Diário da Espinha

The objective of this prospective randomized study was to compare the immediate and long-term clinico-radiological outcome of short segment open versus percutaneous pedicle screw fixation with indirect decompression achieved via distracting the posterior pedicle screw construct in management of single level acute thoracolumbar and lumbar burst fracture (TLBF) with minimal neurological deficit in adults.

All patients had burst fracture of less than 72 hours and loss of vertebral body height ≥50%, angulation ≥30⁰, kyphotic deformity ≥20⁰, canal compromise ≥40⁰, failure of at least 2 columns, with intact pedicle and minimum neurological deficit [Grades C and D; according to American Spinal Injury Association (ASIA) grading system.

Fractures treated either via short segment open pedicle screw fixation with indirect decompression (OPSFD) or short segment percutaneous pedicle screw fixation with indirect decompression (PPSFD) techniques, were corrected using a titanium monoaxial pedicle screw construct. Post-operatively all patients were advice brace and subjected for regular physiotherapy and followed up to 1 years. Data regarding peri-operative events, clinico-radiological outcome, duration of hospital stay and period taken to return to work was collected and analysed.

Those patients treated with PPSFD techniques demonstrated superior outcomes compared to conventional OPSFD techniques, with significantly reduced operative time and blood loss during surgery, hospital stay, better neurological outcomes and early return to work. However, there was no significant difference in view of radiological improvement between the two surgical techniques.

We would recommend PPSFD techniques as the best way of treating acute single level TLBF with minimum neurological deficit in adults.

Background: Occipital cervical fixation (OCF) is an important and difficult technic and has certain risks due to its relation with adjacent special anatomic features. One of specific areas to perform screw fixation and to prevent technical failures is the thickness of the occipital bone which require detailed morphological anatomical knowledge. To our knowledge, no published study has provided thicknesses of occiput in African Continent.

Objective: The aim of this study was to evaluate occipital bony thickness in Moroccan population in order to determine the variability of the occipital bone thickness and to assess the feasibility and safety of hook and screw placement in these patients.

Patients and methods: We evaluated occipital bony thickness using computed tomography (CT) imaging in 100 patients (30 females and 70 males; age range, 18–70; mean, 36.2 ± 11.9 years). Axial CT cutting was made at 1.25 mm intervals.

CT measurements were performed on the bone windows at two levels starting at 1 cm under the external occipital protuberance (EOP) and 1 cm inferior to this level. Three measurements were performed both sides at 1 cm interval. We acquired 14 values.

Results: The mean thickness of occipital bones varied between 10.003 to 13.964 mm in the left and 10.747 to 13.715 mm in the right (± 2.8) and between 9.845 to 11.478 mm in the left and 9.903 to 11.371 in the right (± 2.5) at 1 cm and 2 cm above EOP respectively. The thickest point was in the midline with 17.366 mm and 12.579 mm at 1 cm and 2 cm above EOP respectively,

Intra-individual and inter-individual discrepancies are found between left and right sides (p<0.05) but not between age and sex at two levels in our adult patients.

Conclusion: Our radiological study findings suggest that there were significant differences between individuals and ethnics. The preoperative CT scans of occipital bony thickness as the pedicle size should be thoroughly analysed of patients undergoing occipital cervical fixation. These are essential for successful intraoperative fusion and to further decrease the risk of occipito-cervical fusion.

Background: Several studies have examined the benefits of ankle foot orthosis (AFO) in patients with hemiparesis, but little is known about their effects in patients with peripheral nerve palsy. The purpose of this study was to compare the effects of AFO on functional ambulation in patients with hemiplegia and unilateral lower-extremity palsy. Subjects and methods: This study design was Case control study in rehabilitation units of five hospitals in Japan. The study subjects were 50 normal subjects (control), 49 patients with post-stroke hemiparesis (PSH), and 13 with lower extremity palsy (LEP) due to peripheral nerve palsy. Functional ambulation was assessed with AFO and without AFO by 10-meter maximum walking speed (10 MMWS) and the distance walked in a 6-minute walking test (6 MWT). Functional balance was assessed using the Berg balance scale. Results: The 10 MMWS test showed significantly lower walking speed in PSH and LEP without AFO compared with the control group, and that the speed was faster in the two patient groups with AFO than without AFO. The distance walked during the 6 MWT was significantly shorter in PSH and LEP than the control, but it increased significantly in both groups after wearing the AFO. Furthermore, the significant difference between the control and LEP groups disappeared after wearing the AFO. The Berg balance scale was significantly lower in PSH and LEP groups compared with the control group, but improved significantly with AFO. Conclusion: The results suggest that AFO is beneficial for patients with PSH and those with LEP through improvement of walking distance, walking speed, and functional balance. Many physicians and technicians often avoid the use AFO. However, AFO improved not only walking ability but also functional balance in both groups of patients. Physicians and technicians are encouraged to consider the use of AFO in LEP.

Gestational trophoblastic disease (GTD) is a spectrum of cellular proliferations originating from placental villous trophoblasts. Spinal metastasis of choriocarcinoma is rare, especially after a normal pregnancy. In this paper, we present a rare case of metastatic choriocarcinoma to the lumbar spine as the first manifestation of disease. The patient underwent surgery, and a dark red hemorrhagic, epidural mass was totally removed. Histopathologic studies on the mass and specimen from the episiotomy site led to a diagnosis of metastatic choriocarcinoma. Surgical resection has a limited role in metastatic choriocarcinoma, but it should be considered if rapid-onset neurological deficit appears due to spinal cord compression.

Spinal chondromas are rare tumors, usually classified as periosteal chondroma or enchondroma, according to their origin. We describe a rare case of cervical spine meningeal chondroma in a 79-year-old man, who presented with right-sided weakness and lower-extremity dysesthesia. Magnetic resonance imaging revealed a tumor at the C1-C2 level. We suspected it to be meningioma and performed tumor excision. However, the final pathology diagnosed it as a meningeal chondroma. After surgery, his symptoms gradually improved. This case shows that, although uncommon, spinal chondromas may arise from the meninges. A good outcome is expected after total resection of the tumor.

Objectives: To evaluate the feasibility, sensitivity and specificity of IOM for IDEM and ED metastatic spinal tumours, and to assess usefulness of SSEP for patients in whom MEP was not measurable.

Methods and materials: One hundred and one consecutive patients with IDEM and ED metastatic spinal tumours at the cord level (C1 to L1) received surgery under SSEP and/or MEP was included. Feasibility of IOM was defined to be negative in case of no measurable MEP or SSEP under general anaesthesia after confirmation of reversal of neuromuscular block. More than 50% change of MEP or SSEP amplitude and more than 10% delay of SSEP latency were evaluated as positive signs of IOM change.

Results: MEP was measurable in 74 out of 101 trials, thus feasibility is 73%. Patient with normal motor power showed higher feasibility than those with motor power 3 or less. (93% vs. 39%) Among 74 patients with measurable MEP, 19 patients showed positive MEP change and 14 patients got worse of their motor power postoperatively.

Objectives: Cervical inter-laminar injections at C7-T1 have been routinely performed for many years as an effective means of palliating neck pain. The purpose of this study is to measure the extent of contrast spread following C7-T1 cervical inter-laminar epidural steroid injection (CIESI), and to correlate the upper extent of contrast spread with degree of cervical spinal stenosis.

Methods: We retrospectively identified 41 consecutive patients over a six months’ time frame fulfilling the following inclusion criteria: (1) Had image guided CIESI at C7-T1, (2) Had PA and oblique epidurogram pre and post procedure, (3) Had procedural notes indicating the amounts injected and (4) Had an antecedent MRI. The epidurograms were reviewed for their extent of injectate spread. MRI studies were evaluated separately and blinded to the epidurograms. For each level the degree of cervical spine narrowing was noted. We correlated the extent of contrast spread with the level of maximal cervical narrowing.

Results: Maximal contrast spread was up to the skull base and down to T4-T5; minimal extent was C6-C7 to T2. We found statistically significant correlation (2-tailed Pearson correlation r= 0.867, p<0.001) between the upper-most extent of contrast spread and the lowest level of significant central canal stenosis according to pre-procedure MRI.

Conclusion: Following CIESI injectate will spread up as far as the cranio-cervical junction or near the lowest level where there is moderate degenerative central stenosis.

Electro acupuncture has been widely used to treat demyelinating diseases, such as multiple sclerosis (MS), acute haemorrhagic leukoencephalitis (AHLE), compressed spinal cord injury (CSCI). However, the protective effect of electro acupuncture (EA) on neural myelin sheaths remains controversy attributed to the dimness of its therapeutic mechanism. In this study, we tried to explore the protective mechanism of EA in a custom-designed model of CSCI. Zusanli (ST36) and Huantiao (GB30) acupoints were stimulated by EA. The motor functions were monitored by Basso, Beattie and Bresnahanloco motor rating scale. The pathological changes in axonal myelinated fibers were estimated by luxol fast blue (LFB) and transmission electron microscopy (TEM). Epidermal growth factor receptor (EGFR), oligodendrocyte transcription factor 2 (Olig2), caspase-3 and phosphorylated Akt1 (pAkt1) were detected by immunofluorescence and western blot assays. After 7-day treatment of EA, the expression of p-EGFR, pAkt1 and Olig2 was significantly up-regulated which was consistent with changes of locomotor skill and ultrastructure of myelin sheath. By contrast, the expression of active caspase-3 was obviously down-regulated. Our results indicated that the protective effect of EA on neural myelin sheaths might be mediated via activation of EGFR after CSCI.

Introduction: Thoracolumbar fracture dislocation is a trauma of high energy which generally is treated with longsegment stabilization. Anterior spine exposure may be used alone or in combination with a posterior midline approach in a staged or sequential fashion. In this study, we report the 7-years’ experience of the anterior approach to the thoracolumbar spine fracture dislocations at a single institution.

Patients and methods: Over a 7-year period (2007–2014), 15 patients (9 males and 7 females) with a mean age of 41.1 years ranging between 25 and 61 years, were operated on using an anterior approach at our institution. All patients were submitted to standard anterior spine surgery, thoracotomy (in 9 patients), thoracophrenolumbotomy (in 3 patients) and lumbotomy (in 2 patients), one patient required left thoracotomy alone. In all cases, we used heavy duty plate fixation and autologous bone (rib or vertebral bone) inside the cylinder. The criteria for surgical intervention were: partial or progressive neurologic deficit, kyphotic angulation ≥25º at one segment, progressive kyphosis, lesion with a loss of 50% of vertebral height with angulation and a residual canal diameter 50% of normal. All patients had a failure of the anterior and middle columns as viewed on a CT scan or MRI if available.

Results: The average duration of follow-up was 24 months. One patient died during the follow-up period. Concerning ethiology, there were two types of vertebral body lesions, which were traumatic and infectious. There were also 12 patients with traumatic lesions. The mean age was 41.1 years (range 25-61). There were 10 males and 5 female patients. Six patients had a burst fracture (type A3), with compression failure of the anterior and middle columns of the spine (level T12 in 3, level T11 in 1, level L1 in 2,). All patients with traumatic lesions underwent singlestage anterior fixation by heavy duty conventional plate and screw and the gap filled with autograft (rib and morselized vertebral bone). Three patients were operated because of the thoracic and lumbar tuberculous spondylitis and Hydatid cyst (one patient T9, one at T10, one T5).

Discussion: Initial reports of the anterior thororacotomic approach to the thoracic spine were related to Pott’s disease, spine surgery innovations and aging with a more active population resulting in a progressive increase in spine instrumentation. The main indication for anterior decompression is an incomplete neurological injury with radiographically demonstrated neural compression by bone or disk fragments. The anterior surgical treatment allows direct decompression of the neural elements and correction of the deformity.

Conclusion: The anterior approaches provide excellent exposure of the relevant bony anatomy and can be used to secure anterior column support with bony fusion. Anterior spinal fusion surgery is a safe procedure and can be used with confidence when the nature of a patient’s spinal disorder dictates its use.

Acute Transverse myelitis during pregnancy is rare and is life-threatening for parturient women and their pregnancies. We report a case of young Senegalese parturient woman.

This is a patient old 20 years, 1 pregnancy, 1 parity, with a history of asthma and gestational hypertension, who presented motor deficit of 04 members with progressive installation on twenty days during a pregnancy to term (9 months) from where achieving a scheduled caesarean during labour that allowed the extraction of a girl with no abnormalities. Then the patient was sent to our neurology’s department of Fann Hospital in Dakar where she was hospitalized for suitable care. The diagnosis of acute transverse myelitis was retained on clinical evidence of a spinal interruption syndrome confirmed by Para clinical investigations. The spinal MRI showed extensive hyper intense signal from C4 to C6. An inflammatory syndrome with CRP at 108 mg and a high CSF protein at 2.07 g/l. The patient had received corticosteroids and physical rehabilitation followed by a favourable outcome. The tetraplegia during pregnancy are rare and compromise progression of the latter hence the need to look for spinal suffering signs to objectify etiology which appropriate management depends on.