Diário da Espinha

Background context: For cervical disc replacements to be comparable to the gold standard of cervical discectomy and fusion (ACDF), proper cervical alignment after disc replacement is imperative in preventing accelerated facet degeneration, excessive wear debris and axial neck pain.

Purpose: This study evaluated whether the Synergy Disc (artificial cervical disc replacement) could provide preservation and/or restoration of cervical alignment while normalizing kinematics and providing acceptable clinical outcomes.

Study design/setting: Prospective clinical study for an alignment correcting cervical disc replacement. Patient sample: The Synergy group was comprised of 37 consecutive patients (42 implants) with a minimum follow-up of 1 year (range 12-26 months) on 34 patients (39 implants).

Outcome measures: Quantitative motion analysis (QMA) software was used for kinematic outcome parameters: range of motion (ROM), horizontal translation, center of rotation (COR-X, Y), disc height (DH), disc and shell angle (DA and SA, respectively). Neck Disability Index (NDI) and Visual Analog Scale (VAS) were also assessed.

Methods: The Synergy Disc patients underwent 204 lateral cervical radiographs (34 patients – 39 implants). Static and dynamic radiological assessments were performed prior to surgery and at last follow-up (mean 18 months, range 12-26 months).

Results: At 18 months post-surgery, the average SA of the Synergy Disc was 6 ± 3° of lordosis. Pre-operative ROM, translation and COR X did not change significantly post-surgery.

Conclusions: The Synergy Disc provided segmental lordosis at the surgical level, while maintaining pre-operative ROM, translation and COR X. There was a superior shift of COR Y following insertion of the device. The lordosis of 6 ± 3° provided by the Synergy Disc was comparable to the lordotic correction provided by an ACDF

Introduction: Musculoskeletal disorders and back pain can occur as a result of irregular, asymmetric movement patterns and postures due to muscular weakness, spasticity or imbalance in Multiple Sclerosis (MS).

The aim was to investigate musculoskeletal disorders and risk factors of low back pain in MS patients.

Methods: In this study, patients followed in our large MS centre with confirmed MS with an EDSS score between 4 to 7 were selected. Data of MS history, pain, musculoskeletal disorders, muscle strength and spasticity in lower limbs were collected.

Results: 190 patients were included. The mean age of the patients was 54.9 ± 9.2 years and 32.1% participants were man. The mean disease duration was 19.3 ± 9.9 years, and the median EDSS score was 6. 48.9% of patients had a secondary progressive form and 27.4% had a relapse remitting form. The most common musculoskeletal disorders were: knee osteoarthritis (7.9%), claw toe (6.8%) and genu recurvatum (6.3%). The prevalence of low back pain was 41.6% and was higher in patients with a progressive form (secondary: OR=2.96 (p=0,0079) and primitive OR=2.63; p=0.0398)) or a visual dysfunction at EDSS score (OR=1.41 (p=0.0124)) and decreased in male patients (OR= 0.31 (p=0.0014)).

Conclusions: A progressive form of MS and visual dysfunction increased the risk of low back pain in these patients.

We report a 50-year-old lady who is well known to have cervical spondylotic myelopathy presented to the emergency department with worsening neck pain, numbness and weakness in the hands initially thought to be secondary to progressive cervical myelopathy. However, her symptoms rapidly progressed to flaccid areflexic quadriparesis and respiratory difficulty within few days. Electrophysiological studies and cerebrospinal fluid analysis were consistent with an acquired demyelinating polyradiculoneuropathy. She improved after immunotherapy with intravenous immunoglobulin. Considering this is a rare co-occurrence, neurologists and neurosurgeons should be aware of the coincidence of Guillain-Barré syndrome in a patient who has compressive spondylotic myelopathy to avoid unwanted devastated consequences.

Purpose: This study was conducted to assess short- to mid-range clinical outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for patients with severe low back pain caused by intervertebral disc degeneration showing Modic changes on MRI.

Methods: Thirty-five consecutive patients (mean age: 48.6 years) who underwent single-level MIS-TLIF to treat severe low back pain with Modic changes on MRI were included. Diagnoses were based on temporary pain relief after an intradiscal anesthetic injection, selective nerve blocking, or both. The mean follow-up period was 18 months. Japanese Orthopaedic Association (JOA) scores (29 possible points), JOA-score recovery rates (RR), Visual Analog Pain Scale (VAS) scores for low back pain, and the Oswestry Disability Index (ODI) were evaluated.

Results: The average JOA score improved significantly, from 14.8 ± 3.6 preoperatively to 26.9 ± 1.6 at the final follow-up (P < 0.01). The average JOA-score RR was 84.8 ± 11.7%. Significant improvements were obtained in the average VAS scores for low back pain (preoperative, 7.8 ± 1.9; final follow-up, 1.5 ± 0.7; P < 0.01) and ODI (preoperative, 57.9 ± 16.1; final follow-up, 13.0 ± 8.8; P < 0.01). Modic type 1 changes were observed in 12 patients, and type 2 changes in 23 patients. The JOA-score RR did not differ significantly between patients with Modic type 1 and type 2 (85.7% and 84.1%, respectively).

Conclusions: MIS-TLIF, which is less damaging to the paraspinal muscles than conventional approaches, is a reasonable surgical option for lumbar disc lesion with Modic type 1 and 2 changes.

Spinal dural arteriovenous fistulas are a rare and underdiagnosed pathology. Rapid diagnosis and treatment are, however, major determining factors for the outcome of the disease. The spontaneous course of this pathology can result in a substantial degree of morbidity that may be irreversible. Proper interpretation of the MRI imaging, and particularly the medullar angiography, allow for an appropriate level of therapeutic intervention. In our center, surgery is recommended in case of embolization contraindication or failure or in patients with recurrence of the fistula following embolization.

For recurrent disc hernia, the aim is to eliminate factors, which lead to pain, achieve decompression with injuring underlying neural tissue, and to stabilize the site, if instability is observed, and finally, to early mobilize the patient.

For cases with recurrent disc hernia, patients can tolerate the condition, since enlargement of disc hernia is slow. Total laminectomy and bilateral discectomy will ensure neurological deficit-free postoperative course, if recurrent disc hernia is located at central zone and the size is giant. Moreover, one should carefully avoid tear of dura, when fibrotic tissue is debrided and giant disc hernia is excised.

Objective: Sacrococcygeal epidural (SE) injection is indicated for the relief of lumbo sciatic pain, but is not regularly performed in daily practice. The objective of this study was to evaluate the efficacy and tolerance of SE injections.

Design: Retrospective study with a questionnaire sent to patients who underwent the procedure between January 2007 and September 2012.

Results: A total of 558 patients (202 men: 36%) underwent the procedure. 57 were excluded from the study (28 for an incorrect postal address, 15 because they had died, 7 because no injection was administered, 5 for cognitive impairment and 2 who refused to respond).

Among the 201 respondents (201/501: 40.1%), 53% (n=107) reported an improvement in pain, 64% in less than 5 days after the procedure (68/107), with pain relief lasting for over 6 months in 63% (65/104). 87 patients reported an improvement in walking (87/192: 45%) and in quality of life. Considering that all non-responders had an injection failure, we obtained 19% of success in our sample of 558 patients. The injection was well tolerated by 85% of patients (162/190). 37% of patients (72/194) experienced pain during the procedure, with a mean VAS pain score of 6.8 ± 2.5 mm. 53% (102/191) would agree to have a new injection.

Conclusion: Sacrococcygeal epidural injection provided pain relief in more than half of patients and the procedure was well tolerated. This procedure merits a more prominent place in the management of symptomatic lumbar canal stenosis.

Introduction: The purpose of this work is to report a rare variation of lumbar disc herniation (LDH) not previously reported in the literature.

Case presentation: We describe this single case of young Caucasian male (23 years) afflicted with a double migrated LDH and we examine the problems associated both with the diagnostic aspects both with the therapeutic approach. According to our knowledge, no cases of simultaneous cranial and caudal migration of two adjacent LDH, with the consequent compression of the same spinal root is reported in literature. Specifically, the caudal migration concerned the fragment of the herniation of the level above, while the cranial migration affected the herniation of the level below. Thus these two fragments were placed towards one another, compressing the same spinal root. This atypical pattern of discs-root conflict was defined “kissing herniations”.

Conclusions: Although LDH generally does not provide for the migration of a fragment to the levels above or below, in 10% of the cases this might happen, but it is a single one, ordinarily. Infact a case of a double and convergent migration of two different fragments have never been reported before in the literature. The analysis of this case can help to better understand how a degenerative disc disease can evolve. Especially the analysis of this case allows understanding how the stresses of the discs can focus in some defined areas of the vertebral bodies and thus they can determine the suffering of the discs themselves. This type of case has an impact on various disciplines, including: orthopedics, neurosurgery, spine surgery, rheumatology, physiatry, neurology, general medicine.

Extraforaminal lumbar disc herniations (ELDHs) are a relatively uncommon cause of lumbar radiculopathy. In the patients suffering this kind of disc herniation, severe intractable radiculopathy due to dorsal root ganglion compression usually leads to surgery. However, although the value of conservative strategy for spontaneous resolution of intracanal lumbar sequestrated disc herniation is a well-known scenario, but it is not verified in extraforaminal disc herniation.
Herein, a 53-year-old man with severe left -sided femoral radiculopathy at the vicinity of L3 which was associated with decreased knee jerk is presented. MRI revealed a huge extraforaminal disc herniation at L3-L4 level on the right side. Surgery was recommended, but since the patient was reluctant to undergo surgery, a period of conservative treatment, with transforaminal block, combined with NSAID’s prescription result in dramatic pain amelioration. Control MRI after 3 months showed relative hyperintensity of the corresponding disc. However, MRI at 9- months follow -up where the patient was completely pain free, revealed disappearance of the offending disc. To our knowledge, the scenario of spontaneous resolution of extraforaminal disc herniation has not been reported previously in the literature.

Background: Traumatic occipital-cervical dislocation (OCD) in children and adolescents is a rare and serious injury, which generally leads to death. For those who survive, there are usually severe and permanent neurological deficits.

Purpose: The purpose of this study is to present the case of a 13-year-old boy with OCD, the treatment and results at two years follow-up.

Study design/setting: The study design includes a case report and review of the literature.

Methods: We present a case of OCD survivor, two years of follow-up care, and review of the literature regarding OCD.

Results: A 13-year-old boy was injured in a car accident in 2013. He was admitted to the emergency department with OCD and multiple trauma. After vital signs were stabilized, occipital-cervical spinal fusion was performed. He was discharged home four months after the injury in good general condition, with neurological deficits resulting from the head and spinal cord damage.

Conclusions: OCD in children and adolescents is quite rare and usually fatal. In spite of appropriate treatment (occipital-cervical fusion), the prognosis remains uncertain and at times poor due to irreversible neurological damage. Only a correct prompt diagnosis, along with immediate treatment initiation leads to survival.

Introduction: Surgical treatment for severe scoliosis has been characterized by a combined approach and gradual distraction before final arthrodesis; pedicle screws have reaffirmed the role of posterior approach.

Materials and Methods: Three female patients were treated for severe scoliosis using transient magnetic rods for internal distraction followed by magnetic rod removal and definitive PSF.

MCGR: Case A: 12-year-old female with severe thoracic scoliosis of 120°. First Stage: release (Ponte’s osteotomies), pedicle screws T3-L4 with MCGR, then daily ultrasound guided lengthening with external magnet controller for 3 weeks followed by second stage posterior arthrodesis and thoracoplasty.

Case B: 15-year-old female with thoracic kyphoscoliosis of 115°. The same technique as in case A was performed: pedicle screw instrumentation from T3 to L4.

Case C: 21-year-old female with Noonan syndrome. Thoracic kyphoscoliosis of 130°, the same technique as in case A was performed: pedicle screw instrumentation T4-L3.

Results: A. First stage: Scoliosis decreased to 75°. After the second operation it was equal to 42° with a total correction of 65%. No neurological complication.

B. First stage: Scoliosis decreased to 72°. After the second stage it was 45° with a total correction of 60%. No neurological complication.

C. First stage: Scoliosis decreased to 80° (correction of 38%). The patient showed reduced bone mineral density and developed respiratory distress: she was admitted to an Intensive Care unit. Last x-rays revealed a scoliosis and kyphosis correction in Cobb degrees equal to 59° (correction rate of 49%) and 43° (correction rate of 48%), respectively. Follow-up at two months showed scoliosis and kyphosis in Cobb degrees of 59° and 44°, respectively.

Conclusion: The MGCR is a valid alternative when the use of halo is contraindicated in the presence of myeloradicular malformations or halo traction is not well tolerated by the patient or their family. Results are comparable in terms of correction and the psychological effect of MGCR elongation is favorable. All of the data are available in literature.

Study Design: Retrospective mini case series, single centre.

Objective: To report the efficacy of growing spine distraction-based implants in the treatment of hyperkyphotic and kyphoscoliotic early-onset deformities during initial surgery and lengthening.

Background: Growth-sparing implants, such as growing rod and VEPTR-like systems, are distraction-based systems involving repetitive lengthening procedures, which mean that hyperkyphosis may be a relative contraindication in the treatment of early onset deformities. The role of growing implants in the treatment of coronal deformities is now acknowledged, but there are very few studies on the effect of both primary surgery and several lengthening procedures on sagittal balance.

Methods: Twenty paediatric patients affected with kyphoscoliosis and surgically treated with growing systems were retrospectively reviewed. Etiology was heterogeneous; there were 10 males and 10 females, aged 7 yrs on average. The dual growing rod technique was used in 9 cases, VEPTR in 11. Preoperative main thoracic scoliosis averaged 64° (range, 10° to 100°) and thoracic kyphosis 71° (60° to 90°),67° in patients with Growing Rods and 77° in those with VEPTR with a history of EOS (Early Onset Scoliosis). At Follow-up ranging from 6 months to 7 years, 31 lengthening procedures had been performed (1.9 per patient). For the purpose of this study, patients were divided into two groups: Growing-Rod Group (GR-group) and VEPTR-like-Group (VL-group); preoperative and postoperative degrees of scoliosis and kyphosis were measured, as well as final results at follow-up.

Results: A significant decrease in scoliosis and kyphosis was observed during initial surgery, then a significant loss of correction occurred during the FU period, first on coronal and then on sagittal plane, both in GR-group and in VL-group; however, in the VL-group the loss of correction in terms of kyphosis was significantly higher than in the other group. In particular, after initial surgery, in GR-group thoracic kyphosis was corrected from 67° to 44°, whereas in VLgroup from 77° to 60°. After the lengthening procedures, a loss of correction occurred: in GR-group, thoracic kyphosis increased from 44° to 50° (p<0.05), whereas in VL-group from 58° to 68°. 15 minor complications occurred in 8 patients and revision surgery was performed in 7.

Conclusion: Growing implants can be safely used in the treatment of EOS, even in the presence of hyperkyphosis. Distraction procedures inevitably led to the loss of some correction on sagittal plane which was observed at follow-up and was higher in the VL-group. In any case, the final result was mostly related to the correction of kyphosis achieved during initial surgery and in any case the loss of correction was always lower than the first correction obtained. When the cantilever maneuver is performed during initial surgery, growing rods seem to grant a better sagittal plane restoration compared to VEPTR. The complication rate turned out to be a little higher (30%) than the rate observed after general surgical treatment of EOS, thus confirming an increase in complication rate when hyperkyposis is present; the most frequently encountered complication was proximal failure.

Posterior lumbar fusion with instrumentation provides immediate stability on spine and is an effective surgical technique in deformity correction, whereas ASD remains as a mid/long term issue. In this study, we applied posterior decompression and non-fusion stabilization with SSCS to total of 21 patients (13 males and 8 females), who had undergone posterior lumbar fusion in the previous five years and then suffered ASD. The mean age was 69.4 years (range: 49 to 85) and the mean period between the primary surgery and the revision surgery was 5 years and 9 months (range: 11 months to 18 years). Site of ASD occurrence was at; upper level on 16 patients, lower level on 4 patients and upper/lower level on 1 patient. Preoperative JOA score 14.6 improved to postoperative 23.8 at the follow-up (improvement rate: 63%). ROM of the operated segments was significantly decreased from mean 8.2 to 1.7 degrees. We applied non-fusion stabilization with SSCS to salvage ASD occurred after posterior lumbar fusion with instrumentation. In case that further spinal fusion is applied to ASD, it could cause another ASD. Therefore non-fusion stabilization seems to be meaningful.