RESUMO
Multiple approaches for instrumentation of the upper cervical spine have evolved to treat atlantoaxial instability which, until the 20th century, was largely considered to be inoperable and managed nonsurgically with immobilization. Surgeons set out to provide safe and effective approaches in a clearly dangerous and technically complex anatomic region. It is important to provide a historical analysis of the evolution of techniques that have shaped C1-C2 instrumentation, and how the diligent efforts of surgeons to improve the biomechanical stability and fusion rates of their constructs eventually led to the prevailing Harms technique. This technique is explored by describing its surgical steps, alternative techniques, and associated outcomes. For successful instrumentation of the atlantoaxial joint, a comprehensive understanding of spinal biomechanics, surgical techniques, and anatomic variations is imperative for surgeons to develop a tailored plan for each patient's individual pathology and anatomy.
Assuntos
Articulação Atlantoaxial , Instabilidade Articular , Fusão Vertebral , Humanos , Fusão Vertebral/métodos , Parafusos Ósseos , Vértebras Cervicais/cirurgia , Articulação Atlantoaxial/cirurgia , Instabilidade Articular/cirurgiaRESUMO
BACKGROUND: Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity. CASE REPORT: We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age. DISCUSSION: With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called "Pelvic pain syndrome" and transient osteoporosis of the hip. CONCLUSION: Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications.
RESUMO
Schwannomas are benign tumors affecting the nerve sheath. Their presence in the subperiosteal region is extremely rare. We report a case of a 66-year-old male patient with a 10-year history of unexplained pain of the anterior leg that turned out to be caused by a subperiosteal schwannoma of the mid-tibia. We believe this case report will increase surgeons' index of suspicion about this condition when dealing with cases of unexplained bony pain, consequently allowing for early diagnosis and better outcomes.
RESUMO
We present a case of a 38-year-old female patient, presenting with debilitating simultaneous bilateral avascular necrosis of the femoral head (AVNFH) 10 years after cocaine detoxification, making her wheelchair-bound for six months. This case is reported for the rarity of association of cocaine with AVNFH, and for the unique fact of the simultaneous bilateral condition occurring a long time after cocaine ingestion in the absence of other important risk factors. This report postulates cocaine as a possible cause of bilateral AVNFH, which can increase the index of suspicion of this pathology, allowing early diagnosis and better outcomes.
RESUMO
Minimally invasive posterior spinous process-splitting laminoplasty preserving the paraspinal musculature has been introduced to treat patients with lumbar spinal stenosis. Despite its theoretical advantage of limiting muscular trauma, additional efforts are required to evaluate patients' clinical and functional results following this procedure. Between 2010 and 2012, 37 patients underwent spinous process-splitting laminoplasty for lumbar stenosis at a mean age of 68 years (range, 36-87 years) and were followed for minimum of 1 year (mean, 1.3 years). There were 22 (59%) men and 15 (41%) women. Mean number of levels treated with a spinous process-splitting laminoplasty was 2.2 (range, 1-6 levels). Patients had statistically significant improvements in their scores for all self-reported outcomes, including visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Short Form 36 (SF-36) components. Mean VAS significantly decreased by 4.4±3.2 points for back pain and 3.9±3.7 points for leg pain (P<.0001). Mean ODI significantly decreased by 17.5±19.1 points (P<.0001), and mean SF-36 significantly increased by 29±30.4 points (P=.0017) for the physical component and 21.8±25.6 points (P=.0062) for the mental health component. Four (10.8%) patients had a dural tear requiring repair (3 were intraoperative), 3 (8%) had an epidural hematoma requiring evacuation, 1 (2.7%) had an infection requiring irrigation and debridement, and 2 (5%) had additional decompression for symptom recurrence secondary to instability. Lumbar spinous process-splitting laminoplasty is a novel minimally invasive technique that provides adequate decompression for the neuronal elements and may avoid extensive paraspinal muscular damage associated with conventional laminectomy. Patients demonstrated significant improvements in pain and overall heath and function scores at a minimum 1-year follow-up. [Orthopedics.2016; 39(5):e950-e956.].
Assuntos
Descompressão Cirúrgica/métodos , Laminoplastia/métodos , Vértebras Lombares/cirurgia , Estenose Espinal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor nas Costas/diagnóstico , Descompressão Cirúrgica/efeitos adversos , Dura-Máter/lesões , Feminino , Seguimentos , Humanos , Laminectomia/métodos , Laminoplastia/efeitos adversos , Perna (Membro) , Região Lombossacral/cirurgia , Masculino , Ilustração Médica , Pessoa de Meia-Idade , Medição da Dor , Complicações Pós-Operatórias/cirurgia , Ruptura/cirurgiaRESUMO
We compared open stabilization of vertebral fractures to percutaneous spinal fixation techniques in patients with a diagnosis of either ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). A retrospective review of patients known to have AS or DISH treated for spinal column fracture at a single institution between 1995 and 2011 was performed. Patients were analyzed by the type of fixation, divided into either a percutaneous group (PG) or an open group (OG). There were 41 patients identified with a spinal column fracture and history of AS or DISH who received surgical intervention. There were 17 (42%) patients with AS and 24 (58%) with DISH. Patients in the PG and OG cohorts presented with similar mechanisms of injury, Injury Severity Scale, number of vertebral fractures, number of additional injuries, and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification scores. Mean operative time (254.76minutes versus 334.67minutes, p=0.040), estimated blood loss (166.8 versus 1240.36mL, p<0.001), blood transfusion volume (178.32 versus 848.69mL, p<0.001), and time to discharge (9.58 days versus 16.73 days, p=0.008) were significantly less in the PG cohort. The rate of blood transfusion (36% versus 87.5%, p=0.001) and complications (56% versus 87%, p=0.045) were significantly less in the PG cohort. Percutaneous stabilization of fractures in patients with AS or DISH was associated with lower blood loss, shorter operative times and decreased need for transfusion, shorter hospitalization time and a lower perioperative complication rate.
Assuntos
Hiperostose Esquelética Difusa Idiopática/complicações , Complicações Intraoperatórias/epidemiologia , Procedimentos Ortopédicos/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Fraturas da Coluna Vertebral/etiologia , Fraturas da Coluna Vertebral/cirurgia , Espondilite Anquilosante/complicações , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
The treatment of metastatic disease to the spine involves a comprehensive evaluation of the patient and an individualized treatment plan based on the tumor type and location, the extent of the disease, and the general medical condition of the patient. Careful consideration of these factors dictates the treatment options, which include surgery, radiation, chemotherapy, and/or palliative options. Patients with a good overall prognosis may be considered candidates for more aggressive surgical resections, such as en bloc resections, whereas those with a poor prognosis may benefit from less invasive piecemeal resections to decompress the spine and restore neurologic function while minimizing the morbidity associated with more invasive procedures. The goals of surgery are tailored to the overall prognosis and should be aimed at optimizing the quality of the patient's life.
Assuntos
Procedimentos Ortopédicos/métodos , Neoplasias da Coluna Vertebral/cirurgia , Terapia Combinada , Descompressão Cirúrgica , Embolização Terapêutica , Humanos , Prognóstico , Qualidade de Vida , Radiografia , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/radioterapia , Neoplasias da Coluna Vertebral/secundárioRESUMO
BACKGROUND: Dislocation is a feared complication following total hip replacement (THR). While repairing the piriformis tendon after THR reduces dislocation, we analyze in this study the effect of piriformis tendon preservation on reducing the dislocation rate. MATERIAL AND METHODS: 226 THRs were done following the usual posterior approach and by the same surgeon. All patients received the same prosthetic design. All cases were primary THR. After reaching the external rotators, the piriformis muscle was identified and dissected on its inferior border from the gemellus superior and elevated by a retractor. Further stages were performed in the usual manner. Patients were followed up for a mean of 3 years. RESULTS: 226 THRs were done for 217 patients, 118 of whom were females and 99 were males with a mean age of 62. Nine patients received bilateral THRs. 112 procedures were performed on the right side and 114 on the left side. THR was performed in 70 cases following femoral neck fractures and in 156 cases due to osteoarthritis. No intraoperative or long-term complications were found while preserving the piriformis. Postoperative hip X-rays showed good positioning of both the femoral and acetabular components. No cases of dislocation were identified after a mean follow-up of 3 years. CONCLUSION: Preservation of the piriformis tendon during the postero-lateral approach in THR is a possible surgical technique that is easy to use and reproducible in both arthritic and traumatic conditions. It follows an anatomical intermuscular plan and permits full exposure of both the proximal femur and the acetabulum. Compared to the literature, preserving the piriformis tendon seems to be superior to repairing it in terms of dislocation of THR.
Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Luxação do Quadril/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Feminino , Luxação do Quadril/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , TendõesRESUMO
The objective of this study is to determine the relationship of the variations of the lumbar lordosis angle (LLA) to the aortic bifurcation level and inferior vena cava (IVC) confluence level using CT angiography. A retrospective study was conducted using the data available on abdominopelvic CT angiography scans. The LLA, the level and angle of bifurcation of the aorta, the level and angle of confluence of the IVC were identified using multiplanar and 3D reconstruction. Linear regression models were fitted to the data. We interpreted 181 scans for 181 individuals having a mean age of 55 years (18-89). The most common site of aortic bifurcation was at L4-L5 disc space (34.8%) and that of vena confluence was at the upper of L5 (29.3%). The mean LLA was 34.65° (13°-77°). The mean aortic bifurcation angle was 47.43° (17°-100°) and the mean IVC confluence angle was 71.86° (30°-120°). The positions of the aortic bifurcation and venous confluence levels showed a proximal shift with an increasing LLA P < 0.001. This study showed that the level of bifurcation of the aorta and the level of confluence of the IVC may vary with the variations of the LLA.
Assuntos
Aorta Abdominal/anatomia & histologia , Vértebras Lombares/anatomia & histologia , Veia Cava Inferior/anatomia & histologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal/diagnóstico por imagem , Feminino , Humanos , Imageamento Tridimensional/métodos , Disco Intervertebral/anatomia & histologia , Disco Intervertebral/diagnóstico por imagem , Vértebras Lombares/irrigação sanguínea , Vértebras Lombares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Veia Cava Inferior/diagnóstico por imagemRESUMO
Many studies have attempted to define a safety zone for the axillary nerve in lateral approaches to the deltoid, but with varying results. The main objective of our study was to analyze the variations in the position of this nerve, especially in relation to the length of the humerus. Overall, 16 cadaveric shoulders were dissected. The distances between both the anterolateral edge of the acromin (anterior distance) and the lateral edge of the acromion (posterior distance) to the axillary nerve were measured; the length of the humerus was also measured. Correlation analysis was performed between each distance and the length of the humerus. The average anterior and posterior distance were 7.2 cm ± 0.84 cm and 7.9 cm ± 0.92 cm, respectively; the average length of the humerus was 30.7 cm ± 3.2 cm. A significantly high positive correlation was found between the length of the humerus and both anterior distance (P = .94), and posterior distance (P = .92). In shoulder surgery, prior measurement of the length of the humerus could predict the distance between the acromion and the axillary nerve, and determine its position.
Assuntos
Acrômio/anatomia & histologia , Plexo Braquial/anatomia & histologia , Úmero/anatomia & histologia , Ombro/inervação , Pesos e Medidas Corporais , Cadáver , Dissecação , Humanos , Ombro/anatomia & histologia , Ombro/cirurgiaRESUMO
Aneurysmal bone cysts rarely affect the carpus. We present a case of aneurysmal bone cyst affecting the lunate. Curettage and bone grafting of the lesion was successful, with no recurrence after 2 years of follow-up.
Assuntos
Cistos Ósseos Aneurismáticos/cirurgia , Osso Semilunar , Adulto , Cistos Ósseos Aneurismáticos/diagnóstico por imagem , Humanos , Osso Semilunar/cirurgia , Imageamento por Ressonância Magnética , Masculino , Tomografia Computadorizada por Raios X , Articulação do Punho/diagnóstico por imagem , Articulação do Punho/patologiaRESUMO
Secondary chondrosarcoma is a distinctive type of tumor that originates from a preexisting cartilaginous lesion. Most commonly, it is associated with solitary or multiple osteochondromas. A fraction of cases arises from other conditions, such as Maffucci syndrome and Ollier disease. A sudden increase in the size of the cartilaginous cap of an osteochondroma is a sign of malignant transformation to secondary chondrosarcoma. However, there is no strict cutoff in terms of thickness of the cartilaginous cap that can be regarded as being pathognomonic of malignancy. Most cases of secondary chondrosarcoma are low to intermediate grade. Distant metastasis is uncommon, and the prognosis is good for most patients. Overall survival at 5 years is approximately 90%. Surgical resection with wide margins is the best treatment option, but local recurrence remains a significant problem in approximately 10% to 20% of patients. Patients with secondary chondrosarcoma of the pelvis are especially at risk for local recurrence.
Assuntos
Neoplasias Ósseas/secundário , Neoplasias Ósseas/cirurgia , Condrossarcoma/secundário , Condrossarcoma/cirurgia , Neoplasias Ósseas/genética , Condrossarcoma/genética , Diagnóstico Diferencial , Diagnóstico por Imagem , Humanos , Recidiva Local de NeoplasiaRESUMO
Stress fractures may be easily misdiagnosed as another entity, especially tumors, which may prompt very severe surgical treatment and sometimes amputation. The appropriate use of modern radiography may make the difference in proper diagnosis of stress fractures.
Assuntos
Articulação do Tornozelo/patologia , Fíbula/lesões , Fraturas de Estresse/diagnóstico , Sarcoma de Ewing/diagnóstico , Adulto , Diagnóstico Diferencial , Erros de Diagnóstico , Fíbula/diagnóstico por imagem , Consolidação da Fratura , Fraturas de Estresse/complicações , Fraturas de Estresse/diagnóstico por imagem , Humanos , Imageamento Tridimensional , Masculino , Dor/diagnóstico , Dor/etiologia , Tomografia Computadorizada por Raios X , Resultado do TratamentoAssuntos
Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Ulnar/diagnóstico , Nervo Mediano/patologia , Nervo Ulnar/patologia , Adulto , Síndrome do Túnel Carpal/fisiopatologia , Síndrome do Túnel Ulnar/fisiopatologia , Síndrome do Túnel Ulnar/cirurgia , Diagnóstico Diferencial , Eletrodiagnóstico/métodos , Feminino , Humanos , Nervo Mediano/fisiopatologia , Condução Nervosa/fisiologia , Recuperação de Função Fisiológica , Limiar Sensorial/fisiologia , Resultado do Tratamento , Nervo Ulnar/fisiopatologiaRESUMO
Malignant eccrine porocarcinoma is a rare tumor of sweat glands with a high local recurrence rate and a tendency to metastatic spread. We present a case of a 77-year-old male patient that presented with a recurrent, periungual porocarcinoma mimicking onychomycosis and ingrown toe nail that was successfully treated by surgical excision. To our knowledge no such case has been described in this location in the English literature.