Diário da Espinha

The topical diagnosis and determination of the mechanism of pain of vertebrogenic origin remain the actual problems of medicine. This is due to the difficulty in differential diagnosis, the high incidence of occurrence, the severity of clinical manifestations of the spinal column pathology and their consequences, and the anatomical features of the structure of the vertebrae. From the clinical point of view, the solution to the problem of vertebrogenic pain involves a number of aspects: The definition of the source of pain, the establishment of its mechanisms and paths for its elimination. Thus, ultrasonography is effective for the diagnosis the degenerative-dystrophic changes in the vertebral motor segment as a potential cause for pathophysiological mechanism of back pain.

Introduction: Among the traumatic injuries of atlantoaxial joint (AAJ) in children, a rotational subluxation in the C1-C2 segment is more common. The frequency of its occurrence in children less than 10 years varies from 34% to 73%, in newborns this injury is the most frequent among all spinal injuries (upto 54%). Radiography is the most common method for diagnosing rotational subluxation of the atlas, but has a number of limitations due to poor visualization of the soft tissue structures. MRI study is difficult to organize in newborns, in addition, this method is the most expensive. Ultrasonography is a cheap method, it allows using high-frequency sensors to provide visualization of the ligamentous apparatus and the spinal cord, which is very important in severe forms of trauma. Objective: The aim of the study was to evaluate the possibilities of X-ray and ultrasound imaging methods in diagnosing the Atlanto-axial rotary subluxation (AARS).

Materials and methods: Our survey was based on 28 (45.2%) newborns (group I) and 34 (54.8%) children aged 4-6 years (group II) who were diagnosed with AARS as a result of birth and mechanical trauma, respectively. The comparative group (CG) comprised 50 children - of them 12 newborns, 15 - under the age of 1 year, 23 - at the age of 4-6 years. Everyone children were given radiography, ultrasound and only 12 (19.3%) of them - MRI. Ultrasonographically were determined the structure of the transverse ligament (TL), the distance from the edge of the odontoid process (OP) to the inner lateral masses (LM: Lateral Masses) surface on both sides. The smallest value of this distance was denoted by D1, the largest by D2. Normally the difference between D2 and D1 did not exceed 0.5 mm. The degree of asymmetry was estimated by the formula: D2-D1/D1 × 100%, and normally ranged from 7% to 15%.

Results: According to roentgenological data, in 40.9% of the newborns the ossification nucleus was in the anterior arc C1 and the width of the x-ray gap of the anterior-atlas-axial joint was 1.5-2.0 mm. The average distance between the LM at C1 level in newborns was 16.19 ± 0.78 mm, in children under 1 year of age it was 18.01 ± 1.08 mm, at the age of 4-6 years - 27.87 ± 0.98 mm. At the age of 1 to 3 years, the frontal and posterior arcs of the atlas are fused, its anterior tubercle is clearly pronounced and has the shape of an elongated oval with thickened end plates. Complete ossification of the tooth C2 and its fusion with the vertebral body occurs at the age of 4-6 years. In the lateral projection, apart from the Crucellus joint, the width of the retro-tracheal space was determined, which is 4.5 ± 2 mm at the C1-C3 level, the posterior wall of the larynx and the trachea is normally even, parallel to the vertebral bodies. Ultrasonographically the thickness of the TL averaged 1.92 ± 0.14 mm - in neonates, 2.31 ± 0.17 mm - in children under 1 year and 2.69 ± 0.24 mm in children 4-6 years. The thickness of the synovial bag (gap) between the OP and TL was normally more than 1.5 mm. Cruciform ligament (CL) on the echogram had a mediumlow echogenicity, an even contour and a thickness of 1.6 to 2.5 mm, and an average of 1.83 ± 0.17 mm in newborns, 2.14 ± 0.15 mm in children 1 year and 2.35 ± 0.21 mm - in 4-6 years. On the axial ultrasonic section, the anteriorposterior dimension of the dural sac, the spinal canal (SC) and the spinal cord was determined. The sagittal size of the SC at the C1-C2 level in a newborn was 10.04 ± 0.42 mm, up to a year of 11.23 ± 0.37 mm, at the age of 4-6 years - 14,15 ± 0.51 mm, and the size of the spinal cord was: 5.45 ± 0.26mm, 5.63 ± 0.26mm and 7.32 ± 0.42mm, respectively. Ultrasonographically, the width between LM varied from 15.4 to 18.05 mm, in children with neurological symptomatology (NS) averaged 17.3 ± 0.9 mm, and in the subgroup without NS - 16.3 ± 0.8 mm, in the comparison group (CG) - 16.2 ± 0.7 mm, without significant differences. The average value of D1 for children with NS was 4.4 ± 0.3 mm, without NS, 4.6 ± 0.4 mm, and for CG - 5.3 ± 0.4 mm. The value of D2 was significantly different (P<0.05) between the children with NS (7.6 ± 0.7mm), without NS (6.8 ± 0.5mm), and for CG (5.9 ± 0.4 mm). The D1/D2 index in the groups was 0.6 ± 0.07; 0.7 ± 0.04 and 0.9 ± 0.08, respectively. At the same time, the difference in the value of the D1/D2 index between newborns with AARS of both subgroups and healthy children had a high statistical significance (p<0.001). The degree of asymmetry of the position of OP with respect to LM in health newborns varied within the range of 6.9-15.1% and averaged 11.0 ± 4.1%. In the subgroup of children with AARS and NS, this indicator was 71.7 9.5%, without NS - 46.6 ± 8.3% (p<0.001). Moderate asymmetry in the range of 21-40% among children with NS was observed in 15.4 ± 10.4%, and without NS - in 60.0 ± 13.1% of cases (p<0.01).Expressed asymmetry over 40% among children with NS was observed in 84.6 ± 10.4%, and without NS - in 40.0 ± 13.1% of cases (p<0.01).

Conclusion: The ultrasound symptoms of the rotational subluxation of the atlas in children are: the asymmetry of the odontoid process relative to the lateral masses of more than 1 mm or 20%, the decrease in the gap between the odontoid process and the transverse ligament of less than 1 mm, the irregularity of the thickness of the transverse ligament, the asymmetry of the thickness of the pterygoid ligaments. Signs of a severe form of the rotational subluxation of the atlanta - the asymmetry of the odontoid process with respect to the lateral masses of more than 2.0 mm (or more than 60%), the D1/D2 index is less than 0.60, the absence of visualization of the gap between the odontoid process and the transverse ligament, deformation of the anterior dural space with the presence of a hyperechoic mass in it, an increase in the dimension of the posterior dural space.

Background: In recent years, an increasing number of patients with a spinal cord injury (SCI) have been reintegrating into community life and have been getting back to a more active and independent lifestyle. Consequently, rehabilitation therapies have altered, to address activity limitations that patients may experience, to increase participation in the community and to improve patients’ overall quality of life. An innovative, supportive approach to locomotor training is through use of an exoskeleton, which could be used in those patients who are unable to ambulate by themselves. Study design: Review. Objective: To provide an overview of the current literature regarding ambulation in spinal cord injured patients with emphasis on outcome and the usage of exoskeletons, a new innovative way of rehabilitation therapy after a SCI.

Methods: This is a narrative review of the SCI literature on ambulation outcomes in patients with SCI. A systematic search was performed of all publications mentioning SCI, exoskeletons and ambulation. Relevant studies were included after screening of both title and abstract of the search results. Animal studies and non-English articles were excluded.

Results: Current literature shows that the final degree of motor-function recovery depends on neuronal plasticity, and that the largest amount of recovery can be achieved during the first-year post-injury. Training muscle strength and walking speed are important goals in rehabilitation therapy after a SCI. Furthermore, exoskeletons have been shown to be well tolerated by spinal cord injured patients and could be used by patients without any remaining ambulatory function.

Conclusion: This review showed that it is important to start early with the rehabilitation process after a SCI, to be able to fully benefit from neuroplasticity during the first-year post-injury. In patients without any remaining ambulatory function, such as patients with a complete SCI, exoskeletons have shown to reduce spasticity and improve ambulatory capacity.

Vertebral morphometry is important for spinal analysis, diseases diagnosis and improved implant designs. New technologies available allow us to develop a simple and efficient process of obtaining accurate data of threedimensional (3D) vertebral geometry to create a wide and comprehensive database of vertebral dimension for further research.

The primary aim of this study is to introduce a simple and precise technique of vertebral dimension measurement. The technique involves the segmentation of CT scans of a Caucasian male cadaver’s head and torso specimen to reconstruct 3D images of C1-T3 using 3D imaging processing software (ScanIP Academic, Synopsys Inc.), and 3D modelling software (ANSYS SpaceClaim). A systematic way of defining specific Cartesian coordinate system is done on all reconstructed vertebrae’ images and various standard vertebral parameters are determined accordingly. Finally, the data is compared against previous study to verify the reliability of this method.

The results showed similar trend of vertebral parameters dimensions at vertebral level, except that the dimensions obtained from reconstructed model of CT scans are significantly greater than Asian specimen. The technique applied in this study in the measurement of vertebral parameters is reliable and preferred to other earlier previous methods. The greater dimensions obtained from the specimen can be explained by different specimen ethnic origin, as the vertebral parameters of Caucasian population were reported to be larger than Asian population. To support this latter hypothesis and to create more statistically accurate data, further study on more specimens should be carried out.

The objective of this six weeks quasi-experimental study was to determine the effect of a structured physiotherapeutic treatment plan in the management of non-specific chronic low back pain on the sufferers' activities of daily living which served as the principal outcome measure. Ten (10) participants who met the inclusion criteria were purposively recruited for this research, and a one group pretest posttest design was adopted. A treatment protocol involving the combination of fifteen minutes of Infrared Radiation (IR), twenty minutes of Transcutaneous Electrical Nerve Stimulation (TENS) and ten minutes of Soft Tissue Massage (STM) was used in the management of the condition. Each of the participants received treatment three times a week for six weeks duration and all of them duly completed the study. Data were collected, processed and analyzed descriptively and inferentially. Wilcoxon Signed-Rank test was utilized in testing the null hypothesis at 0.05 level of significance. Statistical analysis revealed a significant improvement in the sufferers’ activities of daily living, hence, it was concluded in this study that the combination of the above physiotherapeutic modalities (IR, TENS and STM) was effective in the management of chronic nonspecific low back pain using activities of daily living as the major dependent variable.

Objective: The aim of this study was to assess the changes in MRI signal intensities of cervical intervertebral discs following corrective surgery in patients with Adolescent Idiopathic Scoliosis (AIS) who were postoperatively followed up for longer than 10 years. Introduction: Sagittal alignment of the cervical spine secondarily may change after corrective surgery in patients with AIS. No previous studies have evaluated MRI images to investigate postoperative changes in cervical intervertebral discs considering cervical alignment that may be influenced by surgical intervention for AIS.

Methods: Eighty-nine patients with AIS who underwent MRI scans preoperatively and 10 years postoperatively following surgery. Control group of volunteers with no neck pain underwent MRI on the cervical spine. Both groups were evaluated the signal intensity and morphology of intervertebral discs (nucleus pulposus) on sagittal T2- weighted MRI images of the C2/3 to C7/T1 discs. Nucleus pulposus signal intensity was assessed using that of the spinal cord as reference and classified as "normal" (N), dehydration (DH), degeneration (DG), and "intermediate" (IM).

Results: The AIS group included 89 cases and the control group included 35 cases. Comparison of pre- and postoperative signal intensity in the AIS group indicated that signal intensity significantly decreased postoperatively for all intervertebral discs (P<0.01) except for the C7/T1 disc. On the other hand, decreased signal intensity accounted for over half of the discs in the control group, except for the C7/T1 disc; however, no statistically significant differences were observed between the postoperative and the control groups.

Conclusion: Postoperative cervical disc intensity had significantly reduced in comparison with preoperative values. However, no statistically significant differences were observed between the control and postoperative group with regard to reduced signal intensity. Pre-to postoperative sagittal cervical alignment changes may have affected the changes in signal intensity.

Introduction: Endoscopic spine surgery has attracted both surgeons and nonsurgeons in increasing numbers as endoscopic spine systems, a variety of spine endoscopes, and new and evolving surgical instrumentation are developed. The procedure, using fluoroscopically guided percutaneous techniques, are getting more standard, easier, safer, readily reproducible, and more cost effective. It has also been an avenue for surgeons and a few appropriately trained and certified non-surgeons to participate in a minimally invasive, procedure oriented health care delivery platform that provides cost effective results after failure of nonsurgical methods. Such a multidisciplinary team has been established at the University of New Mexico through a donation to the University by the first author.

Discussion: Asia, especially China and Korea, has seen adoption of endoscopic spine surgery grow exponentially in the past few years, recognizing that endoscopic spine surgery may be the answer to delivering cost effective spine care to their working and aging population. Two basic methods are the mainstay of current endoscopic techniques. The least invasive techniques in the lumbar spine are transforaminal, but translaminar endoscopic approaches are better accepted and easier for endoscopic surgeons to grasp.

Conclusion: Endoscopic spine surgery has great promise in countries with looking for cost effective delivery of health care to its population. Endoscopic surgery is the least minimally invasive surgical platform that will facilitate a move away from fusion as a first line of surgical treatment, delaying or eliminating fusion for patients who may have indications for decompression and fusion, but do well with an earlier and staged procedure that will mitigate the need for open decompression and fusion by 75%, derived by large individual and group databases known to this author.

Many surgeons have right hand dominance as in the normal population. Right hand dominance may cause difficulties depending on the position of the patient and the surgeon position according to the patient during surgical treatment. Even when the patient is operated on in the neutral position, there are some challenges. In spinal surgery, the difficulties faced by surgeons are in the phase of spinal instrumentation, which requires bilateral application. The challenges experienced by surgeons with left hand dominance are quite different.