Diário da Espinha

Thoracolumbar fractures are an important topic in spinal surgery. In this article, the instability of the thoracolumbar fracture classifications and surgical treatments are discussed, with a particular focus on treatment concepts that are based on the modern classification systems.

The term Vertebral Destruction Syndrome comprises pathologies causing structural changes in the spine in the vertebral body mainly producing mechanical deformity and neurological involvement. Among the pathologies found in this definition are infectious and metabolic tumors. The vertebral osteomyelitis is a disease that occurs mainly in adults >50 years; we speak of spondylodiscitis when condition affects the disc and vertebral body. The most important in the vertebral body is Staphylococcus aureus osteomyelitis, seen in over 50% of cases. Tumors of the spine can start from local or adjacent spinal injuries or distant spread through the blood or lymphatic. Metastases injuries account for about 97% of all tumors of the spine. Primary tumors that most commonly spread to spine is lung, prostate, breast and kidney. Metabolic bone diseases are a group of disorders that occur as a result of changes in calcium metabolism, spine contains large amounts of metabolically active cancellous bone, which must withstand axial loads during stance, and osteoporosis is a metabolic disease that most commonly affects the spine, characterized by low bone mass.

The diagnosis of these entities is important for treatment and prognosis of the patient, the term Vertebral Destruction Syndrome proposes a notarized scheme aimed at improving patient prognosis and their prompt treatment.

Background: Conservative care for degenerative spinal conditions includes several modalities of treatment. Thus, the traction distinguishes as it is capable to elicit the body´s protective proprioceptive response to distraction, reducing intradiscal pressure and minimizing symptoms secondary to disc herniation and axial pain.

Objectives: This work aims to determine the clinical effects of a short treatment course of motorized axial spinal decompression for patients with pain and physical impairment, caused from either lumbar or cervical degenerative disc pathology with no immediate surgical indication.

Methods: A prospective, non-randomized, single center, case series study from patients with both axial and irradiated symptoms from cervical or lumbar spine. Subjects were submitted to a traction protocol using a motorized mechanical axial decompression system (SpineMED®, LAS Brasil, SP). Clinical outcomes as VAS and ODI for lumbar patients 17 and NDI for cervical patients were also collected.

Results: Clinical outcomes improved along the treatment. AP-VAS scores showed an overall reduction of 59% (p<0.001), while IP-VAS scores improved in 56% in the last session (p<0.001). Average ODI showed statistical significance at last session (28 to 18; p=0.014). Average NDI also showed statistical significance at last session (30 to 20; p<0.001). Despite some minor adverse events, no major complication occurred during treatment.

Conclusion: This present spinal decompression treatment significantly improved patient’s clinical outcomes, indicating that this modality of treatment is a safe and effective noninvasive alternative for patients with cervical or lumbar axial pain and radiculopathy.

This paper deals with patient specific bone modeling from non-invasive medical images viz. CT/MRI scans of scoliosis patients. The volumetric data i.e. voxel and triangular facet triangle based models are primarily used for bio-modeling and visualization, which requires huge memory space. On the other side, recent advances in CAD technology facilitate design, prototyping and manufacturing of any object having freeform surfaces. These CAD-based solid modeling is based on boundary representation (B-rep) techniques. Image Processing techniques are proposed to extract point cloud data from stalk of CT scan images. Estimated Point Cloud data is preprocessed and further used for water tight surface model. These patient specific bone models are more accurate, reliable and editable for implant design, trajectory path planning, etc. in robotic surgeries.

Based on the concept of minimally invasive spinal surgery, the retroperitoneal lateral transpsoas access was developed to approach the lumbar spine in a less invasive way. This technique allows access to the intervertebral disc laterally through the fibers of the psoas muscle. This approach is reported to offer adequate disc exposure, with the benefit of reduced iatrogenic injury to abdominal great vessels, sympathetic plexus (reducing incidence of retrograde ejaculation), and neural structures.

Here we minutely pass through the lateral interbody fusion technique, illustrate and highlight some hot points in the literature, while presenting clinical and radiological results and complications inherent to the technique.

Similarly to other minimally invasive approaches, learning curve consist a real barrier to accomplish surgery objectives. So, complete knowledge of the steps and tricks are primordial to perform and evolve this procedure. Patient positioning regards to a critical point of the surgery, when truly perpendicular way to the level has to be set. Safe crossing of the psoas muscle is assured with intraoperative use of EMG, avoiding lumbar plexus and direct neural damage. Ipsilateral and contralateral annulus release provides cortical bone support to the interbody cage at apophyseal ring to prevent cage subsidence.

The use of the lateral access has become popular and usual throughout the orthopedic and neurosurgery practice. However, as every incoming technology and technique, the users of it have to be attentive to its benefits and pitfalls.

Up to date the seasoned spine surgeon has many options for the treatment of Cervical Radiculopathy that range from muscle and motion preserving procedures to the well-known Anterior Cervical Discectomy and Fusion and the Anterior Cervical Disk Replacement surgeries. We wish to present a brief review of the literature to address two minimally invasive and motion preserving techniques known as, Cervical Transcorporeal Tunnel Approach and Percutaneous Endoscopic Cervical Discectomy, respectively.

Introduction: There is no published account of the reliability of the percussion technology on human participants. Our goal was to measure the reliability of the instrument’s analysis protocol on an inert substance and on human participants with expert and novice evaluators.

Method: 15 participants were evaluated by six evaluators, three experienced and three novices.

Results: No participants were excluded from the analysis, based on the NDI, ODI and BMI. Even if the global result from the durometer testing were surprising in their range, the effect size score for the pre and post value on the durometer indicate very good reliability.

Conclusion: The intra-evaluator reliability is very good when testing on the durometer but less predominant when evaluating the participant. In addition a novice chiropractor can use the instrument with a certain degree of ability that will develop over time if he uses this technology on a regular basis.

Context: A 44-year old man with a history of a chronic T12 AIS C spinal cord injury (SCI) presented with a six month history of left chest wall neuropathic pain and upper extremity paresthesias.

Findings: Assessment demonstrated a mixed picture of upper extremity and chest wall paresthesias associated with severe neuropathic pain well above the level of his original injury. MRI of cervical spine and thorax revealed the presence of cervical canal stenosis and a soft tissue tumor at the level of the ninth left intercostal space. Surgical resection of the tumor revealed an encapsulating nerve sheath tumor diagnosed by pathology as a rare peripheral benign schwannoma or neurilemoma.

Conclusion: This unreported cause of neuropathic pain in a person with a chronic spinal cord injury is discussed within the context of the importance of thorough history and physical exam when evaluating individuals with previous spinal cord injury presenting with new neuropathic pain.

Cranio-spinal junction tumors are usually approached through posterior, postero-lateral and far lateral approaches but, in case of prevalently anterior extension, with posterior and postero-lateral displacement of brainstem, anterior transoral approach should be considered to achieve a satisfactory tumor removal. Anterior transoral approach allows a direct exposition of the tumor without necessity of nervous/vascular structures manipulation. Postoperative instability is not frequent, and usually posterior stabilization is rarely required. Although transoral approach allows removing only the median part of the tumor’s and in few cases radical removal can be performed, it presents an extremely low rate of new neurological deficit and a rapid resumption of vital activities. Postoperative tumor remnant can be treated, in our experience, with hypofractionated stereotactic radiotherapy with very satisfactory results concerning tumor regrow and recurrence. We believe that in the modern era its capital to deal with this extremely challenging tumor’s with a different goal: to achieve the maximal clinical result, not the maximal surgical resection at all costs.

Background: Early diagnosis of multiple sclerosis (MS) can lead to preventive treatment and a favorable prognosis. Cervical spinal cord matter that appears normal on conventional MR images may be detected as abnormal using advanced MRI techniques.

Objective: To pinpoint values and cervical spine locations in Diffusion Tensor Imaging (DTI) which best differentiate relapsing-remitting MS from healthy cases.

Methods: 10 relapsing-remitting MS and 8 healthy control patients underwent DTI of the cervical spine. DTI values were measured in anterior, lateral and posterior cord locations.

Results: Differences in values per location show statistical significance among all areas of the cord in both Normal Appearing White Matter (NAWM) and control groups. We derived an ADC cut-off value of 0.8 mm2/sec and λ2 value of 0.8 mm2/sec for optimal differentiation between NAWM and control. Using these cut-off metrics, values above 0.8 for Receiver Operating Characteristics (ROC) (area under curve) may be considered ‘good’ tests for pathology. ROC analysis showed that the optimal differentiation between NAWM of MS patients versus healthy controls was seen in the anterior area of the cervical cord. Sensitivity and specificity for λ2 and ADC are 85.7 & 75.0 and 85.7 & 75.0 respectively.

Conclusion: DTI can detect early changes in relapsing-remitting MS with the anterior area of the cervical spine being the most representative of disease processes. Diagnostic cut-off values should be considered.

The lumbar lordosis is essential to the human spine, as it enhances biomechanical strength and facilitates the unique upright posture of the human species. On average, 90% of the lumbar curve is attributed to the wedging of the discs, emphasizing the important contribution of them in maintaining lumbar lordosis.

Study background: Fibula strut grafts alone during anterior cervical corpectomies have some inherent vulnerability. In contrast PEEK (Polyetheretherketone) cages are more stable but need separate graft material for interbody fusion. The opportunity therefore exists to combine the positive attributes of a fibula strut graft and a PEEK interbody cage for corpectomy. The authors aim to illustrate the use of stacking multiple PEEK cages around a fibula strut graft for cervical corpectomy.

Methods: We present two illustrative cases of the technique of stacking three PEEK cages around a fibula strut graft (group 1). Cases were compared to cohort of 15 patients (group 2) with 3 level anterior cervical discectomy and fusion (ACDF).

Results: Average age and BMI for group 1 was 52 years and 36.9 kg/m2 compared to group 2 average age 59 years and BMI 25 kg/m2, p=0.53 and 0.21 respectively. Mean preop VAS neck score in group 1 of 8.5 compared to group 2 of 6.5, p=0.08. Preop NDI in group 1 of 52 compared to group 2 of 43.4, p=0.355. There was no statistical difference in post op outcomes at 6, 12 and 24 months, p>0.05. There was no evidence of construct failure, subsidence, or focal kyphosis in either group which was demonstrated on CT radiograph.

Conclusion: We have illustrated technique of combining the strength of a fibula strut graft for achieving fusion and PEEK cages for stability and favourable modulus of elasticity of that the vertebrae. The assessment of outcome scores demonstrated similar efficacy of treatment. There were no reported major complications in either group. Further application of this approach is the next steps to establish this technique’s efficacy.

Study design: A case report of Spinal myoclonus.

Objectives: To illustrate an unusual case of spinal myoclonus and its management. Setting: Changi General Hospital, Singapore.

Case report: A 48 year old male was admitted with minor trauma to his lower back for which he needed epidural analgesia. He later developed focal myoclonus of the left lower limb. He was subsequently investigated and treated with a combination of valproate and clonazepam and responded well.

Conclusion: There are various known predisposing factors for the development of spinal myoclonus, which can be challenging to diagnose and treat. Clonazepam with or without sodium valproate can be used as first line agents. Some patients may require more than 2 agents for controlling the movements.

Background context: Alternatives to access the anterior portion of the thoracic spine include thoracotomy, thoracoscopy, and transpedicular approaches. These techniques have proven to be either extremely traumatic or to be technically difficult. Consequently, these approaches are not routinely used. The development of new monitoring systems, instruments, and implants allow conventional anterior thoracic surgery to be accomplished through a minimally disruptive way. The extreme lateral interbody fusion (XLIF) is one of these techniques.

Purpose: To describe a new surgical approach to the anterior thoracic spine.

Study Desing/Setting: Literature overview and case report utilizing the lateral approach to access the anterior thoracic spine.

Methods: The lateral access surgery was first developed to approach the lumbar spine. Here we present our experience using this technique to access the thoracic spine in a minimally invasive fashion.

Results: This minimally disruptive spine procedure allowed an adequate approach to the thoracic discs, with less soft tissue aggression and intra-operative bleeding, shorter operation time and hospital stay, lower postoperative pain and earlier return to work. Therefore, the potential complications with an anterior open approach were avoided, and the procedures were performed through a single, 5-6 cm incision.

Conclusion: The modification of the XLIF technique for thoracic spine is a safe and effective procedure to achieve fusion and indirect decompress the neural structures. This minimal invasive procedure allows through a single small incision the treatment of different conditions of the thoracic spine without the need of posterior supplementation and huge incisions, avoiding open approach complications and maximizing results due to less tissue trauma and adequate exposure of the thoracic discs.

Purpose: The aim of the present study was to assess the quality of life of patients who are candidates for spine surgery using a quality of life measure adjusted according to age and sex.

Methods: The SF-36 health questionnaire was administered consecutively to patients admitted for spine surgery. They were classified according to their clinical status: low back pain, lumbar radiculopathy, neurogenic claudication, cervical radiculopathy and cervical myelopathy. Associated morbidities were registered retrospectively using the Charlson comorbidity index. Bivariate and multivariate analyses were performed to compare the groups with each other, with the general average population and with the average population adjusted by age and sex using standardized T values.

Results: 284 patients with an average age of 49.6 years (SD=12.9) were assessed. Patients awaiting lumbar spine surgery are those who showed the worst results on both the physical and mental scales. Patients with radicular pain only showed worse results than patients with low back pain on the bodily pain scale. These results were not influenced by the associated co-morbidities.

Conclusions: The use of the SF-36 scores through standardized and age- and sex-adjusted T values provides a better appreciation of the differences between various diseases. Patients awaiting lumbar spine surgery are associated with a poorer quality of life than patients awaiting cervical spine surgery. Radicular pain in patients with lumbar pathology is only associated with a worsening on the bodily pain scale.

Back school therapy is a kind of patient education to teach him to how to help him and take active part in the management of the back pain. This is a group therapy of education, flexibility, strength, coordination and endurance training to prevent repetitive micro-trauma to the spinal structures responsible for pain and degeneration. The purpose of back school is not only to create confidence in the patient to cope with his back troubles but also to avoid excess therapy and to decrease the expenses both for the patient and for the society. It is the endeavour of many people which gave birth to the present form of back school concept and design which has not only refined many lives but added one important dimension in the management of low back pain.

Purpose: The aim of this study was to provide evidence of the prevalence and consequences of non-specific low back pain (LBP) in a sample of secondary school students from the Valencian Community, Spain.

Methods: This is a cross-sectional. The sample consisted of a total of 1500 adolescents aged between 12 to 18 years old (mean age=15.18, SD 1.446). Self-reported questionnaires were used to record LBP in health adolescents.

Results: The lifetime prevalence of LBP was 44.5% (n=664). The girls showed a higher percentage of lifetime prevalence of LBP (50.3%, n=362) than boys (38.9%, n=298), with statistically significant differences (χ2=19.863; P=0.000). Lifetime episodes of LBP showed a higher prevalence increasing age (χ2=32.458; P=0.000). Students smokers showed a significant association to suffer lifetime prevalence of LBP (χ2=11.461; P=0.001). The 12 months period prevalence of LBP was 76.1% (n=559). The one week period prevalence of LPB was 28.2% (n=205). The 14.2% (n=104) of students missed school one occasion because LBP. A 16.2% (n=117) of students suffer lower back problems caused by physical education classes.

Conclusions: There are a large number of adolescents suffering back problems. Health status in adolescents back can affect your quality of daily life. School-based longitudinal intervention programs are required on back care.

Background context: “Occult” thoracic spinal stenosis refers to the lack of the typical manifestations, it easily lead to clinical misdiagnosis and missed diagnosis. No previous case of “Occult” thoracic spinal stenosis with tuberculosis in L5/S1 has been reported.

Purpose: To highlight the exactly diagnosis of occult thoracic spinal stenosis accompanying lumbar disease.

Study design: This is a case report of “Occult” thoracic spinal stenosis with tuberculosis in L5/S1.

Methods: Clinical examination, magnetic resonance imaging, CT and surgical resection.

Results: After thoracic surgery, low back pain and leg pain of the patient relieved markedly and anti-tuberculosis medications were continued for lumber pathology. On 12 months follow-up, her JOA score increased from 9 preoperatively to 10 postoperatively. Neurological function recovery rate was 100%.

Conclusions: The “Occult” thoracic spinal stenosis can lead only lower motor neuron dysfunction; more attention should be given, especially accompanying lumbar disease.

Introduction: Lumbar stenosis is a major cause of lower back pain and functional disability especially in elderly. Major symptoms are low back pain and radicular claudication. Medical therapeutic options include painkillers, NSAIDS, Steroids, antiepileptic drugs and epidural infiltrations. Surgery is indicated when medical treatment fails. The objective of our study is to evaluate the efficacy of lumbar epidural infiltrations of corticosteroids in LSS.

Materials and methods: This prospective study was conducted on 60 patients presenting to our institution from January 2013 to January 2014. Isolated LSS was suspected after physical examination and was confirmed by a lumbar MRI. All our patients were treated by NSAIDS and antiepileptic drugs (Gabapentin 800 mg daily) for 6 weeks. 7 patients had laminectomy during the year of follow-up and were excluded from the statistical analysis; 53 patients were followed-up for 1 year (88.3%). The treatment protocol by infiltrations consisted of three interlaminar epidural infiltrations under fluoroscopic guidance of 80 mg Methylprednisolone and 100 mg of Lidocaine administered at 2 weeks interval at the level of the stenosis. Gabapentin 800 mg per day (400 mg BID) was added for 1 month. Evaluation of clinical results was done using 4 scales: the Visual Numerical Scale (VNS), Roland5 Point Scale (R5PS), Walking distance (WD) and the patient satisfaction scale (PSS).

Results: The Mean VNS was significantly ameliorated from (7.27 (4-10) at D0 to, 3, 13 at 2 weeks follow-up and, 3.45 (1 to 6) at 1 year (p<0.0001). The Mean R5PS was also significantly ameliorated. At D0 the score was 4.08 (3 to 5), at D15 1.85 (0 to 3), at 1 y 1.83 (1 to 4) (p<0.0001). Mean WD was significantly increased from 1.85 at D0 to 3.34 at D15 and 3.34 at 1 (p<0.0001). The study of 50% amelioration of VNS, of R5PS and of WD were all significant with a p value <0.0001. The PSS showed very good and good results in 65% of the patients and average and bad results in 35%.

Discussion: Based on our results, epidural corticosteroid infiltrations are efficient in the treatment of LSS. Our study correlates with many results in the literature although few studies were conducted exclusively on LSS. We attributed the efficacy of steroids in LSS to their probable ability to block the nociceptive pathways and to their effect on prostaglandins.

Conclusion: As an alternative for medical treatment, epidural infiltrations of corticosteroids could be a promising option before indicating surgery in LSS, or if surgery is contraindicated.