Adolescent idiopathic scoliosis without limb weakness: a differential diagnosis of core myopathy?

BACKGROUND: Core myopathies are a clinically and genetically heterogeneous group of congenital myopathies with the common defined histopathological feature of focally reduced oxidative activity on muscle biopsy. It has a low incidence, however, recent articles show broad clinical spectrum, suggesting that the real incidence should be considerably larger than previously described. Due to the important association between scoliosis and paravertebral muscle imbalance, numerous authors study, by biopsy of the spinal rotator muscles, potential changes that may elucidate the etiology of adolescent idiopathic scoliosis. CASE PRESENTATION: Two patients have been followed at Spine Group of Department of Orthopedics at Federal University of São Paulo, with an initial diagnosis of idiopathic scoliosis. Both patients had clinical and radiological findings compatible with it. The patients authorized, through the Term of Consent, intraoperative biopsy of muscle multifidus from the apex of the thoracic curve on concave and convex sides. After muscle biopsy was performed a histopathological analysis. As regard to the histopathological features: in both patients were identified, the presence of core structures in extensive areas with reduced oxidative activity running along the muscle fiber. CONCLUSIONS: All patients with 'idiopathic' scoliosis deserve a careful neurological evaluation, even if they have minimal muscle symptoms in the extremities. The frequent occurrence of scoliosis in patients with CORE Myopathies, supports the thesis that the change in the paravertebral muscle fiber must be the underlying pathogenic factor in scoliosis and may help us understand the onset and progression of curves in patients previously diagnosed with idiopathic scoliosis.

Surgical approaches for cervical spine facet dislocations in adults.

BACKGROUND: The choice of surgical approach for the management of subaxial cervical spine facet dislocations is a controversial subject amongst spine surgeons. Reasons for this include differences in the technical familiarity and experience of surgeons with the different surgical approaches, and variable interpretation of image studies regarding the existence of a traumatic intervertebral disc herniation and of the neurological status of the patient. Moreover, since the approaches are dissimilar, important variations are likely in neurological, radiographical and clinical outcomes. OBJECTIVES: To compare the effects (benefits and harms) of the different surgical approaches used for treating adults with acute cervical spine facet dislocation. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 May 2014), The Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 4), MEDLINE (1946 to April Week 5 2014), MEDLINE In-Process & Other Non-Indexed Citations (8 May 2013), EMBASE (1980 to 2014 Week 18), Latin American and Caribbean Health Sciences (9 May 2014), trial registries, conference proceedings and reference lists of articles to May 2014. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials that compared surgical approaches for the management of adults with acute cervical spine facet dislocations with and without spinal cord injury. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias and extracted data. MAIN RESULTS: We included one randomised and one quasi-randomised controlled trial involving a total of 94 participants and reporting results for a maximum of 84 participants. One trial included patients with spinal cord injuries and the other included patients without spinal cord injuries. Both trials compared anterior versus posterior surgical approaches. Both trials were at high risk of bias, including selection bias (one trial), performance bias (both trials) and attrition bias (one trial). Data were pooled for one outcome only: non-union. Reflecting also the imprecision of the results, the evidence was deemed to be of very low quality for all outcomes; which means that our level of uncertainty about the estimates is high.Neither trial found differences between the two approaches in neurological recovery or status, as shown in one study by small clinically insignificant differences in NASS (Northern American Spine Society) neurological scores (0 to 100: optimal score) at one year of follow-up: anterior mean score: 85.23 versus posterior mean score: 83.86; mean difference (MD) 1.37 favouring anterior approach, 95% confidence interval (CI) -9.76 to 12.50; 33 participants; 1 study). The same trial found no relevant between-approach differences at one year in patient-reported quality of life measured using the 36-item Short Form Survey physical (MD -0.08, 95% CI -7.26 to 7.10) and mental component scores (MD 2.88, 95% CI -3.32 to 9.08). Neither trial found evidence of significant differences in long-term pain, or non-union (2/38 versus 2/46; risk ratio (RR) 1.18, 95% CI 0.04 to 34.91). One trial found better sagittal and more 'normal' alignment after the anterior approach (MD -10.31 degrees favouring anterior approach, 95% CI -14.95 degrees to -5.67 degrees), while the other trial reported no significant differences in cervical alignment. There was insufficient evidence to indicate between-group differences in medical adverse events, rates of instrumentation failure and infection. One trial found that the several participants had voice and swallowing disorders after anterior approach surgery (11/20) versus none (0/22) in the posterior approach group: RR 25.19, 95% CI 1.58 to 401.58); all had recovered by three months. AUTHORS' CONCLUSIONS: Very low quality evidence from two trials indicated little difference in long-term neurological status, pain or patient-reported quality of life between anterior and posterior surgical approaches to the management of individuals with subaxial cervical spine facet dislocations. Sagittal alignment may be better achieved with the anterior approach. There was insufficient evidence available to indicate between-group differences in medical adverse events, rates of instrumentation failure and infection. The disorders of the voice and swallowing that occurred exclusively in the anterior approach group all resolved by three months. We are very uncertain about this evidence and thus we cannot say whether one approach is better than the other. There was no evidence available for other approaches. Further higher quality multicentre randomised trials are warranted.

ACUTE RADIATING LOW BACK PAIN IMPACT ON ROUTINE AND FUNCTION OF THE BRAZILIAN POPULATION: A CROSS-SECTIONAL STUDY.

Acute radiating low back pain is a frequently occurring clinical condition among the population, and it represents a significant portion of urgent care in public health services. Objective: Consider the clinical characteristics, demographics, as well as the intensity of the pain, discomfort, and dysfunction of patients who show a clinical diagnosis that is compatible with acute radicular pain, new or reoccurring after an asymptomatic period. Methods: Patients that display a clinical diagnosis that is compatible with acute sciatic nerve pain, with the beginning of it starting within three months, without previous history of a similar occurrence, were seen in an orthopedic health clinic from July 2020 to January 2021. Results: A total of 42 patients were seen with a compatible diagnosis, which represents 1.4% of all medical visits. To the best of our knowledge, no studies have considered the clinical and demographic characteristics of patients with acute radicular pain in the Brazilian population. This study has found a mean value on the disfunction index that is greater than what is suggested by the current literature. Conclusion: About 30% of individuals showed functional involvement that was considered crippling, which presented a stronger association with individuals with the presence of motor deficits, intensity of radiating pain, and professional inactivity. Level of Evidence IV, Cross-Sectional Study.

A lombociatalgia aguda é uma condição clínica bastante frequente na população e representa uma porção expressiva dos atendimentos de urgência nos serviços de saúde pública. Objetivo: Avaliar as características clínicas e demográficas, bem como a intensidade da dor e da disfunção de pacientes com quadro clínico compatível com dor radicular aguda, inédita ou recorrente após período assintomático. Métodos: Consideraram-se pacientes com quadro clínico compatível com dor ciática aguda que tenha se iniciado em até três meses, sem história prévia de episódio semelhante e que foram atendidos em uma unidade de pronto atendimento ortopédico entre julho de 2020 e janeiro de 2021. Resultados: Foram atendidos 42 pacientes com quadro clínico compatível, representando 1,4% do total de atendimentos realizados no serviço. Não há relatos de estudos que buscaram avaliar as características clínicas e demográficas dos pacientes com dor radicular aguda na população brasileira. Neste estudo, contudo, encontrou-se um elevado valor médio no índice de disfunção em comparação com a literatura atual. Conclusão: Cerca de 30% dos indivíduos apresentaram acometimento funcional considerado incapacitante, sendo que a presença de déficits motores, a intensidade de dor irradiada e a inatividade trabalhista foram estatisticamente maiores nesse grupo em relação aos demais. Nível de Evidência IV, Estudo Transversal.

Full-Endoscopic Lumbar Discectomy Approach Selection: A Systematic Review and Proposed Algorithm.

STUDY DESIGN: A systematic review of the literature to develop an algorithm formulated by key opinion leaders. OBJECTIVE: This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients. SUMMARY OF BACKGROUND DATA: Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed. MATERIALS AND METHODS: A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD). RESULTS: In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review. CONCLUSIONS: The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.

Minimally invasive swine spine surgery training: technical aspects, benefits, and anatomical limitations.

OBJECTIVE: To describe the technical specificities and feasibility of simulation of minimally invasive spine surgery in live pigs, as well as similarities and differences in comparison to surgery in humans. METHODS: A total of 22 Large White class swine models, weighing between 60 and 80kg, were submitted to surgical simulations, performed during theoretical-practical courses for training surgical techniques (microsurgical and endoscopic lumbar decompression; percutaneous pedicular instrumentation; lateral access to the thoracic spine, and anterior and retroperitoneal to the lumbar spine, and management of complications) by 86 spine surgeons. For each surgical technique, porcine anatomy (similarities and differences in relation to human anatomy), access route, and dimensions of the instruments and implants used were evaluated. Thus, the authors describe the feasibility of each operative simulation, as well as suggestions to optimize training. Study results are descriptive, with figures and drawings. RESULTS: Neural decompression surgeries (microsurgeries and endoscopic) and pedicular instrumentation presented higher similarities to surgery on humans. On the other hand, intradiscal procedures had limitations due to the narrow disc space in swines. We were able to simulate situations of surgical trauma in surgical complication scenarios, such as cerebrospinal fluid fistulas and excessive bleeding, with comparable realism to surgery on humans. CONCLUSION: A porcine model for simulation of minimally invasive spinal surgical techniques had similarities with surgery on humans, and is therefore feasible for surgeon training.

Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents.

BACKGROUND/OBJECTIVE: In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use. DESIGN: Retrospective, propensity score-matched, controlled, patient-level observational analysis. SETTING: A total of 45 nursing homes in Spain. PARTICIPANTS: A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls. INTERVENTION: Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid. MEASUREMENTS: At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use. RESULTS: Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints. CONCLUSION: We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Acute radiating low back pain impact on routine and function of the brazilian population: a cross-sectional study / Impacto da lombociatalgia aguda na rotina e função da população brasileira: um estudo transversal

ABSTRACT Acute radiating low back pain is a frequently occurring clinical condition among the population, and it represents a significant portion of urgent care in public health services. Objective: Consider the clinical characteristics, demographics, as well as the intensity of the pain, discomfort, and dysfunction of patients who show a clinical diagnosis that is compatible with acute radicular pain, new or reoccurring after an asymptomatic period. Methods: Patients that display a clinical diagnosis that is compatible with acute sciatic nerve pain, with the beginning of it starting within three months, without previous history of a similar occurrence, were seen in an orthopedic health clinic from July 2020 to January 2021. Results: A total of 42 patients were seen with a compatible diagnosis, which represents 1.4% of all medical visits. To the best of our knowledge, no studies have considered the clinical and demographic characteristics of patients with acute radicular pain in the Brazilian population. This study has found a mean value on the disfunction index that is greater than what is suggested by the current literature. Conclusion: About 30% of individuals showed functional involvement that was considered crippling, which presented a stronger association with individuals with the presence of motor deficits, intensity of radiating pain, and professional inactivity. Level of Evidence IV, Cross-Sectional Study.

RESUMO A lombociatalgia aguda é uma condição clínica bastante frequente na população e representa uma porção expressiva dos atendimentos de urgência nos serviços de saúde pública. Objetivo: Avaliar as características clínicas e demográficas, bem como a intensidade da dor e da disfunção de pacientes com quadro clínico compatível com dor radicular aguda, inédita ou recorrente após período assintomático. Métodos: Consideraram-se pacientes com quadro clínico compatível com dor ciática aguda que tenha se iniciado em até três meses, sem história prévia de episódio semelhante e que foram atendidos em uma unidade de pronto atendimento ortopédico entre julho de 2020 e janeiro de 2021. Resultados: Foram atendidos 42 pacientes com quadro clínico compatível, representando 1,4% do total de atendimentos realizados no serviço. Não há relatos de estudos que buscaram avaliar as características clínicas e demográficas dos pacientes com dor radicular aguda na população brasileira. Neste estudo, contudo, encontrou-se um elevado valor médio no índice de disfunção em comparação com a literatura atual. Conclusão: Cerca de 30% dos indivíduos apresentaram acometimento funcional considerado incapacitante, sendo que a presença de déficits motores, a intensidade de dor irradiada e a inatividade trabalhista foram estatisticamente maiores nesse grupo em relação aos demais. Nível de Evidência IV, Estudo Transversal.

Minimally invasive swine spine surgery training: technical aspects, benefits, and anatomical limitations

ABSTRACT Objective To describe the technical specificities and feasibility of simulation of minimally invasive spine surgery in live pigs, as well as similarities and differences in comparison to surgery in humans. Methods A total of 22 Large White class swine models, weighing between 60 and 80kg, were submitted to surgical simulations, performed during theoretical-practical courses for training surgical techniques (microsurgical and endoscopic lumbar decompression; percutaneous pedicular instrumentation; lateral access to the thoracic spine, and anterior and retroperitoneal to the lumbar spine, and management of complications) by 86 spine surgeons. For each surgical technique, porcine anatomy (similarities and differences in relation to human anatomy), access route, and dimensions of the instruments and implants used were evaluated. Thus, the authors describe the feasibility of each operative simulation, as well as suggestions to optimize training. Study results are descriptive, with figures and drawings. Results Neural decompression surgeries (microsurgeries and endoscopic) and pedicular instrumentation presented higher similarities to surgery on humans. On the other hand, intradiscal procedures had limitations due to the narrow disc space in swines. We were able to simulate situations of surgical trauma in surgical complication scenarios, such as cerebrospinal fluid fistulas and excessive bleeding, with comparable realism to surgery on humans. Conclusion A porcine model for simulation of minimally invasive spinal surgical techniques had similarities with surgery on humans, and is therefore feasible for surgeon training.

Reducing Physical Restraints in Nursing Homes: A Report From Maria Wolff and Sanitas.

OBJECTIVE: Physical restraints are associated with severe side effects and suffering. A comprehensive, person-centered, methodology was implemented in 41 Spanish nursing homes to safely eliminate restraints. METHODS: Data were collected in 2 waves: September 2011 (at the beginning of the intervention, n = 4361) and September 2014 (n = 5051). Use of 10 different types of physical restraints was recorded, as well as frequency of psychotropic medication prescription, falls, and mortality. RESULTS: Mean age was 83.4 (SD 8.5) and 63.5% of the residents had dementia. Frequency (95% confidence interval) of people having at least 1 restraint was reduced from 18.1% (17.0-19.3) to 1.6% (1.3-2.0). Use of benzodiazepines was also reduced, with no significant changes in other psychotropic medications and mortality. The rate of total falls increased from 13.1% (12.1-14.1) to 16.1% (15.1-17.1), with no significant increase in injurious falls. CONCLUSION: Physical restraints can almost completely be eliminated with reasonable levels of safety.

Intra- and interobserver reproducibility of the radiographic evaluation of cranial parameters / Reprodutibilidade intra e interobservadores da avaliação radiográfica de parâmetros cranianos / Reproducibilidad intra e interobservadores de la evaluación radiográfica de parámetros craneales

ABSTRACT Objective: To evaluate the intra- and interobserver reproducibility of radiographic cranial parameters. Method: A study of the reproducibility of the radiographic cranial parameters (cranial incidence, cranial tilt, cranial slope and spinocervical angle) of 40 patients by 4 observers with different levels of experience. Results: Cranial incidence (CI) showed poor intraobserver concordance; for the other cranial parameters, good to excellent concordance was observed. In the assessment of interobserver concordance, all the parameters analyzed showed statistical significance, with good CI concordance. Conclusion: Cranial parameters are easily reproducible by orthopedists with different levels of experience. CI showed good interobserver concordance, but only reasonable intraobserver concordance among more experienced observers. Level of evidence IV; Diagnostic Study.

RESUMO Objetivo: Avaliar a reprodutibilidade intra e interobservadores dos parâmetros radiográficos cranianos. Métodos: Estudo de mensuração da reprodutibilidade da avaliação radiográfica de parâmetros cranianos (incidência craniana, inclinação craniana, slope craniano e ângulo espinocervical) de 40 pacientes, por quatro observadores com diferentes níveis de experiência em duas ocasiões distintas. Resultados: Na concordância intraobservador, a incidência craniana (IC) mostrou concordância ruim; nos demais parâmetros cranianos, observou-se concordância boa a excelente. Na avaliação de concordância interobservadores, todos os parâmetros analisados apresentaram significância estatística, com boa concordância da IC. Conclusão: Os parâmetros cranianos são facilmente reprodutíveis por ortopedistas em diferentes estágios de formação. A IC tem boa concordância interobservador, porém concordância apenas razoável na análise de intraobservadores mais experientes. Nível de evidência IV; Estudo Diagnóstico.

RESUMEN Objetivo: Evaluar la reproducibilidad intra e interobservadores de los parámetros radiográficos craneales. Métodos: Estudio de medición de la reproducibilidad de la evaluación radiográfica de parámetros craneales (incidencia craneal, inclinación craneal, slope craneal y ángulo espinocervical) de 40 pacientes, por cuatro observadores con diferentes niveles de experiencia en dos ocasiones distintas. Resultados: En la concordancia intraobservador, la incidencia craneal (IC) mostró concordancia mala; en los demás parámetros craneales, se observó concordancia de buena a excelente. En la evaluación de concordancia interobservadores, todos los parámetros analizados presentaron significancia estadística, con buena concordancia de la IC. Conclusión: Los parámetros craneales son fácilmente reproducibles por los ortopedistas en diferentes etapas de formación. La IC tiene buena concordancia interobservador, aunque concordancia sólo razonable en el análisis de intraobservadores con más experiencia. Nivel de evidencia IV; Estudio Diagnóstico.

Options for surgical treatment of cervical fractures in patients with spondylotic spine: a case series and review of the literature.

INTRODUCTION: The surgical treatment of unstable cervical fractures is challenging for spinal surgeons. Unstable cervical fractures associated with spondyloarthropathy and deformities that alter function, form and stability present a greater challenge. Having multiple options to manage this difficult situation is important to all spine surgeons and the results of each case depends on the singular characteristics of patients. The purpose of this case report is to describe the main forms of presentation of unstable cervical subaxial fractures in the spondylotic spine and their surgical treatments. CASE PRESENTATION: We present three cases of Caucasian men aged 30, 53 and 59 years with spondylosis with unstable cervical fractures and alternatives choices for surgical treatment, and a review of the literature. Each patient underwent a different surgical procedure of the cervical subaxial spine using an isolated anterior, posterior or combined approach demonstrating good outcomes in all cases. CONCLUSIONS: The treatment of subaxial cervical spinal fractures is complex, and when these fractures are associated with the deformities caused by spondyloarthropathies they can be thought provoking for spine surgeons such as orthopedists or neurosurgeons. The isolated anterior, posterior and combined approaches are safe and effective for treating these pathologies.

Histochemical analysis of paraspinal rotator muscles from patients with adolescent idiopathic scoliosis: a cross-sectional study.

Morphological, biochemical, and histopathological alterations in the paraspinal skeletal muscle of patients with adolescent idiopathic scoliosis (AIS) have been extensively reported. We evaluated rotator muscle fibers from the apex vertebra of AIS patients through histological and immunohistochemical analysis. A population of 21 female AIS patients who underwent corrective surgery between 2010 and 2013 had biopsies taken from the paraspinal muscle in the convex and concave sides of the thoracic curve apical vertebra. Serial sections were stained following routine protocols for hematoxylin and eosin (HE), Sudan red, Gomori trichrome, NADH, ATPase, and cytochrome oxidase. We assessed muscular atrophy and hypertrophy, fatty proliferation, endomysial and perimysial fibrosis, the presence of hyaline fibers, mitochondrial proliferation, muscular necrosis, nuclear centralization, and inflammation. Two independent professionals evaluated the slices. The thoracic curves had an average Cobb angle of 68 degree. Comparative analysis of the concave and convex sides was performed with McNemar test at a significance level of 5%. Results showed significant differences in both endomysial and perimysial fibrosis and fatty involution between the two sides of the apex vertebra. Paraspinal muscles in the concave side of the scoliosis apex had significantly more fibrosis and fatty involution. However, both sides showed signs of myopathy, muscular atrophy due to necrosis, presence of hyaline fibers, and mitochondrial proliferation.

Correlation between the schanz screw insertion angle and the loss of kyphosis correction in thoracolumbar fractures / Correlação entre o ângulo de inserção do pino de schanz e a perda de correção da cifose em fraturas toracolombares / Correlación entre el ángulo de inserción del tornillo de schanz y la pérdida de corrección de la cifosis en fracturas toracolumbares

ABSTRACT Objective To compare the Schanz screw insertion angle and the loss of the regional kyphosis correction in thoracolumbar burst fractures following posterior short instrumentation surgery. Methods Patients with a thoracolumbar burst fracture between levels T11-L2 were divided into two groups (parallel and divergent) according to the angle formed between the Schanz screw and the vertebral plateau. Regional kyphosis was evaluated in preoperative, immediate postoperative and last follow-up radiographs. Results Of the 58 patients evaluated, 31 had a parallel assembly and 27 had a divergent assembly. When we analyzed the angle of kyphosis, no statistical difference was observed between the pre- and postoperative radiographs. However, a statistical difference in the last follow-up radiographs and in the final loss of the kyphosis correction was confirmed. Conclusion The insertion of Schanz screws with a divergent assembly presents better radiographic results with less loss of kyphosis correction angle when compared with the parallel assembly technique. Level of Evidence III; Retrospective cohort study.

RESUMO Objetivo Comparar o ângulo de inserção do pino de Schanz e os resultados da perda de correção da cifose regional nas fraturas toracolombares do tipo explosão após tratamento cirúrgico com instrumentação curta por via posterior. Métodos Os pacientes com fratura toracolombar do tipo explosão entre os níveis de T11-L2 foram divididos em dois grupos (paralelo e divergente) de acordo com o ângulo formado entre o pino de Schanz e o platô vertebral. Foi avaliada a cifose regional nas radiografias pré-operatória, pós-operatória imediata e do último acompanhamento. Resultados Dos 58 pacientes avaliados, 31 apresentaram uma montagem paralela e 27 uma montagem divergente. Ao analisarmos o ângulo da cifose, não se observou diferença estatística nas radiografias pré- e pós-operatória imediata. Porém, verificou-se uma diferença estatística nas radiografias do último acompanhamento e na perda final de correção da cifose. Conclusões A inserção do pino de Schanz com uma montagem divergente apresenta melhores resultados radiográficos com menor perda do ângulo de correção da cifose quando comparada com a técnica de montagem paralela. Nível de Evidência III; Estudo de coorte retrospectivo.

RESUMEN Objetivo Comparar el ángulo de inserción del tornillo de Schanz y los resultados de la pérdida de corrección de la cifosis regional en las fracturas toracolumbares del tipo explosión después del tratamiento quirúrgico con instrumentación corta por vía posterior. Métodos Los pacientes con fractura toracolumbar del tipo explosión entre los niveles de T11-L2 fueron divididos en dos grupos (paralelo y divergente) de acuerdo con el ángulo formado entre el tornillo de Schanz y la meseta vertebral. Fue evaluada la cifosis regional en las radiografías preoperatoria, posoperatoria inmediata y del último acompañamiento. Resultados De los 58 pacientes evaluados, 31 presentaron un montaje paralelo y 27 un montaje divergente. Al analizar el ángulo de la cifosis, no se observó diferencia estadística en las radiografías pre y postoperatoria inmediata. Sin embargo, se verificó una diferencia estadística en las radiografías del último acompañamiento y en la pérdida final de corrección de la cifosis. Conclusiones La inserción del tornillo de Schanz con un montaje divergente presenta mejores resultados radiográficos con menor pérdida del ángulo de corrección de la cifosis cuando comparada con la técnica de montaje paralelo. Nivel de Evidencia III; Estudio de cohorte retrospectivo.

Correlation between findings in magnetic resonance and biopsy in the diagnosis of spondylodiscitis / Correlação entre achados na ressonância magnética e a biópsia no diagnóstico de espondilodiscite / Correlación entre hallazgos en la resonancia magnética y la biopsia en el diagnóstico de espondilodiscitis

ABSTRACT Objective To correlate magnetic resonance imaging (MRI) findings with the microbiological and anatomopathological diagnosis of spinal infection. Methods A retrospective, cohort review of online medical records (laboratory, anatomopathology and diagnostic imaging sector) of patients diagnosed with spondylodiscitis, who underwent a full spine MR scan between January 2014 and July 2018 at the Department of Orthopedics and Traumatology of the Universidade Federal de São Paulo. Results Staphylococcus aureus was the most commonly found etiological agent (57%). Blood culture was positive in 76% of cases and 82% of the patients who underwent biopsy had a spondylodiscitis diagnosis. Pain was the most prevalent clinical symptom and the lumbosacral spine was the most frequent site of infection. T1 hyposignal, T2/STIR hypersignal, and terminal plate destruction were verified in almost all MR scans. Conclusions No direct correlation was found between MR findings and any specific etiological agent. Blood culture and biopsy are important diagnostic tools that should be used for accurate diagnosis of the infectious agent . Level of evidence IV; Diagnostic Study.

RESUMO Objetivo Correlacionar os achados de ressonância magnética (RNM) com o diagnóstico microbiológico e anatomopatológico de infecção na coluna vertebral. Métodos Estudo de coorte retrospectivo de revisão de prontuários online (laboratório, anatomopatológico e setor de diagnóstico por imagem) de pacientes com diagnóstico de espondilodiscite, submetidos ao exame de RNM da coluna vertebral e acompanhados pelo Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo, entre janeiro de 2014 e julho de 2018. Resultados O agente etiológico mais comum encontrado foi o S. aureus (57%). A hemocultura mostrou-se positiva em 76% dos casos e 82% dos pacientes submetidos à biópsia apresentaram diagnóstico de espondilodiscite. A dor foi o achado clínico mais prevalente e a coluna lombossacra foi o sítio mais frequente de infecção. No exame de RNM, a presença de hipossinal em T1, hipersinal em T2/STIR e destruição das placas terminais foram identificados em quase todos os casos. Conclusões Não houve correlação direta dos achados na RNM com um agente etiológico específico na espondilodiscite. A hemocultura e a biópsia são ferramentas diagnósticas importantes que devem ser utilizadas para o diagnóstico preciso do agente infeccioso. Nível de evidência IV; Estudo diagnóstico.

RESUMEN Objetivo Correlacionar los hallazgos de resonancia magnética (RNM) con el diagnóstico microbiológico y anatomopatológico de infección de la columna vertebral. Métodos Un estudio de cohorte retrospectivo de revisión de prontuarios en línea (laboratorio, anatomopatológico y sector de diagnóstico por imagen) de pacientes con diagnóstico de espondilodiscitis, sometidos al examen de RNM de la columna vertebral y acompañados por el Departamento de Ortopedia y Traumatología de la Universidad Federal de São Paulo, entre enero de 2014 y julio de 2018. Resultados El agente etiológico más común encontrado fue el S. aureus (57%). El hemocultivo se mostró positivo en 76% de los casos y 82% de los pacientes sometidos a biopsia presentaron diagnóstico de espondilodiscitis. El dolor fue el hallazgo clínico más prevalente y la columna lumbosacra fue el sitio más frecuente de infección. En el examen de RNM, la presencia de hiposeñal en T1, hiperseñal en T2/STIR y destrucción de las placas terminales fueron identificadas en casi todos los casos. Conclusiones No hubo correlación directa de los hallazgos de la RNM con un agente etiológico específico en la espondilodiscitis. El hemocultivo y la biopsia son herramientas diagnósticas importantes, que deben ser utilizadas para el diagnóstico preciso del agente infeccioso. Nivel de evidencia IV; Estudio Diagnóstico.

Impact of surgeons' experience on accuracy of radiographic segmental kyphosis assessment in thoracolumbar fractures: a prospective observational study.

BACKGROUND: The thoracolumbar region is where most fractures of the spine are located. Segmental kyphosis is an important factor for treatment decisions. There are various methods for measuring segmental kyphosis in thoracolumbar fractures. Our objective was to evaluate if the experience of the surgeon has any influence on kyphosis measurement by analyzing three different categories of orthopedic surgeons and evaluate possible clinical impacts. MATERIAL AND METHODS: Six physicians separated into three categories according to the level of experience evaluated 30 lateral view radiographs of the thoracic spine of patients with single-level fracture taken during their outpatient follow-up visits. Images had segmental kyphosis measured by five distinct methods. The x-rays were evaluated twice and in a random order after an eight-week interval. The reproducibility of the measurements was analyzed by the intraclass correlation coefficient (ICC) and its respective 95% confidence interval. RESULTS: The intraclass correlation coefficient (ICC) was calculated to evaluate the inter- and intra-examiner reliability for each method. The methods that disregard the fractured vertebra (1 and 4) achieved the highest intra and inter-observers reliability among the participants. The measurements from methods 3 and 5 were poorly reproducible between examiners. The difference between the averages of the measurements of the five methods studied was greater than 5 degrees in methods 1 and 2, suggesting risk for patient safety. CONCLUSION: Methods that exclude the fractured vertebra were more reproducible for the evaluation of segmental kyphosis in thoracolumbar fractures. The evaluation of the spine fracture must be coupled with other radiographic criteria, more complex image exams and the patient's clinical state to assist the surgeon in deciding between conservative or surgical treatment. The authors suggest that the measurements should be performed by methods that exclude the fractured vertebra and conducted by experienced doctors.

Apophyseal ring fracture associated with two levels extruded disc herniation: case report and review of the literature.

Apophyseal ring fractures are rare injuries that may be associated with lumbar disc herniation in young patients. We report a unique case in the literature of a 15-year-old male patient who played football and was admitted at our service complaining of sciatica radiating into the left leg. An apophysial ring injury of L5 vertebral body was observed. This injury caused two extruded disc herniation in adjacent levels. Surgical procedure was indicated after failure of conservative treatment.

Minimally invasive posterior cervical microforaminotomy in the lower cervical spine and C-T junction assisted by O-arm-based navigation.

Navigated posterior cervical microforaminotomy (PCM) is a promising minimally invasive technique for treating radiculopathy caused by lateral disc herniations and foraminal stenosis. Between December 2009 and October 2010, 14 patients with unilateral foraminal disc herniations or foraminal stenosis at the C6-7 or C7-T1 level underwent PCM assisted by O-arm navigation using the METRx tubular retractor. The main symptoms were radicular arm pain with no significant neck pain. Successful relief of radicular pain was achieved in all 14 patients. Two of the patients were lost during follow-up, and three had to undergo further decompression due to remnant foraminal stenosis being discovered on intraoperative O-arm images. There were no cases of instability or recurrence, and the only complication observed was a dural tear in one patient, which was adequately treated with fibrin glue and bed rest. The duration of symptoms was 4.5 months on average. The mean operation time was 136 minutes, with the additional time required for the image guided surgery assisted by O-arm-based navigation being approximately 28 minutes on average. There were no other complications during the surgical procedure or in the immediate postoperative period. Posterior cervical microforaminotomy assisted by O-arm-based navigation is a safe, effective and minimally invasive procedure for the treatment of lateral disc herniations and foraminal stenosis of the lower cervical spine and C-T junction, offering the possibility of an accurate decompression with a reduced risk of segmental instability.

Assessment of scores in decision making in metastases of the spine / Avaliação de escores na tomada de decisão em metástases na coluna / Evaluación de las puntuaciones en la toma de decisiones en las metástasis de columna

Objective : The aim of this study is to assess the intra- and interobserver concordance of SINS, Harrington, Tokuhashi and Tomita scores among general orthopedic surgeons and spine surgeons with experience above 5 and 10 years in the evaluation of patients with spinal metastasis. Methods : Twenty cases of patients with metastatic lesion of the spine were presented to 10 examiners and the scores aforementioned have been applied. After six weeks, the cases were reintroduced in a different order and data were analyzed. Results : The intraobserver reliability showed better agreement in SINS score among examiners with less experience and Harrington and Tomita scores among those who had more than 10-year experience. The interobserver reliability of the examiners of the group with over 10-year experience showed higher precision when using these scores, especially Harrington and Tomita. The SINS score was the choice for daily practice and was able to modify the management more often. Conclusions : This study demonstrated that the use of predictive scores of instability, Harrington, and prognosis, Tomita, had a higher intra- and interobserver reliability particularly among spine surgeons with experience above 10 years.

Objetivo : O objetivo deste estudo é avaliar a concordância intra e interobservador dos escores SINS, Harrington, Tokuhashi e Tomita entre ortopedistas gerais e cirurgiões de coluna com experiência acima de cinco e 10 anos na avaliação de pacientes com metástase vertebral. Métodos : Foram apresentados 20 casos de pacientes com lesões metastáticas da coluna vertebral a 10 examinadores e os escores citados acima foram aplicados. Após seis semanas, os casos foram reapresentados em ordem diferente e os dados foram analisados. Resultados : A confiabilidade intraobservador apresentou melhor concordância no escore SINS entre os examinadores com menor experiência, e nos escores de Harrington e Tomita entre os que tinham experiência maior que 10 anos. A confiabilidade interobservador dos examinadores do grupo com experiência maior que 10 anos apresentou maior precisão na utilização desses escores, e com destaque para Harrington e Tomita. O escore SINS foi o de eleição para a prática diária e foi capaz de modificar a conduta com mais frequência. Conclusões : Este estudo demonstrou que o uso de escores preditores de instabilidade, Harrington, e prognóstico, Tomita, apresentam maior confiabilidade intra e interobservador, principalmente entre os cirurgiões de coluna com experiência superior a 10 anos.

Objetivo : El objetivo de este estudio es evaluar la concordancia intra e interobservador en las puntuaciones SINS, Harrington, Tokuhashi y Tomita entre los ortopedistas generales y cirujanos de la columna vertebral con experiencia superior a 5 y 10 años en la evaluación de pacientes con metástasis vertebrales. Métodos : Se presentaron 20 casos de pacientes con lesiones metastásicas de la columna vertebral a 10 examinadores, quienes aplicaron las puntuaciones mencionadas. Luego de seis semanas, los casos fueron reintroducidos en un orden diferente y se analizaron los datos. Resultados : La fiabilidad intraobservador mostró mejor concordancia en la puntuación SINS entre los examinadores con menos experiencia y en los puntajes Harrington y Tomita en los que tenían experiencia de más de 10 años. La fiabilidad interobservador de los examinadores del grupo con más de 10 años de experiencia mostró una mayor precisión en el uso de estas puntuaciones, especialmente las puntuaciones Harrington y Tomita. La puntuación SINS fue de elección para la práctica diaria y ha sido capaz de modificar la conducta con más frecuencia. Conclusiones : Este estudio demostró que el uso de las puntuaciones de predicción de inestabilidad, Harrington, y del pronóstico, Tomita, presentan mayor fiabilidad intra e interobservador principalmente entre los cirujanos de columna con más de 10 años de experiencia.

Apophyseal ring fracture associated with two levels extruded disc herniation: case report and review of the literature / Fratura do anel apofisário associada à hérnia discal extrusa de dois níveis: relato de caso e revisão da literatura

Apophyseal ring fractures are rare injuries that may be associated with lumbar disc herniation in young patients. We report a unique case in the literature of a 15-year-old male patient who played football and was admitted at our service complaining of sciatica radiating into the left leg. An apophysial ring injury of L5 vertebral body was observed. This injury caused two extruded disc herniation in adjacent levels. Surgical procedure was indicated after failure of conservative treatment.

As fraturas do anel apofisário são lesões raras, que podem estar associadas à hérnia de disco lombar nos pacientes jovens. Apresentamos aqui um caso único na literatura de paciente de 15 anos, gênero masculino, praticante de futebol, com queixa de ciatalgia para o membro inferior esquerdo. Houve lesão do anel apofisário, nos planaltos superior e inferior do corpo vertebral de L5, ocasionando hérnias discais extrusas nos níveis adjacentes. O procedimento cirúrgico foi indicado após a falha do tratamento conservador.