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Traumatic spinal cord injury (SCI) is a devastating condition without an effective therapy. Cellular therapies are among the promising treatment strategies. Adult stem cells, such as mesenchymal stem cells, are often used clinical research for their immunomodulatory and regenerative potential. This study aimed to evaluate the effect of human adipose tissue-derived stem cells (ADSC) infusion through the cauda equina in rats with SCI. The human ADSC from bariatric surgery was isolated, expanded, and characterized. Wistar rats were subjected to blunt SCI and were divided into four groups. Two experimental groups (EG): EG1 received one ADSC infusion after SCI, and EG2 received two infusions, the first one after SCI and the second infusion seven days after the injury. Control groups (CG1 and CG2) received infusion with a culture medium. In vivo, cell tracking was performed 48 h and seven days after ADSC infusion. The animals were followed up for 40 days after SCI, and immunohistochemical quantification of myelin, neurons, and astrocytes was performed. Cellular tracking showed cell migration towards the injury site. ADSC infusion significantly reduced neuronal loss, although it did not prevent the myelin loss or enhance the area occupied by astrocytes compared to the control group. The results were similar when comparing one or two cell infusions. The injection of ADSC distal to the injured area was shown to be a safe and effective method for cellular administration in spinal cord injury.
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BACKGROUND: In the context of anterior approach to the cervical spine, dysphagia is a common complication and still without a clear distinction of risk factors. OBJECTIVE: To analyze the risk factors of dysphagia after cervical spine surgery. METHODS: Multicenter prospective study evaluated patients who underwent anterior cervical spine surgery for degenerative pathologies, studying surgical, anesthesia, base disease, and radiological variables (preoperatively, 24 hours, 1 and 3 weeks, and 6 months after surgery), with control group matched. Postoperative dysphagia was assessed by Swallowing Satisfaction Index and Swallowing Questionnaire; besides, based on multiple logistic regression model, a risk factor analysis correlation was applied. RESULTS: In total, 233 cervical patients were evaluated; most common level approached was C5-C6 (71.8%). All showed same decreasing trade for dysphagia incidence-with more cases on cervical group ( P < .05); severe cases were rare. At postoperative day 1, identified risk factors were approach to C3-C4 (4.11, P < .01), loss of preoperative cervical lordosis (2.26, P < .01), intubation attempts ≥2 (3.10, P < .01), and left side approach (1.85, P = .02); at day 7, body mass index ≥30 (2.29, P = .02), C3-C4 (3.42, P < .01), and length of surgery ≥90 minutes (2.97, P = .005); and at day 21, C3-C4 were kept as a risk factor (3.62, P < .01). CONCLUSION: A high incidence level of dysphagia was identified, having a clear decreasing trending (number of cases and severity) through postoperative time points; considering possible risk factors, strongest correlation was the approach at the C3-C4 level-statistically significant at the 24 hours, 7 days, and 21 days assessment.
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Trastornos de Deglución , Fusión Vertebral , Humanos , Estudios Prospectivos , Trastornos de Deglución/epidemiología , Trastornos de Deglución/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Vértebras Cervicales/cirugía , Cuello , Fusión Vertebral/efectos adversosRESUMEN
Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit. Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up. Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p > 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p > 0.05), quality of life (EQ-5D), and return to work (DWS). Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.
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Objective The present study evaluates radiographic outcomes and the lumbar lordosis achieved with a transforaminal lumbar interbody fusion (TLIF) arthrodesis technique according to the positioning of an interbody device (cage) in the disc space. Methods This is a retrospective radiographic analysis of single-level surgical patients with degenerative lumbar disease submitted to a TLIF procedure and posterior pedicle instrumentation. We divided patients into two groups according to cage positioning. For the TLIF-A group, the cages were anterior to the disc space; for the TLIF-P group, cages were posterior to the disc space. Considering the superior vertebral plateau of the lower vertebra included in the instrumentation, cages occupying a surface equal to the anterior 50% of the midline were placed in the TLIF-A group, and those in a posterior position were placed in the TLIF-P group. We assessed pre- and postoperative orthostatic lateral radiographs to obtain the following measures: lumbar lordosis (LL) (angle L1-S1), segmental lordosis (LS) (L4-S1), and segmental lordosis of the cage (SLC). Results The present study included 100 patients from 2011 to 2018; 44 were males, and 46 were females. Their mean age was 50.5 years old (range, 27 to 76 years old). In total, 43 cages were "anterior" (TLIF-A) and 57 were "posterior" (TLIF-P). After surgery, the mean findings for the TLIF-A group were the following: LL, 50.7°, SL 34.9°, and SLC 21.6°; in comparison, the findings for the TLIF-P group were the following: LL, 42.3° ( p < 0.01), SL 30.7° ( p < 0.05), and SLC 18.8° ( p > 0.05). Conclusion Cage positioning anterior to the disc space improved lumbar and segmental lordosis on radiographs compared with a posterior placement.
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STUDY DESIGN: A multicenter, pilot study, for radiological assessment of thoracolumbar spine fractures was performed with the participation of 7 centers in Africa, Europe, Asia, and South America as a part of the AO Foundation network. OBJECTIVES: To determine the interobserver variability for computed tomography (CT) scan-based evaluation of posterior ligament complex (PLC) injury in thoracolumbar fractures. METHODS: Forty-two observers including 1 principal investigator at each participating center performed variability assessment. Each center contributed toward a total of 91 patient images with A3 or A4 thoracolumbar burst fractures (T11-L2) with or without suspected PLC injury. Pathological fractures, multilevel injuries, obvious posterior bony element injury and translation/dislocation injuries were excluded. Ten patients were randomly selected and commonly reported CT parameters indicating PLC injury, including superior inferior endplate angle, vertebral body height loss, local kyphotic deformity, interspinous distance and interpedicular distance were assessed for variability. Observer values were compared with an experienced gold rater in spinal trauma. Analysis of variability was performed for all observers, between the principal investigators and also between observers participating in each center. RESULTS: The studied parameters showed considerable variability in measurements among all observers and amongst all participating centers. The variability between the principal investigators was lower, but still substantial. The deviation of observer measurements from the gold rater were also significant for all CT parameters. CONCLUSIONS: CT-based radiological parameters previously reported to be suggestive of PLC injury showed considerable variability and magnetic resonance imaging verification of a PLC injury in all doubtful cases is suggested.
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Abstract Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit. Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up. Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p> 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p> 0.05), quality of life (EQ-5D), and return to work (DWS). Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.
Resumo Objetivo Comparar os resultados clínicos entre os tratamentos conservador (CS) e cirúrgico (CXS) das fraturas A3 e A4 sem déficit neurológico. Métodos Estudo prospectivo observacional de paciente com fraturas toracolombares tipo A3 e A4. Esses pacientes foram separados entre os grupos cirúrgico e conservador e avaliados sequencialmente através da escala numérica de dor (NRS), do questionário de incapacidade de Roland-Morris (RMDQ), do EuroQol-5D (EQ-5D) e da escala de trabalho de Denis (DWS) até 2,5 anos de acompanhamento. Resultados Ambos os grupos apresentaram melhora significante, sem diferença estatística nos questionários de dor (NRS: CXS 2,4 ± 2,6; CS 3,5 ± 2,6; p> 0,05), funcionalidade (RMDQ: CS 7 ± 6,4; CXS 5,5 ± 5,2; p> 0,05), qualidade de vida (EQ-5D) e retorno ao trabalho (DWS). Conclusão Ambos os tratamentos são opções viáveis e com resultados clínicos equivalentes. Há uma tendência a melhores resultados no tratamento cirúrgico das fraturas A4.
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Humanos , Fracturas de la Columna Vertebral/cirugía , Resultado del Tratamiento , Tratamiento Conservador , Fijación Interna de FracturasRESUMEN
ABSTRACT: Objective: Evaluation of the profile of the population with adolescent idiopathic scoliosis (AIS) treated at a center specializing in spine surgery in Curitiba-PR. Methods: Prospective multicenter study, being analyzed, at the moment, only data from the center in question. All patients referred from the basic health service for evaluation of deformity underwent panoramic radiography of the total spine to evaluate the curvature using the Cobb method, evaluation of skeletal maturity using the Risser classification, and the classification of scoliosis using the Lenke classification. Clinical photographs of all patients and an assessment of the quality of life using the SRS-30 questionnaire were also taken. Results: Thirty patients with scoliosis and a mean age of 14.63 ± 3 years were evaluated. Prevalence of female:male 1.5:1. Patients had a mean Cobb of 45.96°, and most were close to Risser 4 skeletal maturity (48.3%). 60% had a thoracic curve (Lenke 1), and 13.3% had a double curve (Lenke 3 or 6). 63.3% of cases had a delay in medical care, taking an average of 18 months between referral and consultation with a specialist. 60% of patients were referred for surgical treatment after the first appointment. Conclusion: The population sample of this center follows the literature. A Cobb >40° in the first consultation with a specialist and a high referral rate to surgery suggest the failure of early diagnosis and the need for public policies for better knowledge and assistance for adolescent idiopathic scoliosis. Level of Evidence IV; Descriptive Epidemiological Study.
RESUMO: Objetivo: Avaliação do perfil da população com escoliose idiopática do adolescente (EIA) atendida no centro especializado em cirurgia de coluna em Curitiba-PR. Métodos: Estudo multicêntrico prospectivo, sendo analisados, no momento, somente os dados do centro em questão. Todos os pacientes encaminhados do serviço de saúde básica para avaliação de deformidade foram submetidos a radiografia panorâmica de coluna total para avaliação da curvatura através do método de Cobb, avaliação da maturidade esquelética pela classificação de Risser e classificação da escoliose por Lenke. Foram, também, realizadas fotos clínicas de todos os pacientes e avaliação da qualidade de vida pelo questionário SRS-30. Resultados: Foram avaliados 30 pacientes com escoliose e idade média de 14,63 ± 3 anos. Prevalência de sexo feminino:masculino 1,5:1. Os pacientes apresentavam Cobb médio 45,96° e a maioria estava próxima da maturidade esquelética Risser 4 (48,3%). 60% apresentavam curva torácica (Lenke 1) e 13,3% dupla curva (Lenke 3 ou 6). 63,3% dos casos apresentaram atraso na assistência médica, demorando em média 18 meses entre o encaminhamento e a consulta com especialista. 60% dos pacientes foram encaminhados para tratamento cirúrgico após a primeira consulta com um especialista. Conclusão: A amostra populacional deste centro encontra-se consoante a literatura. Pelo Cobb >40° na primeira consulta com o especialista e a alta taxa de encaminhamento para cirurgia, fica demonstrado a falha do diagnóstico precoce e necessidade de políticas públicas para melhor conhecimento e assistência da escoliose idiopática do adolescente. Nível de evidência: IV; Estudo Epidemiológico Descritivo.
RESUMEN: Objetivo: Evaluación del perfil de la población con escoliosis idiopática del adolescente (EIA) tratada en un centro especializado en Curitiba-PR. Métodos: Estudio multicéntrico prospectivo, analizándose, por el momento, únicamente los datos del centro en cuestión. A todos los pacientes derivados del servicio básico de salud para evaluación de deformidad se les realizó radiografía panorámica de columna total para evaluación de la curvatura mediante el método de Cobb, evaluación de la madurez esquelética mediante la clasificación de Risser y clasificación de escoliosis mediante la clasificación de Lenke. También se tomaron fotografías clínicas de todos los pacientes y evaluación de la calidad de vida mediante el cuestionario SRS-30. Resultados: Se evaluaron 30 pacientes con escoliosis y edad media de 14,63 ± 3 años. Prevalencia femenino:masculino 1,5:1. Los pacientes tenían un Cobb medio de 45,96° y la mayoría estaba cerca de la madurez esquelética Risser 4 (48,3%). El 60% tenía curva torácica (Lenke 1) y el 13,3% tenía doble curva (Lenke 3 o 6). El 63,3% de los casos tuvo retraso en la atención médica, transcurriendo en promedio 18 meses entre la derivación y la consulta con un especialista. El 60% de los pacientes fueron derivados para tratamiento quirúrgico después de la primera cita. Conclusión: La muestra poblacional de este centro está de acuerdo con la literatura. Por Cobb > 40° en la primera consulta con un especialista y una alta tasa de derivación a cirugía, se sugiere el fracaso del diagnóstico precoz y la necesidad de políticas públicas para mejorar el conocimiento y la asistencia de la escoliosis idiopática del adolescente. Nivel de Evidencia IV; Estudio Epidemiológico Descriptivo.
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Humanos , Adolescente , OrtopediaRESUMEN
ABSTRACT Objective: To evaluate the influence of intertransverse septal anesthetic block (BASIT) on postoperative pain in lumbar spine surgery. Methods: The study was carried out prospectively and observationally. Were included 105 patients who underwent posterior lumbar spine surgery, divided into two groups: 35 patients in the experimental group, who received BASIT at the end of the procedure, and 70 patients in the control group, without BASIT. Patients were assessed for low back pain (visual pain scale), opioid consumption on the 1st postoperative day, complications related to the procedure, and length of stay after surgery. Results: The sample consisted of 46 men and 59 women, with a mean age of 57.7 years (21 to 90 years). Mean postoperative pain in the experimental group was 1.88, and in the control group 2.11 (p<0.05). There was a trend towards less morphine use in the experimental group with p = 0.053. There was a statistical difference in morphine consumption between patients who did not previously use opioids and those who already used them (p 0.04). There was no difference between the groups regarding length of stay. Conclusion: Anesthetic blockade of the intertransverse septum reduced the consumption of opioids and the levels of low back pain after surgery (p<0.05), with no statistical difference in length of hospital stay or complications related to the technique. Level of Evidence II; Clinical Prospective Study.
RESUMO: Objetivo: Avaliar a influência do bloqueio anestésico do septo intertransverso (BASIT) sobre a dor pós-operatória em cirurgia de coluna lombar. Metodologia: O estudo foi realizado de modo prospectivo e observacional. Foram incluídos no estudo 105 pacientes submetidos à cirurgia da coluna lombar por via posterior e divididos em dois grupos: 35 pacientes no grupo experimental, que recebeu o BASIT ao final do procedimento e 70 pacientes no grupo controle, sem o BASIT. Os pacientes foram avaliados quanto à dor lombar (escala visual de dor), consumo de opioide no 1º dia pós-operatório, complicações referentes ao procedimento e tempo de internamento após a cirurgia. Resultados: A amostra consistiu em 46 homens e 59 mulheres, com média de idade de 57,7 anos (21 a 90 anos). A média de dor pós-operatória do grupo experimento foi 1,88 e no grupo controle 2,11 (p<0,05). Houve uma tendência a menor uso de morfina no grupo experimento com p = 0,053. Houve diferença estatística no consumo de morfina entre os pacientes que não utilizavam opioides previamente quanto comparados aos que já faziam uso (p 0,04). Não houve diferença entre os grupos quanto ao tempo de internamento nem eventos adversos relacionados à técnica. Conclusão: O bloqueio anestésico do septo intertransverso reduziu o consumo de opioides e os níveis de dor lombar após cirurgia (p<0,05), não havendo diferença estatística no tempo de internamento, nem intercorrências relacionadas a técnica. Nível de Evidência II; Estudo Prospectivo Clínico.
RESUMEN: Objetivo: Evaluar la influencia del bloqueo anestésico del septo intertransverso (BASIT) sobre el dolor posoperatorio en cirugía de columna lumbar. Método: El estudio se realizó de forma prospectiva observacional. Fueron incluidos en el estudio 105 pacientes sometidos a cirugía de columna lumbar posterior y se dividieron en dos grupos: 35 pacientes en el grupo experimental, recibieron BASIT al final del procedimiento, y 70 pacientes en el grupo control, sin BASIT. Los pacientes fueron evaluados por dolor lumbar (escala visual de dolor), consumo de opioides en el primer día postoperatorio, complicaciones relacionadas con el procedimiento y tiempo de estancia hospitalaria después de la cirugía. Resultado: La muestra consistió en 46 hombres y 59 mujeres, con una edad media de 57,7 años (21 a 90 años). El dolor postoperatorio medio en el grupo experimental fue de 1,88 y en el grupo control de 2,11 (p<0,05). Hubo una tendencia hacia un menor uso de morfina en el grupo experimental con p = 0,053. Hubo una diferencia estadística en el consumo de morfina entre los pacientes que no usaban previamente opioides en comparación con los que ya los usaban (p 0,04). No hubo diferencia entre los grupos con respecto a la duración de la estancia. Conclusión: El bloqueo anestésico del septo intertransverso redujo el consumo de opioides y los niveles de dolor lumbar posoperatorio (p<0,05), sin diferencia estadística en la estancia hospitalaria ni en las complicaciones relacionadas con la técnica. Nivel de Evidencia II; Estudio Clínico Prospectivo.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Operativos , Procedimientos OrtopédicosRESUMEN
Abstract Objective The present study evaluates radiographic outcomes and the lumbar lordosis achieved with a transforaminal lumbar interbody fusion (TLIF) arthrodesis technique according to the positioning of an interbody device (cage) in the disc space. Methods This is a retrospective radiographic analysis of single-level surgical patients with degenerative lumbar disease submitted to a TLIF procedure and posterior pedicle instrumentation. We divided patients into two groups according to cage positioning. For the TLIF-A group, the cages were anterior to the disc space; for the TLIF-P group, cages were posterior to the disc space. Considering the superior vertebral plateau of the lower vertebra included in the instrumentation, cages occupying a surface equal to the anterior 50% of the midline were placed in the TLIF-A group, and those in a posterior position were placed in the TLIF-P group. We assessed pre- and postoperative orthostatic lateral radiographs to obtain the following measures: lumbar lordosis (LL) (angle L1-S1), segmental lordosis (LS) (L4-S1), and segmental lordosis of the cage (SLC). Results The present study included 100 patients from 2011 to 2018; 44 were males, and 46 were females. Their mean age was 50.5 years old (range, 27 to 76 years old). In total, 43 cages were "anterior" (TLIF-A) and 57 were "posterior" (TLIF-P). After surgery, the mean findings for the TLIF-A group were the following: LL, 50.7°, SL 34.9°, and SLC 21.6°; in comparison, the findings for the TLIF-P group were the following: LL, 42.3° (p< 0.01), SL 30.7° (p< 0.05), and SLC 18.8° (p> 0.05). Conclusion Cage positioning anterior to the disc space improved lumbar and segmental lordosis on radiographs compared with a posterior placement.
Resumo Objetivo Avaliar os resultados radiográficos e comparar a lordose pós-operatória em técnica de artrodese intersomática lombar transforaminal (TLIF, na sigla em inglês), considerando como variável o posicionamento do dispositivo intersomático (cage) em relação ao espaço discal. Métodos Análise retrospectiva radiográfica de pacientes cirúrgicos, em nível único, por doença lombar degenerativa, aplicando-se TLIF e instrumentação pedicular posterior. Os pacientes foram divididos, conforme a posição do cage, em 2 grupos: 1. TLIF-A - cages na posição anterior do espaço discal; e 2. TLIF-P, cages na posição posterior do espaço discal (considerando-se o platô vertebral superior da vértebra inferior incluída na instrumentação, cages que ocuparam a superfície correspondente a 50% anterior da linha média, compuseram o grupo TLIF-A; opostamente, cages em posicionamento posterior compuseram o grupo TLIF-P). Procedeu-se à avaliação dos exames radiográficos ortostáticos em perfil no pré- e pós-operatórios, com a tomada das seguintes medidas: lordose lombar (LL) (ângulo L1-S1); lordose segmentar (LS) (L4-S1) e lordose segmentar do cage (LSC). Resultados Cem pacientes foram incluídos de 2011 a 2018, sendo 44 homens e 46 mulheres, com idade média de 50.5 anos (27-76 anos). Um total de 43 cages foram classificados como "anteriores" (TLIF-A) e 57, "posteriores" (TLIF-P); considerando o grupo TLIF- A, os resultados pós-operatórios médios foram: LL 50.7°, LS 34.9° e LSC 21.6°; para o grupo TLIF-P, comparativamente: LL 42.3° (p< 0,01), LS 30.7° (p< 0,05) e LSC 18.8° (p> 0,05). Conclusão O posicionamento anterior do cage em relação ao espaço discal correlaciona-se a melhora da lordose lombar e segmentar na radiografia em comparação com o posicionamento posterior do implante.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Fusión Vertebral , Espondilolistesis , Lordosis , Región LumbosacraRESUMEN
OBJECTIVE: The objective of this research was to evaluate the influence of autologous mononuclear stem cells injections on histological changes of collagen in the fibrous annulus of the intervertebral disk after experimental injury. METHODS: 32 New Zealand rabbits were submitted to intervertebral disk puncture, followed by intradiscal injection of mononuclear cells from the iliac crest versus saline injection in the following time periods: two months after the injury (SC2M and SS2M), two weeks (SC2W and SS2W) immediately after injury (SCCP and SSCP), and without inducing degeneration (SCSP and SSSP). Two months after cell therapy, the animals were euthanized and collagen changes in the intervertebral discs were histologically evaluated. RESULTS: There were significant differences in ELAF between SS2W and SS2S groups (p = 0.018). This difference was due to an increase in type I collagen in SS2W group (56.7%) compared to SC2S (13.28%). CONCLUSION: Treatment with mononuclear mesenchymal stem cells reduced changes in the type I and III collagen distribution in rabbits AF degenerated discs up to two weeks after the induction of degeneration.
OBJETIVO: Avaliar a influência da injeção de células-tronco mononucleares autólogas sobre as alterações histológicas do colágeno no ânulo fibroso do disco intervertebral após lesão experimental. MÉTODOS: Foram submetidos 32 coelhos New Zealand a punção do discos intervertebrais lombares seguida de injeção intradiscal de células mononucleares provenientes da crista ilíaca versus injeção de solução salina nos seguintes períodos tempo: dois meses após a lesão (CT2M e SS2M), duas semanas (CT2S e SS2S), imediatamente após a lesão (CTCP e SSCP) e sem induzir a degeneração (CTSP e SSSP). Após dois meses da terapia celular, os animais foram submetidos a eutanásia e as alterações do colágeno nos discos intervertebrais foram avaliadas histologicamente. RESULTADOS: Houve diferença estatisticamente significativa na CEAF entre os grupos CT2S e SS2S (p = 0,018). Essa diferença decorreu de um aumento do colágeno do tipo I no grupo SS2S (56,7%) comparado com o CT2S (13,28%). CONCLUSÃO: O tratamento com células mononucleares precursoras mesenquimais é capaz de reduzir as alterações na distribuição do colágeno do tipo I e III no AF de discos degenerados de coelhos até duas semanas após a indução da degeneração.
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ABSTRACT Objective To describe the minimally invasive technique for the lateral retropleural approach to the thoracolumbar spine and its viability in several affections of the region, demonstrating its indications, potential advantages, and necessary precautions, with an emphasis on the local anatomy, especially the diaphragm. Methods After a review of the literature, the initial experience of the Service is reported, comparing it to the published results. The surgical technique used is described with emphasis on the surgical anatomy of the diaphragm. Results The minimally invasive lateral retropleural approach to the thoracolumbar junction with the application of an expandable tubular retractor was described step-by-step in this study, with emphasis on the crucial points of technical execution, such as preoperative planning, access to the retropleural plane, and an orthogonal approach for adequate discectomy and/or corpectomy and subsequent implant placement. It can be used in the treatment of deformities, degenerative diseases, trauma, tumors, and infections and it allows for adequate interbody arthrodesis fusion rates associated with a smaller skin incision and less soft tissue damage, blood loss, and postoperative pain. Thus, it results in better postoperative mobility and a shorter hospital stay, which can also be observed in the data from initial experience of this Service. Conclusions The minimally invasive technique for the lateral retropleural approach to the thoracolumbar spine with the application of an expandable tubular retractor was shown to be promising and safe for the treatment of several spinal diseases despite the complex and challenging local anatomy and it presents advantages over the morbidity rates observed in the traditional approach. Level of evidence IV; Case series.
RESUMO Objetivo Descrever a técnica minimamente invasiva para acesso lateral retropleural à coluna toracolombar e sua viabilidade em diversas afecções da região, demonstrando suas indicações, vantagens em potencial e cuidados necessários, com destaque para a anatomia local, especialmente o diafragma. Métodos Após revisão da literatura, relata-se a experiência inicial do serviço, comparando-a aos resultados publicados. Descreve-se a técnica cirúrgica empregada, com ênfase na anatomia cirúrgica do diafragma. Resultados A técnica de acesso lateral retropleural minimamente invasivo à junção toracolombar, com aplicação de retrator tubular expansível, foi descrita passo a passo neste estudo, com destaque de pontos cruciais de execução técnica, tais como planejamento pré-operatório, acesso ao plano retropleural e abordagem ortogonal para discectomia e/ou corpectomia adequadas e posterior colocação de implante. Ela pode ser usada no tratamento de deformidades, doenças degenerativas, trauma, tumor e infecções e possibilita taxas adequadas de fusão pela artrodese intersomática associada à menor incisão de pele, dano aos tecidos moles, perda sanguínea e dor pós-operatória. Resulta, assim, em melhor mobilidade pós-cirúrgica e menor período de internação hospitalar, o que pode ser observado também nos dados da experiência inicial do Serviço. Conclusões A técnica de acesso lateral retropleural minimamente invasivo à junção toracolombar com aplicação de retrator tubular expansível mostra-se promissora e segura para tratamento de diversas doenças da coluna, apesar da anatomia local complexa e desafiadora e apresenta vantagens diante da morbidade decorrente da abordagem tradicional. Nível de evidência: IV; Série de casos.
RESUMEN Objetivo Describir la técnica mínimamente invasiva para acceso lateral retropleural a la columna toracolumbar y su viabilidad en diversas afecciones de la región, demostrando sus indicaciones, ventajas en potencial y cuidados necesarios, destacando la anatomía local, especialmente el diafragma. Métodos Después de revisión de la literatura, se relata la experiencia del Servicio, comparándola a los resultados publicados. Se describe la técnica quirúrgica empleada, con énfasis en la anatomía quirúrgica del diafragma. Resultados La técnica de acceso lateral retropleural mínimamente invasivo a la junción toracolumbar, con aplicación de retractor tubular expansible, fue descrita paso a paso en este estudio, con destaque de puntos cruciales de ejecución técnica, tales como planificación preoperatoria, acceso al plano retropleural y abordaje ortogonal para discectomía y/o corpectomía adecuadas y posterior colocación de implante. La misma puede ser usada en el tratamiento de deformidades, enfermedades degenerativas, trauma, tumor e infecciones y posibilita tasas adecuadas de fusión por artrodesis intersomática asociada a la menor incisión de piel, daño a los tejidos blandos, pérdida sanguínea y dolor postoperatorio. Resulta, así, en mejor movilidad postquirúrgica y menor período de internación hospitalaria, lo que puede ser observado también en los datos de la experiencia inicial del Servicio. Conclusiones La técnica de acceso lateral retropleural mínimamente invasivo a la junción toracolumbar con aplicación de retractor tubular expansible se muestra prometedora y segura para tratamiento de diversas enfermedades de la columna, a pesar de la anatomía local compleja y difícil, y presenta ventajas delante de la morbilidad del abordaje tradicional. Nivel de evidencia IV; Serie de casos.
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Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos , Columna Vertebral , Cavidad PleuralRESUMEN
ABSTRACT Objective: To evaluate the influence of the MIS-TLIF technique on the spinopelvic parameters of patients submitted to lumbar arthrodesis up to three levels for the treatment of vertebral degenerative conditions without deformity. Methods: Retrospective radiographic evaluation of 52 patients submitted to the surgical treatment of lumbar arthrodesis using the MIS-TLIF technique in up to three levels. The spinopelvic parameters - pelvic incidence (PI), pelvic tilt(PT), lumbar lordosis (LL), segmental lordosis (Lseg), and the difference between lumbar lordosis and pelvic incidence (LL-PI mismatch) were analyzed in orthostatic lateral radiographs in the pre- and postoperative periods, with a minimum follow-up of 1 year. The patients were divided into three groups: PI <45°, PI between 45° and 55° and PI >55°. Results: Sixty-nine operated levels were evaluated in 15 patients with PI <45°, 19 with PI between 45° and 55° and 18 with PI >55°. The mean value of the pelvic incidence was 52.3° (± 11.5), lumbar lordosis 46.1° (pre)/45.6° (post); segmental lordosis 20.3° (pre)/20.6° (post); pelvic tilt 18.5° (pre)/18.2° (post); "mismatch" (PI-LL) 7° (pre)/ 6.6° (post), with no statistical difference among all parameters (p>0.05). Conclusions: The MIS-TLIF technique had no influence on postoperative spinopelvic parameters of patients undergoing lumbar arthrodesis surgery. Level of evidence: III. Retrospective comparative study.
RESUMO Objetivos: Avaliar a influência da técnica MIS-TLIF nos parâmetros espinopélvicos de pacientes submetidos à artrodese lombar até três níveis para tratamento de condições degenerativas vertebrais sem deformidade. Métodos: Avaliação radiográfica retrospectiva de 52 pacientes submetidos a tratamento cirúrgico de artrodese lombar pela técnica MIS-TLIF em até três níveis. Os parâmetros espinopélvicos - incidência pélvica (PI), versão pélvica (PT), lordose lombar (LL), lordose segmentar (Lseg), diferença entre lordose lombar e incidência pélvica ("mismatch" PI-LL) foram analisados em radiografias em perfil ortostático no pré e pós-operatório, com segmento mínimo de 1 ano. Os pacientes foram divididos em três grupos: PI<45°; PI entre 45° e 55°e PI> 55°. Resultados: Foram avaliados 69 níveis operados - PI < 45°, 15 pacientes; PI entre 45° e 55°, 19 e PI > 55°, 18. O valor médio da incidência pélvica foi 52,3° (+/- 11,5), lordose lombar 46,1° (pré) / 45,6° (pós); lordose segmentar 20,3° (pré) / 20,6° (pós); rotação pélvica 18,5° (pré) / 18,2° (pós); "mismatch" (PI-LL) 7° (pré) / 6,6°(pós), sem diferença estatística entre todos os parâmetros (p>0,05). Conclusão: A técnica MIS-TLIF não apresentou influência nos parâmetros espinopélvicos no pós-operatório de pacientes submetidos à cirurgia de artrodese lombar. Nível de evidência III. Estudo retrospectivo comparativo.
RESUMEN Objetivo: Evaluar la influencia de la técnica MIS-TLIF sobre los parámetros espinopélvicos de pacientes sometidos a artrodesis lumbar de hasta tres niveles para el tratamiento de condiciones vertebrales degenerativas sin deformidad. Métodos: Evaluación radiográfica retrospectiva de 52 pacientes sometidos a tratamiento quirúrgico de artrodesis lumbar por la técnica MIS-TLIF en hasta tres niveles. Los parámetros espinopélvicos como incidencia pélvica (IP), inclinación pélvica (PT), lordosis lumbar (LL), lordosis segmentaria (Lseg) diferencia entre lordosis lumbar e incidencia pélvica ("mismatch" LL-) se analizaron en radiografías laterales ortostáticas en el pre y postoperatorio, con seguimiento mínimo de 1 año. Los pacientes se dividieron en tres grupos: IP < 45°, IP entre 45° y 55° e IP > 55°. Resultados: Se evaluaron 69 niveles operados en 15 pacientes con IP < 45°, 19 con IP entre 45° y 55° y 18 con IP > 55°. El valor promedio de la incidencia pélvica fue 52,3° (± 11,5), lordosis lumbar 46,1° (pre)/45,6° (post), lordosis segmentaria 20,3° (pre)/20,6° (post), rotación pélvica 18,5° (pre)/18,2° (post), "mismatch" IP-LL 7° (pre)/6,6° (post), sin diferencia estadística entre todos los parámetros (p > 0,05). Conclusiones: La técnica MIS-TLIF no influenció los parámetros espinopélvicos en el postoperatorio de pacientes sometidos a cirugía de artrodesis lumbar. Nivel de evidencia: III. Estudio retrospectivo comparativo.
Asunto(s)
Humanos , Columna Vertebral/cirugía , Artrodesis , Curvaturas de la Columna Vertebral , Enfermedades de la Columna VertebralRESUMEN
Symptomatic disc degeneration is a complex pathological condition that involves a cascade of events and is not totally understood. In this context, animal models gain an important role, allowing for better understanding of the degenerative process and therapeutic interventions. There are several models with different methods of evaluation of experimental disc degeneration (EDD), including imaging, biochemical, genetics, and histological approaches, but no real gold standard has been set. The authors aim to evaluate EDD by means of automated morphometric analysis and to determine values for differentiating normal and degenerated discs by this method. The criteria mean and total cellular area, mean and total cytoplasm area, and total nuclear area of cells in the nucleus pulposus were able to differentiate the condition of degeneration (p < 0.05). In conclusion, by applying the histomorphometric analysis of EDD, the authors could present an objective measure of EDD changes within the nucleus pulposus, reducing the evaluator bias in future studies and presenting highly sensitive and specific criteria for EDD.
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ABSTRACT OBJECTIVE: The objective of this research was to evaluate the influence of autologous mononuclear stem cells injections on histological changes of collagen in the fibrous annulus of the intervertebral disk after experimental injury. METHODS: 32 New Zealand rabbits were submitted to intervertebral disk puncture, followed by intradiscal injection of mononuclear cells from the iliac crest versus saline injection in the following time periods: two months after the injury (SC2M and SS2M), two weeks (SC2W and SS2W) immediately after injury (SCCP and SSCP), and without inducing degeneration (SCSP and SSSP). Two months after cell therapy, the animals were euthanized and collagen changes in the intervertebral discs were histologically evaluated. RESULTS: There were significant differences in ELAF between SS2W and SS2S groups (p = 0.018). This difference was due to an increase in type I collagen in SS2W group (56.7%) compared to SC2S (13.28%). CONCLUSION: Treatment with mononuclear mesenchymal stem cells reduced changes in the type I and III collagen distribution in rabbits AF degenerated discs up to two weeks after the induction of degeneration.
RESUMO OBJETIVO: Avaliar a influência da injeção de células-tronco mononucleares autólogas sobre as alterações histológicas do colágeno no ânulo fibroso do disco intervertebral após lesão experimental. MÉTODOS: Foram submetidos 32 coelhos New Zealand a punção do discos intervertebrais lombares seguida de injeção intradiscal de células mononucleares provenientes da crista ilíaca versus injeção de solução salina nos seguintes períodos tempo: dois meses após a lesão (CT2M e SS2M), duas semanas (CT2S e SS2S), imediatamente após a lesão (CTCP e SSCP) e sem induzir a degeneração (CTSP e SSSP). Após dois meses da terapia celular, os animais foram submetidos a eutanásia e as alterações do colágeno nos discos intervertebrais foram avaliadas histologicamente. RESULTADOS: Houve diferença estatisticamente significativa na CEAF entre os grupos CT2S e SS2S (p = 0,018). Essa diferença decorreu de um aumento do colágeno do tipo I no grupo SS2S (56,7%) comparado com o CT2S (13,28%). CONCLUSÃO: O tratamento com células mononucleares precursoras mesenquimais é capaz de reduzir as alterações na distribuição do colágeno do tipo I e III no AF de discos degenerados de coelhos até duas semanas após a indução da degeneração.
Asunto(s)
Animales , Conejos , Tratamiento Basado en Trasplante de Células y Tejidos , Colágeno , Histología , Disco IntervertebralRESUMEN
OBJECTIVE: To validate radiographic evaluation of a rabbit model for disc degeneration. METHODS: Lumbar intervertebral discs of New Zealand rabbits were stabbed three times with a 18G needle at a limited depth of 5mm, through lateral approach. Serial radiographic images were taken on the early pre-and postoperative periods, and after four, eight and 12 weeks of the procedure, with subsequent analysis of disc height, osteophyte formation, endplate sclerosis, and presence of disc degeneration. The statistical analysis of data was validated by the Kappa coefficient, with a confidence interval (CI) of 95%. RESULTS: A significant reduction of disc space was found on AP X-ray images after 12 postoperative weeks, with Kappa = 0.489 for CI 95% (0.25-0.72) with p < 0.001. X-ray signs of disc degeneration also presented Kappa = 0.63 for CI 95% (0.39-0.86) with p < 0.001. The remaining assessed criteria showed positive results, but with a lower Kappa value. CONCLUSION: The disc degeneration model using rabbits as proposed in this study was shown to be feasible, with positive X-ray correlation between pre- and postoperative images, validating the potential to induce disc degeneration in this animal model for future studies.
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OBJETIVO: Validar um método para avaliação histológica da degeneração discal experimental em coelhos, baseando-se na confiabilidade da análise interobservador. MÉTODOS: Treze coelhos da raça New Zealand foram submetidos a procedimento de indução da degeneração discal através de punção direta de três discos intervertebrais (DIV) consecutivos com agulha 18G sob anestesia. Ao fim de dois meses, coletou-se a coluna vertebral completa de cada coelho e procedeu-se preparo das peças para análise histológica dos discos intervertebrais (Experimentais e Controle), sendo coradas pelo método hematoxilina-eosina. As lâminas histológicas foram avaliadas quanto à ocorrência de degeneração através da análise dos seguintes critérios: presença de vasos sanguíneos; presença de protrusão do núcleo pulposo (NP) através do ânulo fibroso (AF); e ruptura das fibras do AF. RESULTADOS: Ao final dos processos de eutanásia, retirada da coluna e preparo histológico, obteve-se 60 DIV viáveis para avaliação de degeneração. Deste total, 25 peças eram de DIV experimentais e 35 peças de DIV controle. A presença de vaso sanguíneo foi observada em 18 dos 25 DIV degenerados, com concordância de Kappa = 0,95 entre os observadores. A presença da extrusão do NP foi identificada em 19 dos 25 DIV experimentais, com concordância de Kappa = 0,78 entre os observadores. Com relação à ruptura das fibras do AF, pode-se identificar a positividade em 24 dos 25 DIV degenerados, com concordância entre os observadores de Kappa = 0,65. CONCLUSÃO: Este modelo de avaliação histológica da degeneração experimental do DIV mostrou-se viável, com alto grau de concordância entre os observadores na identificação da degeneração discal.
OBJECTIVE: To validate a method for histological evaluation of disc degeneration in rabbits based on the reliability of interobserver analysis. METHODS: Thirteen New Zealand white rabbits underwent a procedure to induce disc degeneration through direct puncture of three consecutive intervertebral discs (IVD) with an 18G needle under anesthesia. After two months, the complete spine of each rabbit was collected, and further prepared for histologic examination of the intervertebral discs (Experimental and Control), and stained with the hematoxylin-eosin method. Histology slides were evaluated for the occurrence of degeneration by analyzing the following criteria: presence of blood vessel, presence of protrusion of the nucleus pulposus (NP) through the annulus fibrosus (AF), and rupture of the fibers of the AF. RESULTS: After the euthanasia procedures, collection of the spine and histological preparation, 60 viable IVD were obtained for degeneration assessment. Of a total of 60 pieces, 25 pieces were from Experimental IVD and 35 pieces were from Control IVD. The presence of blood vessel was observed in 18 of 25 degenerated IVD with agreement among observers of Kappa = 0.95. The presence of the extrusion of the NP was identified in 19 of 25 experimental IVD with interobserver agreement of Kappa = 0.78. The rupture of the fibers of AF could be identified in 24 of 25 degenerated IVD, with interobserver agreement of Kappa = 0.65. CONCLUSION: This model of histological assessment of experimental IVD degeneration is feasible, with a high degree of interobserver agreement in the identification of disc degeneration.
OBJETIVO: Validar un método para evaluación histológica de la degeneración discal experimental en conejos, basándose en la confiabilidad del análisis interobservadores. MÉTODOS: Trece conejos de la raza New Zealand fueron sometidos a procedimiento de inducción de la degeneración discal a través de punción directa de tres discos intervertebrales (DIV) consecutivos con aguja 18G bajo anestesia. Al fin de dos meses, se colectó la columna vertebral completa de cada conejo y se procedió a la preparación de las piezas para análisis histológico de los discos intervertebrales (Experimentales y Controles), siendo coloreadas por el método hematoxilina-eosina. Las láminas histológicas fueron evaluadas cuanto a ocurrencia de degeneración a través del análisis de los siguientes criterios: presencia de vasos sanguíneos; presencia de protrusión del núcleo pulposo (NP) a través del anillo fibroso (AF); y rotura de las fibras del AF. RESULTADOS: Al final de los procesos de eutanasia, remoción y preparación histológica de la columna, se obtuvieron 60 DIV viables para evaluación de degeneración. De este total, 25 piezas eran de DIV experimentales y 35 piezas de DIV control. La presencia de vaso sanguíneo fue observada en 18 de los 25 DIV degenerados, con concordancia de Kappa = 0,95 entre los observadores. La presencia de la extrusión del NP fue identificada en 19 de los 25 DIV experimentales, con concordancia de Kappa = 0,78 entre los observadores. Con relación a la rotura de las fibras del AF, se puede identificar la positividad en 24 de los 25 DIV degenerados, con concordancia entre los observadores de Kappa = 0,65. CONCLUSIÓN: Este modelo de evaluación histológica de la degeneración experimental del DIV se mostró viable, con alto grado de concordancia entre los observadores en la identificación de la degeneración discal.
Asunto(s)
Humanos , Salud , Histología , Disco Intervertebral , Modelos Animales , Conejos , Reproducibilidad de los ResultadosRESUMEN
OBJETIVO: Validar a avaliação radiográfica da degeneração discal experimental em coelhos. MÉTODOS: Os discos intervertebrais lombares de coelhos New Zealand foram puncionados três vezes com uma agulha 18G com profundidade limitada de 5mm, através de abordagem lateral. Foram realizadas radiografias seriadas pré e pós-operatórias imediatas, e depois de quatro, oito e 12 semanas do procedimento, com posterior análise da altura discal, formação de osteófito, esclerose da placa vertebral e presença de degeneração discal. A análise estatística dos dados foi validada pelo coeficiente de concordância Kappa, com intervalo de confiança (IC) de 95 por cento. RESULTADOS: Observou-se diminuição significativa do espaço discal nas radiografias em AP após 12 semanas de pós-operatório, com Kappa = 0,489 para IC 95 por cento (0,25-0,72) com p < 0,001. Os sinais radiográficos de degeneração discal também apresentaram valor de Kappa = 0,63 para IC 95 por cento (0,39-0,86) com p < 0,001. Os demais critérios avaliados tiveram resultados positivos, porém, com menor valor de Kappa. CONCLUSÃO: O modelo de degeneração discal em coelhos proposto neste estudo mostrou-se factível, com correlação radiológica positiva entre as imagens pré e pós-operatórias, validando a possibilidade de indução de degeneração discal nesse modelo animal para futuros estudos.
OBJECTIVE: To validate radiographic evaluation of a rabbit model for disc degeneration. METHODS: Lumbar intervertebral discs of New Zealand rabbits were stabbed three times with a 18G needle at a limited depth of 5mm, through lateral approach. Serial radiographic images were taken on the early pre-and postoperative periods, and after four, eight and 12 weeks of the procedure, with subsequent analysis of disc height, osteophyte formation, endplate sclerosis, and presence of disc degeneration. The statistical analysis of data was validated by the Kappa coefficient, with a confidence interval (CI) of 95 percent. RESULTS: A significant reduction of disc space was found on AP X-ray images after 12 postoperative weeks, with Kappa = 0.489 for CI 95 percent (0.25-0.72) with p < 0.001. X-ray signs of disc degeneration also presented Kappa = 0.63 for CI 95 percent (0.39-0.86) with p < 0.001. The remaining assessed criteria showed positive results, but with a lower Kappa value. CONCLUSION: The disc degeneration model using rabbits as proposed in this study was shown to be feasible, with positive X-ray correlation between pre- and postoperative images, validating the potential to induce disc degeneration in this animal model for future studies.