Diário da Espinha

Purpose: Evaluate the reliability of the change from the flat, posterolaterally oriented facets of the thoracic segments to the curved, posteromedially oriented facets of the lumbar spine, the “facet transition”, as a marker for the T12 segment and determine if variations in rib number are associated with lumbosacral transitional segments.

Materials and methods: 244 patients underwent whole spine CT examinations and the positions of the thoracolumbar facet transition, type of thoracolumbar facet transition (gradual or abrupt), position of the lowest thoracic ribs, and presence or absence of lumbosacral transitional anatomy were recorded. A Fisher Exact Test was used to determine if there was an association between a variant number of ribs and transitional anatomy at the lumbosacral junction.

Results: The thoracolumbar facet transition was located at the eighteenth segment in 50/244 (20%), nineteenth segment in 184/244 (75%), and twentieth segment in 10/244 (4%) of cases. The thoracolumbar facet transition was abrupt in 227/244 (93%). The lowest set of ribs was observed at the nineteenth segment in 225/244 (92%), twentieth segment in 11/244 (5%), and eighteenth segment in 8/244 (3%). The lowest fully-formed intervertebral disc was located between the twenty-third and twenty-fourth segments in 9/244 (4%), twenty-fourth and twenty-fifth segments in 216/244 (88%), and twenty-fifth and twenty-sixth segments in 19/244 (8%). Coexistent lumbosacral transitional anatomy was seen in 5/7 (71%) with eleven, 8/11 (73%) with thirteen, and 24/234 (10%) with twelve ribs. There was an association between variant numbers of ribs and coexistent lumbosacral transitional anatomy (p<0.5).

Conclusion: The thoracolumbar facet transition is not a reliable method of identifying the T12 segment. There are no known landmarks that reliably identify the lumbar segments. Accurate numbering of the lumbar spine requires counting caudally from C2.

Failed back surgery syndrome (FBSS) is a prevalent, debilitating condition that affects the quality of life of many patients. The role of peridural fibrosis in FBSS continues to be a source of controversy. The authors report an association between peridural fibrosis and tactile allodynia, but not neurological dysfunction in a rodent cauda equine crush injury model. Methods Twenty-one rats were equally divided into three different treatment arms: 1) sham, 2) laminectomy-alone, and 3) laminectomy plus cauda equina crush injury. Tactile allodynia was tested and open field locomototor testing was completed according to a predetermined schedule. Animals were sacrificed on postoperative day 42. Histological sectioning was used to determine the degree of peridural fibrosis present in each group of animals. Results Animals who underwent greater surgical manipulation showed greater degrees of peridural fibrosis on histological analysis. Animals in group 3 showed significantly more allodynia at all time points during the study. Laminectomy animals showed more allodynia than sham animals, but less than crush injury animals. Locomotor function was worse in laminectomy-only animals on post-operative days 8 and 15, compared with sham animals. Locomotor scores improved thereafter to that of sham animals. Crush injury animals remained functionally impaired through the duration of the study. Histological analysis demonstrated greater degrees of peridural fibrosis in laminectomy and crush injury animals, as compared with sham. Conclusions Greater degrees of tactile allodynia were demonstrated in rodents with more surgical manipulation. Alternatively, neurological function, as measured by open field locomotor testing, was unaffected in laminectomy-only animals, though tactile allodynia remained worse compared with sham animals. Histological analysis qualitatively demonstrated an association between degree of surgical manipulation and peridural fibrosis. Peridural fibrosis, although associated with greater degrees of allodynia, did not appear related to neurological injury.

The waiting time for surgical procedures is becoming longer in most specialties. This may have adverse effect on patients with Adolescent Idiopathic Scoliosis (AIS) with additional procedures being required or more complex surgery being performed. This retrospective study was performed in the period between December 2007- January 2010 looking on the surgical waiting time on patients with AIS and its effect on curve progression and the type of surgery performed and the final outcome. 215 patients met the inclusion criteria and have complete medical records to be included in the study. Mean age was 13.6 years, 184 patients (86%) were females, 172 were treat in public hospitals and 43 in a private hospital, mean cobb angle of the main curve was 71º. During the study period, 55 patients underwent surgery for scoliosis correction, with a statistical difference in the waiting time between public and private hospitals (36 and 9 weeks respectively), average curve progression was 24º during the waiting period with additional fusion levels being required in 15 cases. Patients with underlying intra spinal pathology and young patients showed the most significant curve progression. Our study support the previous report of the optimal waiting time for surgical correction of scoliosis being less than 6 months and it suggest those younger patients and those with intra spinal pathology and the ones at higher risk for progression.

Introduction: Blood loss is a major cause of morbidity in scoliosis surgery. Jehovah’s Witnesses pose a unique challenge, as their religious convictions restrict them from receiving blood products. There is a paucity of literature regarding blood conservation protocols in pediatric Jehovah’s Witness patients undergoing scoliosis surgery. Methods: Ten consecutive Jehovah’s Witness patients under 21 years of age, who underwent posterior spinal fusion for scoliosis between 1995 and 2013, were retrospectively evaluated. Medical charts were used to assess curve type and magnitude, blood conservation techniques used, operative time, estimated blood loss (EBL), hemoglobin levels and postoperative complications. Results: Diagnoses included 5 idiopathic, 3 syndromic, and 2 neuromuscular scoliosis. An average of 11.5 levels were fused with 58% curve correction. The mean operative time was 325 minutes. Commonly employed blood conservation techniques were electrocautery (100%), cell saver (70%), supplemental iron (70%), and epinephrinesoaked gauze (60%). Anti-fibrinolytics were consistently used in 4 cases since 2010, and the bipolar sealer device in 5 cases since 2007. Hemodilution and hypotensive anesthesia were used in 2 and one case, respectively. EBL was 544 ml. No surgery was aborted due to blood loss. The preoperative and nadir postoperative hemoglobin levels averaged 14.1 and 9.8 g/dL, respectively. There were 4 postoperative complications, which were unrelated to blood loss. At a mean 4-year follow-up, all patients were stable. Conclusion: Posterior spinal fusion can be safely performed in standard fashion in the pediatric Jehovah’s Witness population. The variety of blood conservation techniques has increased over recent years. More aggressive techniques such as hemodilution and hypotensive anesthesia are not always imperative for efficacious surgery. Our institution is currently establishing a blood conservation protocol for spinal deformity surgery.

The treatment of surgical procedure of lower lumbar burst fractures is challenged. The optimal method remains controversial. To assess the usefulness and safety of a novel both decompression and reconstructive procedures known as transdural approaches of lower lumbar spine burst fracture. For this reason, we presented the results of a trans-dural approach which is a new technique. We presented the reconstruction and dural repairing results of 5 cases that were operated on between the years 1995-2011 due to lower lumbar burst fractures with a trans-dural surgical technique. Cases were chosen for this technique according to the presence of lamina fractures displayed on tomography (CT) and lumbar (MRI). Intra canal fragments, lamina fractures were determined. The postoperative opening of the spinal canal, the loss of height of the middle and anterior column and the postoperative fusion results were investigated. The surgical results of the cases were classified according to the Odom’s criteria. No instances of neurological deterioration and instrument failure occurred and no complications were noted with the use of this technique. All five patients had neurological function recovery at the most recent follow-up visit. In conclusion, this reported new surgical approach is an efficient and safe method for the treatment of traumatic lower lumbar burst fractures.

Surgeries for Lumbar Spinal Stenosis (LSS) aim at decompressing spinal nerves and relieving symptoms of radiculopathy or myelopathy. Frequently after surgery, stenosis may progress in adjacent spinal segments, but the etiology of adjacent segment degeneration is still unclear. It is hypothesized that surgical approaches for LSS may alter the normal biomechanics of adjacent segments, eventually contributing to the development of stenosis. This study investigated implications of established decompressive surgical approaches on adjacent segments biomechanics. A realistic finite element model of a L1-L5 human lumbar spine was used for assessing changes in spine segments’ biomechanics due to laminotomy and laminectomy surgeries. First, the model was validated by comparing its predictions to previously reported spine kinematic data obtained after multi-level laminotomy and laminectomy. Subsequently, using a hybrid loading protocol, segments’ kinematics, intradiscal pressure, and stress in flexionextension were investigated simulating single level (L4-L5) laminotomy and laminectomy procedures. Alterations of spine segments biomechanics due to laminotomy were minimal. In contrast, after laminectomy, the L3-L4 range of motion, intradiscal pressure, and stress increased up to 50%, 20%, and 120%, respectively. These results suggest that laminotomy represents a better approach than laminectomy for reducing risks of spine instability or mechanically-accelerated disc degeneration in adjacent segments.

Background: It is widely accepted that postoperative Antimicrobial Prophylaxis (AMP) is effective in reducing the risk of surgical site infections (SSI) following spinal surgery. After publication of the Guideline for Prevention of Surgical Site Infection by the Centers for Disease Control and Prevention in 1999, a large number of studies confirmed the effectiveness of AMP. Due to the possible emergence of AMP resistant bacteria or appearance of side-effects, we have treated and managed patients who underwent spinal surgery without post operative antimicrobial agents since 2003.

Purpose: To investigate the incidence of SSI in patients without administration of antibiotics after spinal instrumentation surgery.

Subjects: A consecutive 468 patients (230 males and 238 females) were adopted in this study from November 2003 to June 2010. Mean age at the time of operation was 52.1 years. We defined this group as the non-postoperative dose group. There were 121 patients (25.9%) who underwent instrumentation surgery. On the other hand, we defined patients who were administered postoperative multiple doses of AMP between January 2000 and October 2003 as the postoperative dose group. There were 340 cases, consisting of 198 males and 142 females in this group. Average age at the time of operation was 51.3 years. There were 146 patients (42.9%) who underwent spinal instrumentation surgery.

Methods: All patients were administered 1 g of cefazolin within 30 minutes of skin incision, and the same dose of antimicrobial agent was added every four hours during surgery in the non-postoperative dose group. We administered AMP before and for 7 days after surgery in the postoperative dose group.

Results: The postoperative infection rate was 1.92% (9 cases), of which 7 cases were superficial infections and 2 cases were deep infections in the non-post operative dose group. In the post operative dose group, there were 9 confirmed post operative wound infections in the 340 patients for an overall SSI rate of 2.65%. There was no significant difference between the two groups. The incidence of SSI in patients who underwent spinal instrumentation surgery was 0.83% (one of 121 patients) in the non-postoperative dose group and 2.04% (three of 147 patients) in the postoperative dose group. There was no significant difference between the two groups even with the use of spinal implants.

Conclusions: The duration of antimicrobial prophylaxis was not related to the SSI rate at our institution. Postoperative administration of antibiotics appears to be unnecessary for spinal surgery even with spinal implants when perioperative management was achieved for the patient condition and surroundings as recommended in the CDC guidelines.

Objective: Very few studies researched the treatment modalities in treating degenerative disc disease for two adjacent levels of the cervical spine. In order to reduce distress on the adjacent segments and minimize implant subsidence we analyzed the use of a hybrid approach combining arthroplasty with cage fusion.

Methods: 64 “fusion-only” and 47 hybrid patients between the age of 30 and 60 years were clinically evaluated using ODI, Odon’s criteria. X-rays in two planes of the cervical spine were taken, measuring alpha and C2-C7 beta angles using Harrison’s tangent. Signs of subsidence in the sagittal plane were recorded, where subsidence was defined as a shift by more than 40% of the respective implant height.

Results: 10 cages combined with arthroplasty and 2 prostheses showed signs of subsidence compared to 47 cages in the fusion group (25 singe level and 11 on two levels). Overall subsidence after two years was found in 49% of the fusion group opposing 18% in our arthroplasty group. Patients with subsidence showed a longer recovery time to work, 14 weeks vs. 26, p=0.21; compared to the fusion group, 13/22 weeks, p=0.34. Odon’s criteria and Oswestry results were favorable and comparable in both groups. Revision rates were higher for arthroplasty 10.6% vs. 3.1%.

Conclusion: We found two level ACDF implants to subside more frequently than in ACDF in combination with arthroplasty, indicating a reduced distress in the arthroplasty group. Absence of subsidence may have led to a faster return to work as may the implementation of arthroplasty. Overall the clinical outcome of both groups was comparable. However with the hybrid approach a higher revision rate occurred.

Multiple myeloma is a systemic malignancy that causes bone destruction due to bone marrow infiltration. Treatment options for myeloma of the spine include radiation therapy and surgery. The case of a 59-year-old woman with multiple myeloma is reported. She was Stage 3B according to the Durie-Salmon staging system and responded to highdose chemotherapy and peripheral blood stem cell transplantation and achieved complete remission. However, her skull base and cervical bones showed marked osteolysis which required external fixation and bed rest. Surgery with occipito-thoracic (OT) fusion was performed, which yielded neurological improvement and could walk completely on her own 2 months after surgery. She had no recurrence over a 5-year follow-up period. Surgical stabilization allowed this multiple myeloma patient to remain ambulatory.

Introduction: Chordoma is a rare type of low-grade malignant neoplasm that arised from the remnants of the embryonic notochord. Observed mainly in the clivus and sacrum but can occur anywhere along the spine. Several treatment approaches are described. Treatment outcomes are significantly influenced by the size and location of the tumor.

Clinical presentation and follow up: We report a 19-year-old female professional athlete with a cervical chordoma, involving C2, C3 and C4 vertebrae with spinal cord compression. Diagnosis was established by open biopsy. The patient was surgically treated in three steps: one anterior resection of the lesion was carried out, followed by a posterior resection and finally an arthrodesis and anterior fixation. The patient was referred to rehabilitation and one year after the first surgery she resumed competitive sport activities. No recurrences were observed within fifteen years of follow-up.

The developing Magnetic Resonance Imaging technologies have led to significant changes in the radiological diagnostic criteria of the Spinal Cord Injury without Radiological Abnormality (SCIWORA). Moreover, some authors even introduced alternative definitions for this specific disease recently. The aims of this study were to report an adolescent case with pure SCIWORA and to clarify its definition in the literature. A 16 year-old adolescent patient with thoracolumbar SCIWORA together with a pelvic fracture after a vehicle accident was presented in this case report. In neurological examination, both extremities were graded as Frankel type A. The X-ray and Magnetic Resonance Imaging revealed the right ischium-superior pubic ramus fracture and only edema of the spinal cord at T12, L1 and L2 vertebral levels, subsequently. A high dose of methyl-prednisolone was administered. Pelvic fracture was promptly fixed with an external fixator. After a follow-up period of two years, the neurological status of the patient showed progression to Frankel B. The patient continues to his life with wheelchair. In conclusion, an adolescent case with SCIWORA that fulfills all its original criteria was reported and a review of the literature was discussed in this study. In order to describe this special pathology, SCIWORA seems still to be the best ideal term.

Cervical traumas in children are often misunderstood and treated incorrectly. Injuries of the cervical spine are relatively rare in children but are a distinct clinical entity compared with those found in adults. The unique biomechanics of the pediatric cervical spine leads to a different distribution of injuries and distinct radiographic features. The treatment of cervical spine injuries in children must be founded on an understanding of spine development. Differences in injury patterns, interpretation of radiographic studies, and management of injuries are a direct result of the unique anthropometrics and biomechanics of a child. The literature specifically addressing cervical spine injuries in children is scarce most studies have been focused on adults. In more recent years, as distinct aspects of the pediatric spine have been better appreciated, more attention has been given exclusively to injuries of the cervical spine in younger patients. We describe two cases of cervical trauma of different entity for which the incorrect evaluation of the trauma led to a difficult diagnostic-therapeutic path.

Adult non-dysraphic intradural spinal lipomas are rare entities. Here we report two cases of adult non-dysraphic intradural lumbar lipoma.
Case 1: A 66-year-old man experienced gradual progression of sensory disturbance and numbness in the lower extremities bilaterally over the course of 2 years. Magnetic resonance imaging (MRI) suggested an intradural lipoma at T12 with no evidence of dysraphism. Adequate decompression and duraplasty were performed with intraoperative monopolar stimulation to elicit evoked electromyography responses.
Case 2: A 54-year-old man with a 10-year history of lower back pain and gradual progression of weakness of the right lower extremity over the course of 2 years was referred to our hospital, where he presented with urinary disturbance. An MRI suggested intradural lipoma at L2 without evidence of dysraphism. Roentgenograms revealed L5 isthmic spondylolisthesis. Adequate resection, duraplasty, and L4-S posterior lumbar interbody fusion were performed with intraoperative monopolar stimulation monitoring. Both patients received pathological diagnoses of lipomas, and neurological symptoms improved postsurgically in both cases. Adequate resection is recommended for adult lumbar lipomas without dysraphism in order to achieve a good clinical outcome. The evoked electromyography response was a simple and useful intraoperative tool to demonstrate adequate decompression of adult non-dysraphic intradural spinal lipomas in both of these cases.

Although pediatric spine traumas are seen less compared to adults, they display particular anatomical differences and biomechanical behaviors. They also differ in themselves from infancy to early childhood. All these differences cause some difficulty in diagnosis. Also the treatment procedures may require a different approach than they would for adults. In this study, main topics regarding diagnosis and treatment of the pediatric spinal traumas will be discussed.