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Introducción. El síndrome de la arteria mesentérica superior, también conocido como síndrome de Wilkie, es una entidad infrecuente en la que una reducción del ángulo o espacio aorto-mesentérico determina una compresión extrínseca con obstrucción del tercio distal del duodeno, demostrando síntomas y signos característicos de obstrucción intestinal. El pilar del tratamiento es el manejo médico conservador con repleción nutricional, con el objetivo de aumentar el grosor de la grasa retroperitoneal y con esto resolver la compresión duodenal. Caso clínico. Paciente de 16 años, con un curso crónico marcado por dolor abdominal, estreñimiento, distensión, pirosis y pérdida de peso. Inicialmente se trató como una enfermedad ácido-péptica, con pobre mejoría, por lo que se realizaron estudios imagenológicos con lo que se documentó una disminución del ángulo aortomesentérico. Resultado. Se instauró un manejo médico con un protocolo de repleción nutricional por vía oral, para lograr ganancia de peso y evitar la cirugía. Conclusión. Con base a los síntomas y hallazgos en imágenes diagnósticas se hizo el diagnóstico de síndrome de la arteria mesentérica superior, que es una causa de obstrucción intestinal con muy baja incidencia. Su presentación clínica incluye gran variedad de síntomas, entre los que destaca el dolor abdominal y la pérdida de peso. Es frecuente la confusión con otras enfermedades más frecuentes, como enfermedad ácido-péptica, reflujo gastrointestinal y malabsorción. Su diagnóstico requiere un alto índice de sospecha, por lo que es importante conocer esta entidad y considerarla en el estudio de pacientes con los síntomas mencionados.
Introduction. Superior mesenteric artery syndrome, also known as Wilkie syndrome, is a rare entity in which a reduction in the aorto-mesenteric angle or space determines extrinsic compression with obstruction of the distal third of the duodenum, demonstrating characteristic symptoms and signs of intestinal obstruction. The mainstay of treatment is conservative medical management with nutritional repletion, with the aim of increasing the thickness of the retroperitoneal fat and thereby resolving duodenal compression. Clinical case. A 16-year-old patient, with a chronic course marked by abdominal pain, constipation, bloating, heartburn and weight loss. Initially was treated as an acid-peptic disease, with poor improvement. Imaging studies were performed, which documented a decrease in the aorto-mesenteric angle. Conclusion. Based on the symptoms and findings on diagnostic images, the diagnosis of superior mesenteric artery syndrome was made, which is a cause of intestinal obstruction with a very low incidence. Its clinical presentation includes a wide variety of symptoms, among which abdominal pain and weight loss stand out. Confusion with other more common diseases is common, such as acid-peptic disease, gastrointestinal reflux and malabsorption. Its diagnosis requires a high index of suspicion, so it is important to know this entity and consider it in the study of patients with the aforementioned symptoms.
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Humanos , Síndrome de la Arteria Mesentérica Superior , Dolor Abdominal , Obstrucción Intestinal , Arteria Mesentérica Superior , Duodeno , Dolor CrónicoRESUMEN
BACKGROUND: The Spinal Instability Neoplastic Score (SINS) classification system is a validated and the most widely accepted instrument for defining instability in vertebral metastasis (VM), in which lesions scoring between 7 and 12 are defined as indeterminate and the treatment is controversial. This study aimed to determine which variables more frequently are considered by spine surgeons for choosing between the conservative and the surgical treatment of VMs among patients with an indeterminate SINS. METHODS: A single-round online survey was conducted with 10 spine surgeons with expertise in the management of VMs from our AO Spine Region. In this survey, each surgeon independently reviewed demographic and cancer-related variables of 36 real-life cases of patients with vertebral metastases scored between 7 and 12 in the SINS. Bivariate and multivariate analyses were performed to identify significant SINS and non-SINS variables influencing the decision-making on surgical treatment. RESULTS: The most commonly variables considered important were the SINS element "mechanical pain", rated important for 44.4% of the cases, "lesion type" for 36.1%, and "degree of vertebral collapse" and the non-SINS factor "tumor histology" rated for 13.9% of cases. By far the factor most commonly rated unimportant was "posterior element compromise" (in 72.2% of cases). CONCLUSIONS: Surgeons relied on mechanical pain and type of metastatic lesion for treatment choices. Vertebral collapse, spinal malalignment, and mobility were less influential. Spinal mobility was a predictor of surgical versus non-surgical treatment. The only variables not identified either by surgeons themselves or as a predictor of surgery selection was the presence/degree of posterolateral/posterior element involvement.
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Toma de Decisiones Clínicas , Inestabilidad de la Articulación , Neoplasias de la Columna Vertebral , Humanos , Neoplasias de la Columna Vertebral/secundario , Neoplasias de la Columna Vertebral/cirugía , Masculino , Femenino , Persona de Mediana Edad , Inestabilidad de la Articulación/cirugía , Anciano , Adulto , Cirujanos , Encuestas y CuestionariosRESUMEN
Study Design: Systematic literature reviewObjective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF)Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF.Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between .5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%.Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations.
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STUDY DESIGN: Guideline. OBJECTIVES: To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions. METHODS: The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. RESULTS: Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. CONCLUSION: This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.
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BACKGROUND: Reporting complications and/or adverse events after spinal surgical procedures enables the estimation of their prevalence and of their impact on patient outcomes. However, the documentation of complications is relatively infrequent and highly heterogeneous. The purpose of this study was to evaluate the quality of complication and adverse event reporting in spinal surgery literature. METHODS: A systematic review of the literature from 5 international, peer-reviewed, indexed spinal journals was performed. Included studies were published between January and December 2020 and reported the surgical results of spinal procedures. Data on the level of evidence and study design were collected and analyzed as well as whether the studies were single-center or multicenter studies. The quality of complication reports was evaluated through a 5-item checklist, with 5 questions divided into 3 parts: definition, evaluation, and report. RESULTS: Complications associated with spinal surgical procedures were reported in 292 studies. According to the level of evidence, significantly higher reporting quality was seen in level I and II studies compared with level III and IV studies (P = 0.003). Regarding the 5-item checklist, 49% (143/292) of studies fulfilled the definition section, 16.4% (48/292) fulfilled the evaluation section, and 92% (270/292) fulfilled the report section. CONCLUSIONS: Overall quality assessment when reporting complications in surgical spinal studies showed that only 13% (38/292) of publications that reported complications as part of the outcomes exhibited all items of the 5-item checklist. Additionally, significantly better reports were observed in level I studies compared with level II-IV studies.
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Lista de Verificación , Procedimientos Neuroquirúrgicos , Humanos , Procedimientos Neuroquirúrgicos/efectos adversos , Proyectos de InvestigaciónRESUMEN
OBJECTIVE: We sought to compare the outcomes of single-position (SP) circumferential lumbar interbody fusion in lateral decubitus versus dual-position (DP) fusion. METHODS: A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in PubMed, Web of Science, and Scopus databases to identify comparative studies reporting the outcomes of SP lumbar interbody fusion versus DP. For risk of bias assessment, the ROBINS-I (risk of bias in nonrandomized studies of interventions) tool was used. RESULTS: Four comparative studies were included from an initial search of 3780 papers. All 4 studies were retrospective cohort studies comparing outcomes of SP versus DP LLIF. A total of 349 patients were operated using SP versus 254 using DP. All studies involved reported operating time, estimated blood loss, length of stay, change in segmental lordosis, and complications. From a general perspective, baseline variables were similar in both groups in all the studies and all reported a significant decrease in operative time and length of stays with SP. CONCLUSIONS: Literature comparing SP versus lateral-then-prone lumbar fusion shows a tendency toward shorter operating time and hospital stays in SP lumbar fusion while maintaining similar perioperative outcomes.
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Enfermedades de la Columna Vertebral/cirugía , Fusión Vertebral/métodos , Columna Vertebral/cirugía , Humanos , Tiempo de Internación , Tempo Operativo , Posicionamiento del Paciente , Complicaciones Posoperatorias/etiología , Fusión Vertebral/efectos adversosRESUMEN
BACKGROUND: Many efforts are expended to improve health care quality in the surgical treatment of spinal conditions. However, the prevalence of reporting complications in spinal surgeries is highly heterogeneous, which is partially due to the lack of a universal and comprehensive system. METHODS: A systematic review of the literature was performed in 5 international and indexed spine journals from January to December 2020. All clinical studies that had surgical procedures in any spinal region were classified according to level of evidence, study design, category of spinal condition, and primary outcome. The prevalence and quality of complication reporting were evaluated through a checklist. RESULTS: Of 455 articles screened, complications were reported in 64.2% (292 articles). A significant higher prevalence of reports was observed in randomized compared with nonrandomized studies (P < 0.05). In 89 articles, at least 1 classification was used to report complications, with 12 different classification systems employed in the total sample. Timing to record complications was as follows: 47 (16.1%) articles reported complications at 30 days, 31 (10.6%) reported complications at 90 days, and 88 (30.1%) reported complications during all follow-ups. In 126 (43.1%) articles, complications were not mentioned. CONCLUSIONS: Almost one-third of spine surgical studies did not report complications in their results despite reporting clinical outcomes. The evidence quality of the study was directly related with the reporting of complications. A high heterogeneity regarding complication reporting was seen in the literature.
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Procedimientos Neuroquirúrgicos/efectos adversos , Complicaciones Posoperatorias , Enfermedades de la Columna Vertebral/cirugía , HumanosRESUMEN
BACKGROUND: Intraoperative neurophysiological monitoring (IOM) has become valuable in spine surgery. Unfortunately, it is not always available in many spine centers, especially in developing countries. Our aim was to evaluate the accessibility and barriers to IOM in spine surgery in Latin America. METHODS: We designed a questionnaire to evaluate the characteristics of surgeons and their opinions on the usefulness of IOM for different spine operations. The survey was sent to 9616 members and registered users of AO Spine Latin America (AOSLA) from August 1, 2019, to August 21, 2019. Major variables studied included nationality, years of experience, specialty (orthopedics or neurosurgery), level of complexity of the hospital, number of spine surgeries performed per year by the spine surgeon, the types of spinal pathologies commonly managed, and how important IOM was to the individual surgeon. General questions to evaluate use included accessibility, limitations of IOM usage, management of IOM changes, and the legal value of IOM. The results were analyzed and compared between neurosurgeon and orthopedics, level of surgeon experience, and country of origin. RESULTS: Questionnaires were answered by 200 members of AOSLA from 16 different countries. The most common responses were obtained from orthopedic surgeons (62%), those with more than 10 years of practice (54%); majority of surgeons performed more than 50 spine surgeries per year (69%) and treated mainly spine degenerative diseases (76%). Most surgeons think that IOM has a real importance during surgeries (92%) and not just a legal value. Although surgeons mostly considered IOM essential to scoliosis surgery in adolescents (70%), thoracolumbar kyphosis correction (68%), and intramedullary tumors (68%), access to IOM was limited to 57% for economic reasons. Of interest, in 64% of cases, where IOM was available and significant change occurred, the actual operative procedures were significantly altered. CONCLUSION: Despite the fact that 68% of spine surgeons believe IOM to be indispensable for complex spine surgery, cost remains the main barrier to its use/availability in Latin America.
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OBJECTIVE: To evaluate access to the technologies and education needed to perform minimally invasive spine surgery (MISS) in Latin America. METHODS: We designed a questionnaire to evaluate surgeons' practice characteristics, access to different technologies, and training opportunities for MISS techniques. The survey was sent to members and registered users of AO Spine Latin from January 6-20, 2020. The major variables studied were nationality, specialty (orthopedics or neurosurgery), level of hospital (primary, secondary, tertiary), number of surgeries performed per year by the spine surgeon, types of spinal pathologies commonly managed, and number of MISS performed per year. Other variables involved specific access to different technologies: intraoperative fluoroscopy, percutaneous screws, cages, tubular retractors, microscopy, intraoperative computed tomography, neuronavigation imaging, and bone morphogenetic protein. Finally, participants were asked about main obstacles to performing MISS and their access to education on MISS techniques in their region. RESULTS: The questionnaires were answered by 306 members of AO Spine Latin America across 20 different countries. Most answers were obtained from orthopedic surgeons (57.8%) and those with over 10 years of experience (42.4%). Most of the surgeons worked in private practice (46.4%) and performed >50 surgeries per year (44.1%), but only 13.7% performed >50 MISS per year, mainly to manage degenerative pathologies (87.5%). Most surgeons always had access to fluoroscopy (79%). Only 26% always had access to percutaneous screws, 24% to tubular retractors, 34.3% to cages (anterior lumbar interbody fusion, lateral lumbar interbody fusion, or transforaminal lumbar interbody fusion), and 43% to microscopy. Regarding technologies, 71% reported never having access to navigation, 83% computed tomography, and 69.3% bone morphogenetic protein. The main limitations expressed for widely used MISS technologies were the high implant costs (69.3%) and high navigation costs (49.3%). Most surgeons claimed access to online education activities (71%), but only 44.9% reported access to face-to-face events and 28.8% to hands-on activities, their limited access largely because the courses were expensive (62.7%) or few courses were available on MISS in their region (51.3%). CONCLUSIONS: Most surgeons in Latin America have limited resources to perform MISS, even in private practice. The main constraints are implant costs, access to technologies, and limited face-to-face educational opportunities.
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Educación a Distancia/estadística & datos numéricos , Procedimientos Quirúrgicos Mínimamente Invasivos/educación , Neuronavegación/estadística & datos numéricos , Procedimientos Neuroquirúrgicos/educación , Procedimientos Ortopédicos/educación , Equipo Quirúrgico/estadística & datos numéricos , Proteínas Morfogenéticas Óseas , Fluoroscopía/estadística & datos numéricos , Humanos , Cuidados Intraoperatorios/estadística & datos numéricos , América Latina , Microscopía/estadística & datos numéricos , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Neurocirugia/educación , Procedimientos Neuroquirúrgicos/instrumentación , Procedimientos Ortopédicos/instrumentación , Ortopedia/educación , Encuestas y Cuestionarios , Tecnología , Tomografía Computarizada por Rayos X/estadística & datos numéricosRESUMEN
BACKGROUND: Our aim was to evaluate differences in neurosurgeons versus orthopedists access to technologies needed to perform minimally invasive spine surgeries (MISS) in Latin America. METHODS: We sent a survey to members of AO Spine Latin America (January 2020), and assessed the following variables; nationality, level of hospital (primary, secondary, and tertiary), number of spinal operations performed per year, spinal pathologies addressed, the number of minimally invasive spine operations performed/year, and differences in access to MISS spinal technology between neurosurgeons and orthopedists. RESULTS: Responses were returned from 306 (25.6) members of AO Spine Latin America representing 20 different countries; 57.8% of respondents were orthopedic surgeons and 42.4% had over 10 years of experience. Although both specialties reported a lack of access to most of the technologies, the main difference between the two was greater utilization/access of neurosurgeons to operating microscope (e.g., 84% of the neurosurgeons vs. 39% of orthopedic spine surgeons). CONCLUSION: Although both specialties have limited access to MISS spinal technologies, orthopedic spine surgeons reported significantly lower access to operating microscopes versus neurosurgeons (P < 0.01).
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Resumen El dolor torácico es uno de los principales motivos de consulta al sistema de urgencias, y este es secundario a condiciones como el síndrome coronario agudo entre otras. Para su diagnóstico se requiere no sólo el resultado de la troponina, sino una evaluación clínica completa en la que se tengan en cuenta factores de riesgo cardiovascular, características del dolor y hallazgos electrocardiográficos. La interpretación inadecuada de las troponinas ultrasensibles lleva a que se someta al paciente a riesgos innecesarios a causa de estudios como el cateterismo cardiaco. Se llevó a cabo un estudio de corte trasversal en un hospital de Bogotá, en el que la causa principal de consulta en el servicio de urgencias fue el dolor torácico, y la primera causa de hospitalización en Cardiología el síndrome coronario agudo. Se recolectaron datos de 411 pacientes a quienes se les realizó arteriografía coronaria, la mayoría hombres con factores de riesgo como hipertensión arterial, tabaquismo y un evento coronario previo. Dentro de los estudios paraclínicos, la fracción de eyección promedio estuvo cercana al 50% y sólo en 201 pacientes se encontraron lesiones epicárdicas significativas.De la muestra analizada, el 13% tenía creatinina mayor de 1,5 mg/dl como causa alterna de elevación del biomarcador y 28% tenía disfunción ventricular izquierda de algún grado. La mayoría de los pacientes en quienes no se documentaron lesiones angiográficamente significativas en el cateterismo cardiaco, la troponina no cumplía criterios de positividad con base en el aumento del 20% respecto al valor inicial si este era positivo o de 50% en caso de que el primer valor fuese negativo. Adicionalmente, del grupo de pacientes con enfermedad coronaria angiográficamente significativa fue más frecuente la combinación de tres o más factores de riesgo cardiovascular en presencia de biomarcador positivo.
Abstract Chest pain is one of the main reasons for consulting the Emergency Department, and it is secondary to conditions, such as acute coronary syndrome. For its diagnosis, it not only requires a Troponin result, but also a full clinical evaluation, in which factors like cardiovascular risk have to be taken into account, as well as characteristics of the pain and the findings on the electrocardiogram. The poor interpretation of the ultrasensitive Troponins leads to the patient being subjected to unnecessary risks due to studies such as cardiac catheterisation. A cross-sectional study was conducted in a hospital in Bogota, in which chest pain was the main reason for consulting the Emergency Department, and acute coronary syndrome the first cause of admission to Cardiology. The study included a total of 411 patients on whom a coronary angiography was performed. The majority were males with risk factors such as arterial hypertension, smokers, and with a previous coronary event. Among the para-clinical studies, the mean ejection fraction was around 50%, and significant epicardial lesions were found in only 201 patients.Of the sample analysed, 13% had a creatinine greater than 1.5 mg/dl as an alternative cause of the elevation of the biomarker, and 28% had some degree of left ventricular function. the majority of patients that did not have significant angiographic lesions in the cardiac catheterisation documented, the Troponin did not meet the criteria for being positive, based on an increase of 20% as regards the initial value if this was positive or 50% in the case where the first value was negative. Furthermore, of the patient group with significant angiographic coronary disease, the combination of three or more cardiovascular risk factors was the most frequent in the presence of a positive biomarker.
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Humanos , Masculino , Femenino , Síndrome Coronario Agudo , Infarto del Miocardio con Elevación del ST , Angina de Pecho , Angiografía Coronaria , Troponina T , Infarto del MiocardioRESUMEN
RESUMEN Se presenta un método para la solución del problema de ruteo de mensajeros en motocicleta con ventanas de tiempo. En este se identifican dos fases: en la primera, se conforman grupos de clientes, cada grupo es asignado a una ruta y cada ruta es atendida por un vehículo; en la segunda, por medio de un modelo de programación lineal entera mixta, se hace un ruteo para cada una de las agrupaciones respetando las ventanas de tiempo estrictas de algunos clientes. Para validar el método, se utilizó como caso de estudio el área de mensajería de un centro de servicios compartidos de Cali, Colombia. Los resultados muestran que, al probar diferentes métodos de agrupación (fase 1), no se influye de forma significativa en el tiempo total de permanencia del vehículo en la ruta; en cambio, una reagrupación de los clientes después del ruteo (fase 2), mejora considerablemente la duración total de la ruta, aunque en algunos casos, aumenta la distancia recorrida por el vehículo.
ABSTRACT In this work, a method to solve a motorcycle messenger routing problem with time windows is presented. This has two phases: in the first one, clusters of clients are formed, each group is assigned to a route and each route is served by a vehicle; in the second phase, through a mixed integer linear programming model the routing for each cluster is made while respecting hard time windows of some clients. To validate the method, the mail delivery section of a shared service center in Cali - Colombia is used as case study The results show that, when testing different clustering methods (phase l) these do not significantly influence the vehicle's duration on the road; On the other hand, regrouping the clients after routing (phase 2) can considerably improve the total duration of the route, although in some cases, increasing the distance traveled by the vehicle.
RESUMO Neste trabalho se apresenta um método para a solução do problema de roteiro de mensageiros de motocicleta com janelas de tempo. Nele identificam-se duas fases: na primeira, conformam-se grupos de clientes, cada grupo é atribuído a uma rota e cada uma delas é servida por um veículo; na segunda, por meio de um modelo de programação linear todo misto, faz-se um roteiro para cada uma das agrupações respeitando as janelas de tempo estritas de alguns clientes. Para validar o método, usou-se como caso de estudo a área de mensageria de um centro de serviços compartilhados na cidade de Cali, na Colômbia. Os resultados mostram que ao testar diferentes métodos de agrupamento (fase l), não influem de maneira significativa no tempo total de permanência do veículo na rota; por outro lado, um reagrupamento dos clientes após do roteiro (fase 2), melhora consideravelmente a duração total do percurso, porém em alguns casos, aumenta a distância percorrida pelo veículo.