final disability on the ODI(C: 13.5% vs S: 29.8% p=0.006). Two conservatively treated patients had a >20º increase in kyphosis at final follow-up and one required surgery. In the S group the reoperation rate was 22%.

Conclusion: Fractures with doubtful posterior ligamentous complex instability are better treated by conservative means. Kyphosis would not be restored, but clinical outcomes will result better than if treated surgically, with less complication.

The pre-pubertal age can be considered as the most important for prevention and treatment of postural deformity. Postural adjustments to maintain static and dynamic balance depend on the relationship between sensory input organs (captors) and the environment. Currently, there are three captors known: the eye, the vestibule and the soles of the feet. Postural insoles work as exteroceptors and aim to reorganize the muscle group’s tone and influence the body posture by proprioceptive reflexes and subsequent correction. Besides the proprioceptive insoles, the Pilates method for spine treatment and postural deviations has been widely applied, and it presents great adhesion and good outcomes for school children and pre-teens. The baropodometric projection of the body center of pressure (COP) could be used in clinical practice as an evaluation tool in the treatment of postural dysfunctions and spinal deviations, through a baropodometer device, but little has been published about its clinical outcomes on everyday use. This study described the case of an 11 year old with pelvic deviation due to short leg length and the treatment chosen accordingly to a baropodometric evaluation, such as the use of postural insoles combined with Pilates sessions for 40 days. After this period, it was noted a better plantar surface and peak pressures distribution, as well as a more homogeneous weight bearing on both feet, which can induce improvements on postural behavior and prevents spinal injuries.

Spondyloptosis is defined as greater than 100% subluxation of one vertebra over another; it most commonly develops due to dysplastic spondyloslisthesis but can also develop as a result of traumatic fracture-dislocations. In the past, given the significant force associated with this injury, most patients did not survive the initial trauma and resuscitation. However, as early care of patients with multiple traumatic injuries continues to improve, a larger number of patients with traumatic spondyloptosis will require treatment. In general, the goals of surgical intervention are to treat symptoms, preserve and improve neurologic status, restore and maintain sagittal balance, and obtain a solid arthrodesis while fusing as few segments as possible. There is, however, considerable controversy about specific surgical management in achieving these goals. We present a case of traumatic spondyloptosis including a discussion of our surgical approach, which is a modified Gaines procedure with a corpectomy, interbody fusion, and posterior spinal decompression and fusion. Alternate approaches are also discussed from both our institutional experience and from a review of the current literature.