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The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.
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Traumatismos da Medula Espinal , Traumatismos da Coluna Vertebral , Humanos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/cirurgia , Descompressão Cirúrgica/métodos , Europa (Continente) , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/cirurgia , Recuperação de Função Fisiológica , Resultado do TratamentoRESUMO
OBJECTIVE: This study investigated the expectations of individuals with spinal cord injury (SCI) regarding exoskeletons. DESIGN: The survey consisted out of questions regarding multiple aspects of exoskeleton technology. SETTING: An online survey was distributed via the monthly newsletter of the Dutch Patient Association for Spinal Cord Injury (SCI). PARTICIPANTS: Individuals with SCI who are members of the Dutch Patient Association for SCI. OUTCOME MEASURES: General impression of exoskeleton technology, expectations regarding capabilities and user-friendliness, training expectations and experiences, future perspectives and points of improvement. RESULTS: The survey was filled out by 95 individuals with SCI, exoskeletons were considered positive and desirable by 74.7%. About 11 percent (10.5%) thought one could ambulate faster, or just as fast, while wearing an exoskeleton as able-bodied people. Furthermore, 18.9% expected not to use a wheelchair or walking aids while ambulating with the exoskeleton. Twenty-five percent believed that exoskeletons could replace wheelchairs. Some main points of improvement included being able to wear the exoskeleton in a wheelchair and while driving a car, not needing crutches while ambulating, and being able to put the exoskeleton on by oneself. CONCLUSION: Individuals with SCI considered exoskeletons as a positive and desirable innovation. But based on the findings from the surveys, major points of improvement are necessary for exoskeletons to replace wheelchairs in the future. For future exoskeleton development, we recommend involvement of individuals with SCI to meet user expectations and improve in functionality, usability and quality of exoskeletons.
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Exoesqueleto Energizado , Traumatismos da Medula Espinal , Cadeiras de Rodas , Humanos , Inquéritos e Questionários , CaminhadaRESUMO
BACKGROUND: Progressive equinovarus deformities are common in people with Duchenne Muscular Dystrophy (DMD); they may provoke pain, pressure spots, cause problems with wearing footwear, and may lead to an unstable sitting position. OBJECTIVE: Explore indications and compare complications and long-term outcomes after soft tissue and osseous interventions in people with DMD. METHODS: Retrospective, monocenter, longitudinal study. Data on indications, equinus and varus deformity before and after surgery, wound healing problems, 'pain', edema, and long-term outcomes were collected from medical files. Soft tissue interventions were compared with osseous interventions. RESULTS: From a series of 18 patients, data on 32 surgical interventions and 169 follow-up visits were analyzed. 'Footrest placement' was the most frequent surgical indication, followed by pain. Osseous interventions were performed in older patients with rigid deformities. Directly after surgery remaining deformities were reported after soft tissue interventions (18 %), no remaining deformities were reported after osseous interventions. Pain and edema were frequently present, especially after osseous surgery. Longitudinal follow-up showed that surgical interventions could lead to a neutral foot for a for more than 3 years on average years. Relapses of foot deformity occurred, especially the recurrence of varus deformity after osseous interventions. CONCLUSIONS: Surgical interventions can successfully lead to a neutral foot position for for more than 3 years on average. Soft tissue interventions appear to be superior to osseous corrections, considering the varus recurrence period and complications, and may be considered when feet are still (partly) correctable. Pain management and edema prevention should be anticipated before surgery. Future research on patient reported outcomes as well as evaluating the outcome of the initial indication is needed to further identify benefits.
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Deformidades do Pé , Distrofia Muscular de Duchenne , Procedimentos Ortopédicos , Idoso , Humanos , Estudos Longitudinais , Distrofia Muscular de Duchenne/complicações , Procedimentos Ortopédicos/efeitos adversos , Estudos RetrospectivosRESUMO
PURPOSE: To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma). METHODS: Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach's α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test-retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST. RESULTS: Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach's α = 0.96, itcc 0.50-0.86), with also good Spearman correlations (0.25-0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p < .001). Also test-retest reliability was excellent (ICC = 0.92). Concerning responsiveness analysis, very good results were seen with ES = 1.81 and SRM = 2.03 (p < 0.001). Factor analysis revealed two possible dimensions (Eigenvalues > 1), explaining 65.4% of variance. CONCLUSIONS: Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.
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Traumatismos da Coluna Vertebral , Transferência Intratubária do Zigoto , Humanos , Países Baixos , Medidas de Resultados Relatados pelo Paciente , Reprodutibilidade dos TestesRESUMO
CONTEXT: No consensus about classification, treatment, and clinical relevance of occipital condyle fractures (OCFs) exists. AIMS: The aim of the study was to determine radiological, clinical, and functional outcome of OCFs and thereby determine its clinical relevance. SETTINGS AND DESIGN: This was a retrospective analysis of a prospective follow-up study. MATERIALS AND METHODS: From May 2005 to May 2008, all OCFs were included from a Level-1 trauma center. Patient files were reviewed for patient and fracture characteristics. Fracture classification was done according to the Anderson criteria. Clinical outcome was assessed by completing two questionnaires, radiological outcome by computed tomography imaging, and functional outcome by measuring active cervical range of motion using a Cybex EDI-320. STATISTICAL ANALYSIS USED: A Fisher's exact Test was used in categorical variables and a one-sample t-test for comparing means of active cervical range of motion in occipital fracture patients with normal values. An independent samples t-test was carried out to compare the means of groups with and without accompanying cervical fractures for each motion. RESULTS: Thirty-nine patients were included (4 type I, 16 type II, and 19 type III). Twenty-seven patients completed follow-up, of whom 26 were treated conservatively. Fracture healing was established in 25 of 28 fractures at a median follow-up of 19 months. Eleven patients had none to minimal pain or disability at follow-up, 12 had mild, and two had moderate pain or disability on questionnaires. No statistically significant difference in active cervical range of motion was identified comparing means stratified for accompanying cervical fractures. CONCLUSIONS: Conservatively treated patients with an OCF generally show favorable radiological and clinical outcome.
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STUDY DESIGN: Multicenter prospective cohort. OBJECTIVE: To discern neurological- and functional recovery in patients with a traumatic thoracic spinal cord injury (TSCI), conus medullaris syndrome (CMS), and cauda equina syndrome (CES). SETTING: Specialized spinal cord injury centers in Europe. METHOD: Lower extremity motor score (LEMS) and spinal cord independent measure (SCIM) scores from patients with traumatic TSCI, CMS, and CES were extracted from the EMSCI database. Scores from admittance and during rehabilitation at 1, 3, 6, and 12 months were compared. Linear mixed models were used to statistically analyse differences in outcome, which were corrected for the ASIA Impairment Scale (AIS) in the acute phase. RESULTS: Data from 1573 individuals were analysed. Except for the LEMS in patients with a CES AIS A, LEMS, and SCIM significantly improved over time for patients with a TSCI, CMS, and CES. Irrespectively of the AIS score, recovery in 12 months after trauma as measured by the LEMS showed a statistically significant difference between patients with a TSCI, CMS, and CES. Analysis of SCIM score showed no difference between patients with TSCI, CMS, or CES. CONCLUSION: Difference in recovery between patients with a traumatic paraplegia is based on neurological (motor) recovery. Regardless the ceiling effect in CES patients, patients with a mixed upper and lower motor neuron syndrome (CMS) showed a better recovery compared with patients with a upper motor neuron syndrome (TSCI). These findings enable stratifications of patients with paraplegia according to the level and severity of SCI.
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Síndrome da Cauda Equina/fisiopatologia , Doença dos Neurônios Motores/fisiopatologia , Avaliação de Resultados em Cuidados de Saúde , Paraplegia/fisiopatologia , Recuperação de Função Fisiológica/fisiologia , Compressão da Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Adulto , Síndrome da Cauda Equina/etiologia , Síndrome da Cauda Equina/reabilitação , Europa (Continente) , Feminino , Humanos , Vértebras Lombares/lesões , Masculino , Pessoa de Meia-Idade , Doença dos Neurônios Motores/etiologia , Doença dos Neurônios Motores/reabilitação , Paraplegia/etiologia , Paraplegia/reabilitação , Estudos Prospectivos , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/reabilitação , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/reabilitação , Vértebras Torácicas/lesõesRESUMO
BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterised by ossification of the ligaments around the spinal column due to unknown aetiology. This is often asymptomatic, but it can cause dysphagia in rare cases. CASE DESCRIPTION: A 64-year-old man was referred to the ENT department with progressive dysphagia symptoms he had had for years. Extensive analysis by the ENT specialist did not reveal any abnormalities of the swallowing motor functions. However, osteophytes of the cervical spine of the patient were visible in the X-ray of the cervical spine. The patient was referred to an orthopaedic surgeon. The osteophytes were surgically removed from the cervical spine using a ventral approach. Immediately after the surgery, the patient no longer had problems swallowing. CONCLUSION: In rare cases, dysphagia can be caused by osteophytes of the cervical spine in patients with DISH. Surgical removal of these osteophytes usually has good results.
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Vértebras Cervicais/diagnóstico por imagem , Transtornos de Deglutição , Hiperostose Esquelética Difusa Idiopática , Procedimentos Ortopédicos/métodos , Osteófito , Radiografia/métodos , Vértebras Cervicais/patologia , Vértebras Cervicais/cirurgia , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Humanos , Hiperostose Esquelética Difusa Idiopática/diagnóstico , Hiperostose Esquelética Difusa Idiopática/diagnóstico por imagem , Hiperostose Esquelética Difusa Idiopática/cirurgia , Masculino , Pessoa de Meia-Idade , Pescoço , Osteófito/complicações , Osteófito/diagnóstico por imagem , Osteófito/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Motor impairment and loss of ambulatory function are major consequences of a spinal cord injury (SCI). Exoskeletons are robotic devices that allow SCI patients with limited ambulatory function to walk. The mean walking speed of SCI patients using an exoskeleton is low: 0.26 m/s. Moreover, literature shows that a minimum speed of 0.59 m/s is required to replace wheelchairs in the community. OBJECTIVE: To investigate the highest ambulatory speed for SCI patients in a Lokomat. METHODS: This clinical pilot study took place in the Rehabilitation Center Kladruby, in Kladruby (Czech Republic). Six persons with motor-complete sub-acute SCI were recruited. Measurements were taken at baseline and directly after a 30 min Lokomat training. The highest achieved walking speed, vital parameters (respiratory frequency, heart rate, and blood pressure), visual analog scale for pain, and modified Ashworth scale for spasticity were recorded for each person. RESULTS: The highest reached walking speed in the Lokomat was on average 0.63 m/s (SD 0.03 m/s). No negative effects on the vital parameters, pain, or spasticity were observed. A significant decrease in pain after the Lokomat training was observed: 95% CI [0.336, 1.664] (p = 0.012). CONCLUSION: This study shows that it is possible for motor-complete SCI individuals to ambulate faster on a Lokomat (on average 0.63 m/s) than what is currently possible with over-ground exoskeletons. No negative effects were observed while ambulating on a Lokomat. Further research investigating walking speed in exoskeletons after SCI is recommended.
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Terapia por Exercício/métodos , Robótica/métodos , Traumatismos da Medula Espinal/terapia , Velocidade de Caminhada , Adulto , Terapia por Exercício/instrumentação , Exoesqueleto Energizado , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular , Projetos Piloto , Robótica/instrumentação , Traumatismos da Medula Espinal/patologia , Traumatismos da Medula Espinal/reabilitaçãoRESUMO
BACKGROUND: Idiopathic ventral herniation of the spinal cord is rarely seen as a cause of gradually increasing neurologic deficit. Its cause has never been clarified. It could be the result of a developmental disorder at 30- to 60-day gestational age. Neuropathologic analysis of herniated spinal cord tissue could probably support this hypothesis. CASE DESCRIPTION: In a patient suffering from idiopathic ventral herniation of the spinal cord, a biopsy was performed in order to reduce the space-occupying effect. The biopsy was taken while intraoperative neuromonitoring was used. The patient recovered uneventfully without any additional deficit. Tissue analysis included histopathologic, immunohistochemical, and molecular examination (methylation profiling). The tissue did not appear as a normally functioning spinal cord; instead, a non-neoplastic glio-(neuronal) proliferation was found. CONCLUSION: These findings support a developmental disorder as a cause for idiopathic ventral spinal cord herniation.
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Hamartoma/diagnóstico por imagem , Hamartoma/cirurgia , Hérnia Ventral/diagnóstico por imagem , Hérnia Ventral/cirurgia , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Hamartoma/complicações , Hérnia Ventral/complicações , Humanos , Masculino , Medula Espinal/anormalidades , Adulto JovemRESUMO
PURPOSE: The aim of this study was to determine the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) and magnetic resonance imaging (MRI) in diagnosing vertebral osteomyelitis. METHODS: From November 2015 until December 2016, 32 patients with suspected vertebral osteomyelitis were prospectively included. All patients underwent both 18F-FDG-PET/CT and MRI within 48 h. All images were independently reevaluated by two radiologists and two nuclear medicine physicians who were blinded to each others' image interpretation. 18F-FDG-PET/CT and MRI were compared to the clinical diagnosis according to international guidelines. RESULTS: For 18F-FDG-PET/CT, sensitivity, specificity, PPV, and NPV in diagnosing vertebral osteomyelitis were 100%, 83.3%, 90.9%, and 100%, respectively. For MRI, sensitivity, specificity, PPV, and NPV were 100%, 91.7%, 95.2%, and 100%, respectively. MRI detected more epidural/spinal abscesses. An important advantage of 18F-FDG-PET/CT is the detection of metastatic infection (16 patients, 50.0%). CONCLUSION: 18F-FDG-PET/CT and MRI are both necessary techniques in diagnosing vertebral osteomyelitis. An important advantage of 18F-FDG-PET/CT is the visualization of metastatic infection, especially in patients with bacteremia. MRI is more sensitive in detection of small epidural abscesses.
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Imageamento por Ressonância Magnética , Osteomielite/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fluordesoxiglucose F18 , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Estudos Prospectivos , Compostos Radiofarmacêuticos , Sensibilidade e Especificidade , Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/patologia , Tomografia Computadorizada por Raios XRESUMO
STUDY DESIGN: A prospective cohort of 142 patients underwent either anterior cervical discectomy alone, anterior cervical discectomy with fusion by cage stand-alone, or anterior cervical discectomy with arthroplasty. We then followed up on their condition for a mean of 9.1±1.9 years (5.6-12.2 y) later. OBJECTIVE: We aimed to evaluate the annual rate of clinically symptomatic adjacent segment disease (ASD) and to analyze predictive factors. SUMMARY OF BACKGROUND DATA: Until recent, ASD has been predominantly evaluated radiologically. It is not known whether all patients had complaints. A frequent cited annual rate of ASD is 2.9%, but a growing number of studies report a lower annual rate. Furthermore, maintaining motion to prevent ASD is one reason for implanting a cervical disk prosthesis. However, the results of studies contradict one another. METHODS: Participants took part in a randomized controlled trial that ended prematurely because of the publication of evidence that did not justify continuation of the trial. The patients were randomly allocated to 3 groups, each of which received one of the abovementioned treatments. We defined symptomatic ASD as signs and symptoms caused by degeneration of an intervertebral disk adjacent to a level of previous anterior cervical disk surgery. At the last follow-up, we were able to ascertain whether clinically symptomatic ASD was present in any of the participants. RESULTS: The overall annual rate of symptomatic ASD was 0.7%. We found no statistically significant correlations between any of the investigated factors and symptomatic ASD except for the surgical method used. Symptomatic ASD was seen less often in anterior cervical discectomy solely or anterior cervical discectomy with arthroplasty than in anterior cervical discectomy with fusion by plate fixation. CONCLUSIONS: The annual rate of symptomatic ASD after an anterior cervical discectomy procedure was estimated to be 0.7%. This seems to be related to the procedure, although firm conclusions cannot be drawn. LEVEL OF EVIDENCE: Level 2-prospective cohort.
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Vértebras Cervicais/cirurgia , Discotomia , Degeneração do Disco Intervertebral/cirurgia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: Walking speed is assumed to be a key factor in regaining ambulation after spinal cord injury (SCI). However, from the literature it remains unclear which walking speed usually results in independent community ambulation. OBJECTIVE: The primary aim of this study was to determine at which walking speed SCI patients tend to walk in the community instead of using a wheelchair. The secondary aim was to investigate clinical conditions that favor independent ambulation in the community. METHODS: Data from SCI patients were collected retrospectively from the European Multicenter Study about Spinal Cord Injury database. We determined a cutoff walking speed at which the patients tend to walk in the community by plotting a receiver operating characteristics curve, using the Spinal Cord Independence Measure for outdoor mobility. Univariate analyses investigated which factors influence independent community ambulation. RESULTS: A walking speed of 0.59 m/s is the cutoff between patients who do and do not ambulate independently in the community, with a sensitivity of 91.6% and a specificity of 80.3%. Age, injury severity, and lower limb muscle strength have a significant influence on independent community ambulation. CONCLUSIONS: Patients with an SCI who regain a walking speed of 0.59 m/s tend to achieve a level of walking effectiveness that allows for independent community walking. Although such patients tend to be younger and less severely injured, this walking speed can be a target for locomotor training in rehabilitation and clinical trials that lead to a meaningful outcome level of community walking.
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Transtornos dos Movimentos/etiologia , Traumatismos da Medula Espinal/complicações , Velocidade de Caminhada/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia por Exercício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos dos Movimentos/diagnóstico , Transtornos dos Movimentos/reabilitação , Força Muscular/fisiologia , Curva ROC , Recuperação de Função Fisiológica/fisiologia , Características de Residência , Estudos Retrospectivos , Fatores de Tempo , Caminhada , Adulto JovemRESUMO
BACKGROUND: To investigate the efficacy of adding supplemental fusion or arthroplasty after cervical anterior discectomy for symptomatic mono-level cervical degenerative disease (radiculopathy), which has not been substantiated in controlled trials until now. METHODS: A randomized controlled trial is reported with 9 years follow up comparing anterior cervical anterior discectomy without fusion, with fusion by cage standalone, or with disc prosthesis. Patients suffering from symptomatic cervical disk degeneration at one level referred to spinal sections of department of neurosurgery or orthopedic surgery of a large general hospital with educational facilities were eligible. Neck Disability Index (NDI), McGill Pain Questionnaire Dutch language version (MPQ-DLV), physical-component summary (PCS), and mental-component summary (MCS) of the 36-item Short-Form Health Survey (SF-36), and re operation rate were evaluated. FINDINGS: 142 patients between 18 and 55 years were allocated. The median follow-up was 8.9±1.9 years (5.6 to 12.2 years). The response rate at last follow-up was 98.5%. NDI at the last follow-up did not differ between the three treatment groups, nor did the secondary outcomes as MPQ-DLV and PCS or MCS from SF-36. The major improvement occurred within the first 6 weeks after surgery. Afterward, it remained stable. Eleven patients underwent surgery for recurrent symptoms and signs due to nerve root compression at the index or adjacent level. CONCLUSIONS: This randomized trial could not detect a difference between three surgical modalities for treating a single-level degenerative disk disease. Anterior cervical discectomy without implant seems to be similar to anterior cervical discectomy with fusion by cage stand-alone or with disk prosthesis. Due to the small study sample size, this statement should be considered as inconclusive so far. TRIAL REGISTRATION: ISRCTN41681847.
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Vértebras Cervicais/cirurgia , Degeneração do Disco Intervertebral/cirurgia , Radiculopatia/cirurgia , Fusão Vertebral/métodos , Substituição Total de Disco/métodos , Adolescente , Adulto , Avaliação da Deficiência , Feminino , Seguimentos , Humanos , Degeneração do Disco Intervertebral/complicações , Masculino , Pessoa de Meia-Idade , Radiculopatia/etiologia , Fusão Vertebral/efeitos adversos , Substituição Total de Disco/efeitos adversos , Resultado do Tratamento , Adulto JovemRESUMO
Current immobilization techniques of the cervical spine are associated with complications including pressure ulcers, discomfort, and elevated intracranial pressures with limited access to the thorax and airway. In this study, a newly developed craniothoracic immobilizer (Pharaoh mattress) for critical care patients with cervical injury was tested for its restriction of cervical movement, peak interface pressures, comfort, and radiolucency, and compared with headblocks strapped to a spineboard. Cervical movement was measured by roentgen stereophotogrammetric analysis in 5 fresh frozen cadavers. Peak interface and discomfort pressures were measured in 10 healthy volunteers. Radiographic absorption was calculated by measuring the total emission radiation with and without immobilizer. The Pharaoh mattress caused a mean restriction of 59% (SD: 15) flexion-extension, 77% (SD: 14) lateral bending, and 93% (SD: 3) rotation, compared with the unrestricted situation. No significant differences in restriction of cervical movement were found between headblocks strapped to a spineboard and the Pharaoh mattress. The mean peak pressures on the Pharaoh mattress were significantly lower than on the spineboard. Healthy volunteers gave significantly lower numeric discomfort scores on the Pharaoh mattress than on the spineboard. The Pharaoh mattress absorbed more x-rays than the spineboard. The Pharaoh mattress provides similar restriction of cervical movement compared with headblocks strapped to a spineboard but with lower interface pressures and increased comfort. This new mattress could be useful for immobilization of the cervical spine in critical care patients with mechanically instable spinal fractures.
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Leitos , Vértebras Cervicais/lesões , Cuidados Críticos/métodos , Imobilização/métodos , Fraturas da Coluna Vertebral/terapia , Engenharia Biomédica/métodos , Estado Terminal , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Lesões do Pescoço/diagnóstico , Lesões do Pescoço/terapia , Países Baixos , Amplitude de Movimento Articular/fisiologia , Fraturas da Coluna Vertebral/diagnóstico por imagemRESUMO
BACKGROUND CONTEXT: The results of meta-analyses are frequently reported, but understanding and interpreting them is difficult for both clinicians and patients. Statistical significances are presented without referring to values that imply clinical relevance. PURPOSE: This study aimed to use the minimal clinically important difference (MCID) to rate the clinical relevance of a meta-analysis. STUDY DESIGN: This study is a review of the literature. PATIENT SAMPLE: This study is a review of meta-analyses relating to a specific topic, clinical results of cervical arthroplasty. OUTCOME MEASURE: The outcome measure used in the study was the MCID. METHODS: We performed an extensive literature search of a series of meta-analyses evaluating a similar subject as an example. We searched in Pubmed and Embase through August 9, 2016, and found articles concerning meta-analyses of the clinical outcome of cervical arthroplasty compared with that of anterior cervical discectomy with fusion in cases of cervical degenerative disease. We evaluated the analyses for statistical significance and their relation to MCID. MCID was defined based on results in similar patient groups and a similar disease entity reported in the literature. RESULTS: We identified 21 meta-analyses, only one of which referred to MCID. However, the researchers used an inappropriate measurement scale and, therefore, an incorrect MCID. The majority of the conclusions were based on statistical results without mentioning clinical relevance. CONCLUSIONS: The majority of the articles we reviewed drew conclusions based on statistical differences instead of clinical relevance. We recommend introducing the concept of MCID while reporting the results of a meta-analysis, as well as mentioning the explicit scale of the analyzed measurement.
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Artroplastia/normas , Vértebras Cervicais/cirurgia , Metanálise como Assunto , Artroplastia/efeitos adversos , Artroplastia/métodos , HumanosRESUMO
STUDY DESIGN: Cadaveric radiostereometric analysis study. OBJECTIVE: To quantify the ability of five commonly used immobilizers to restrict cervical spine movement, including intervertebral movement, in three directions. SUMMARY OF BACKGROUND DATA: Evidence about the ability of many clinically used cervical immobilizers to restrict cervical movement is limited. Furthermore, their effect on intervertebral movement is unknown. METHODS: Radiographic inert beads were implanted in the cervical vertebral bodies of five fresh-frozen human cadavers. After application of different immobilizers (Stifneck, Sternal Occipital Mandibular Immobilizer (SOMI), halo-traction, spineboard, halo-vest) and controlled flexion-extension, lateral bending, and rotation torques, radiostereometric analysis was used to determine the overall and intervertebral three-dimensional movement of each vertebral level. Restriction of cervical movement was described as a mean restriction percentage (MRP) and classified on an arbitrary basis (poor: <20%, fair: 20%-40%, moderate: 40%-60%, substantial: 60%-80%, nearly complete: >80%). RESULTS: Most of the restriction of flexion/extension was observed at C0-C1, while most rotational restriction was seen at C1-C2. Lateral bending was restricted at C1 to C7.The Stifneck provided the least immobilization with a moderate restriction of flexion-extension (MRP: 41%, SD: 14%), fair restriction of lateral bending (MRP: 29%, SD: 13%), and substantial restriction of rotation (MRP: 64%, SD: 15%). The halo-vest was the most restrictive immobilizer and reduced movement of the cervical spine substantially for flexion-extension (MRP: 70%, SD: 11%), substantially for lateral bending (MRP: 77%, SD: 14%), and nearly complete for rotation (MRP: 92%, SD: 3%). CONCLUSION: The restriction of movement from lowest to highest was: Stifneck, SOMI, halo-traction, head blocks on a spine board, and halo-vest. Notably, the standard deviations of the restrictions were smaller for the cranio-thoracic devices than for the cervico thoracic devices. With this new knowledge of external immobilizers and their ability to restrict intervertebral cervical movement, their indication and application in clinical practice can be improved for all patients with (suspected) cervical injury. LEVEL OF EVIDENCE: N/A.
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Vértebras Cervicais/diagnóstico por imagem , Imageamento Tridimensional/métodos , Imobilização/instrumentação , Movimento/fisiologia , Amplitude de Movimento Articular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos/fisiologia , Cadáver , Vértebras Cervicais/lesões , Vértebras Cervicais/patologia , Feminino , Humanos , Imobilização/métodos , Masculino , Equipamentos Ortopédicos , Estudos Prospectivos , Estudos Retrospectivos , RotaçãoRESUMO
PURPOSE: The purpose of this study was to evaluate the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT scan) and magnetic resonance imaging (MRI) in diagnosing spondylodiscitis and its complications, such as epidural and paraspinal abscesses. METHODS: From January 2006 to August 2013 patients with a clinical suspicion of spondylodiscitis, with an infection, or with fever of unknown origin were retrospectively included if 18F-FDG-PET/CT and MRI of the spine were performed within a 2-week time span. Imaging results were compared to the final clinical diagnosis and follow-up data were collected. RESULTS: Sixty-eight patients were included of whom 49 patients were diagnosed with spondylodiscitis. MRI showed an overall sensitivity of 67 % and specificity of 84 %. Diagnostic accuracy was 58 %, when MRI was performed within 2 weeks after the start of symptoms and improved to 82 %, when performed more than 2 weeks after onset of symptoms. 18F-FDG-PET/CT showed a sensitivity of 96 % and a specificity of 95 %, with no relation to the interval between the scan and the start of symptoms. CONCLUSIONS: As compared to MRI, 18F-FDG-PET/CT has superior diagnostic value for detecting early spondylodiscitis. After 2 weeks both techniques perform similarly.
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Discite/diagnóstico por imagem , Fluordesoxiglucose F18/uso terapêutico , Imageamento por Ressonância Magnética/métodos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Discite/patologia , Abscesso Epidural , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/patologia , Adulto JovemRESUMO
PURPOSE: To review the ability of various types of external immobilizers to restrict cervical spine movement. METHODS: With a systematical review of original scientific articles, data on range of motion, type of used external immobilization device and risk of bias were extracted. The described external immobilization devices were grouped and the mean restriction percentage and standard deviation were calculated. Finally, each device was classified based on its ability to restrict movement of the cervical spine, according to five levels of immobilization: poor (MIL <20 %), fair (MIL 20-40 %), moderate (MIL 40-60 %), substantial (MIL 60-80 %), and nearly complete (MIL ≥80 %). RESULTS: The ability to reduce the range of motion by soft collars was poor in all directions. The ability of cervico-high thoracic devices was moderate for flexion/extension but poor for lateral bending and rotation. The ability of cervico-low thoracic devices to restrict flexion/extension and rotation was moderate, while their ability to restrict lateral bending was poor. All cranio-thoracic devices for non-ambulatory patients restricted cervical spine movement substantial in all directions. The ability of vests with non-invasive skull fixation was substantial in all directions. No studies with healthy adults were identified with respect to cranial traction and halo vests with skull pins and their ability to restrict cervical movement. CONCLUSIONS: Soft collars have a poor ability to reduce mobility of the cervical spine. Cervico-high thoracic devices primarily reduce flexion and extension, but they reduce lateral bending and rotation to a lesser degree. Cervico-low thoracic devices restrict lateral bending to the same extent as cervico-high thoracic devices, but are considerably more effective at restricting flexion, extension, and rotation. Finally, cranio-thoracic devices nearly fully restrict movement of the cervical spine.
Assuntos
Vértebras Cervicais , Imobilização/instrumentação , Aparelhos Ortopédicos , Amplitude de Movimento Articular , Fenômenos Biomecânicos , Humanos , Movimento , Pescoço , RotaçãoRESUMO
PURPOSE: The role of radiotherapy in stabilizing metastatic bones is unclear. This systematic review assessed the effects of (1) radiotherapy, (2) radiotherapy combined with bisphosphonates, and (3) radiotherapy combined with RANK ligand (RANKL) inhibitors on bone quality and bone strength in bone metastases originating from solid tumors. METHODS: Pubmed, EMBASE and the Cochrane Library were searched. Any type of study design and type and dose of radiotherapy, bisphosphonates and RANKL inhibitors were allowed. RESULTS: 39 articles were identified. Animal studies showed that radiotherapy had similar effects on bone quality and strength as receiving no treatment, whereas adding bisphosphonates to radiotherapy restored bone quality and strength. In patient studies, bone density increased after radiotherapy and radiotherapy combined with bisphosphonates. However, due to the often non-optimal study design and study quality, it was unclear whether this increase could be attributed to these treatments. There was insufficient evidence to assess the additional effect of bisphosphonates or RANKL inhibitors. CONCLUSION: Despite the clinical experience that radiotherapy is an effective treatment for bone metastases, there was no sufficient evidence for a positive effect on bone quality and fracture risk. Animal studies showed that adding bisphosphonates to radiotherapy restored bone quality and strength, whereas this was not proven in patients. There were no studies addressing the adjunct effect of RANKL inhibitors to radiotherapy. Although associated with several methodological, practical and ethical challenges, randomized controlled trials are needed.
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Neoplasias Ósseas/secundário , Neoplasias Ósseas/terapia , Difosfonatos/uso terapêutico , Ligante RANK/antagonistas & inibidores , Animais , Densidade Óssea , Quimiorradioterapia , HumanosRESUMO
INTRODUCTION: Cloacal exstrophy is a complex and rare congenital malformation. Because of improvements in medicine, operative techniques, and perioperative management the survival rates are now approaching 100%. Currently, treatment is focused on improving quality of life. Since 1974, we encountered 20 patients with cloacal exstrophy in our hospital. The aim of this study is to evaluate our clinical experience and outcome during the last 39 years. PATIENTS AND METHODS: A retrospective study of the medical records was performed. We evaluated anatomical status, phenotype and genotype at birth, subsequent surgical treatment and current gastrointestinal, urinary, spinal, genital, and gender status and outcome. RESULTS: The records of all 20 patients who were treated in our center were included in this study. Of the 20 patients, 18 were primary patients, 2 referred. Six patients died within the first year of life. Median age of the surviving 14 patients was 25 years (range, 4-39 years) at time of evaluation. At the last follow-up, 11 patients had an endileostomy or endcolostomy. Three patients had a pull-through; two of them were continent for feces. Two patients were continent for urine; one with a sinus urogenitalis and one after urethra reconstruction. Eleven patients are incontinent; six of them had an incontinent urinary deviation (Bricker deviation). Of the other five incontinent patients, two had a urethral reconstruction, one vesicovaginal anastomosis, one perineotomy, and one epispadias bladder. Urinary continence was unknown in one patient. Of the surviving patients, nine have 46 XY karyotype and five 46 XX karyotype. Initially, six XY patients underwent external genital reconstruction with reassignment to female gender; however, one died postoperatively. One declared to feel like a man at age of 15 years. Remaining four XY patients underwent male external genital reconstruction. All XX patients underwent vagina or vulva reconstruction, except for one who still has aplasia vaginae. All patients were born with varying types of spinal dysraphism. DISCUSSION: Despite medical efforts and development in treatment and support, satisfaction in outcome of cloacal exstrophy remains a challenge. Although reconstruction may be very difficult, male genital reconstruction in 46 XY patients has been given preference for more than a decade. A specialized multidisciplinary team should provide lifelong colorectal, urological, sexual, and psychosocial support to these patients, taking into account their age and phase of life.