Navigating the Indeterminate Zone: Surgeons' Decision-Making Factors in Treating Vertebral Metastases with Spinal Instability Scores of 7-12.

BACKGROUND: The Spinal Instability Neoplastic Score (SINS) classification system is a validated and the most widely accepted instrument for defining instability in vertebral metastasis (VM), in which lesions scoring between 7 and 12 are defined as indeterminate and the treatment is controversial. This study aimed to determine which variables more frequently are considered by spine surgeons for choosing between the conservative and the surgical treatment of VMs among patients with an indeterminate SINS. METHODS: A single-round online survey was conducted with 10 spine surgeons with expertise in the management of VMs from our AO Spine Region. In this survey, each surgeon independently reviewed demographic and cancer-related variables of 36 real-life cases of patients with vertebral metastases scored between 7 and 12 in the SINS. Bivariate and multivariate analyses were performed to identify significant SINS and non-SINS variables influencing the decision-making on surgical treatment. RESULTS: The most commonly variables considered important were the SINS element "mechanical pain", rated important for 44.4% of the cases, "lesion type" for 36.1%, and "degree of vertebral collapse" and the non-SINS factor "tumor histology" rated for 13.9% of cases. By far the factor most commonly rated unimportant was "posterior element compromise" (in 72.2% of cases). CONCLUSIONS: Surgeons relied on mechanical pain and type of metastatic lesion for treatment choices. Vertebral collapse, spinal malalignment, and mobility were less influential. Spinal mobility was a predictor of surgical versus non-surgical treatment. The only variables not identified either by surgeons themselves or as a predictor of surgery selection was the presence/degree of posterolateral/posterior element involvement.

Clinical-radiographic correlation of degenerative changes of the spine - systematic review / Correlação clínico-radiológica das alterações degenerativas da coluna - revisão sistemática / Correlación clínico-radiológica de los cambios degenerativos de la columna - revisión sistemática

ABSTRACT Systematic review of the literature on the evaluation of images of degenerative changes of the spine and its clinical correlation. A systematic literature review was conducted, and the results evaluated for the presence of clinical correlation, as well as the type of imaging method used. The search terms were "Intervertebral Disc Degeneration", "Intervertebral disc", "Classification", "Anulus fibrosus", "Nucleus pulposus", "Lumbar spine", "Degenerative disc disease", "Degeneration", "Zygapophyseal Joint". We also assessed whether there were inter- and intraobserver agreement in the selected works and possible guidelines regarding the treatment and prognosis of patients. Of the 91 reviewed abstracts, 31 articles were selected that met the inclusion criteria. Six articles were related to the cervical spine, 13 to the lumbar spine and 12 were about changes not related specifically to a single segment of the spine. Articles that determined limiting values considered normal were also included, since variations were considered signs of degeneration or pathology. It was not possible to establish the relationship between the changes identified in imaging and the clinical history of patients, either define treatment and prognosis guidelines.

RESUMO Revisão sistemática da literatura de avaliação por imagem das alterações degenerativas da coluna e sua correlação clínica. A revisão sistemática da literatura foi realizada e seus resultados, avaliados com relação à presença de correlação clínica, assim como o tipo de método de imagem utilizado. Os termos de pesquisa foram "Intervertebral Disc Degeneration", "Intervertebral disc", "Classification", "Anulus fibrosus", "Nucleus pulposus", "Lumbar spine", "Degenerative disc disease", "Degeneration", "Zygapophyseal Joint". Também se avaliou se houve concordância inter e intraobservador nos trabalhos selecionados e possíveis orientações com relação ao tratamento e ao prognóstico dos pacientes. Dos 91 resumos revisados, foram selecionados 31 artigos que satisfizeram os critérios de inclusão. Seis artigos estavam relacionados com a coluna cervical, 13 com a coluna lombar e 12 versavam sobre alterações não relacionadas especificamente com um único segmento da coluna. Os artigos que determinaram valores limítrofes considerados normais também foram incluídos, uma vez que suas variações foram consideradas sinais de degeneração ou patologia. Não foi possível estabelecer a relação entre alterações identificadas nos exames de imagem e a história clínica dos pacientes, tampouco definir orientações de tratamento e prognóstico.

RESUMEN Revisión sistemática de la literatura sobre evaluación por imágenes de los cambios degenerativos de la columna y su correlación clínica. Fue realizada una revisión sistemática de la literatura y sus resultados evaluados cuanto a la presencia de correlación clínica, así como al tipo de método de imagen utilizado. Los términos de búsqueda fueron "Intervertebral Disc Degeneration", "Intervertebral disc", "Classification", "Anulus fibrosus", "Nucleus pulposus", "Lumbar spine", "Degenerative disc disease", "Degeneration", "Zygapophyseal Joint". Se evaluó también si había concordancia inter e intraobservador en los trabajos seleccionados, además de las posibles orientaciones en cuanto al tratamiento y al pronóstico de los pacientes. De los 91 resúmenes revisados, treinta y un artículos que cumplieron los criterios de inclusión fueron seleccionados. Seis artículos estaban relacionados con la columna cervical, 13 con la columna lumbar y 12 eran acerca de cambios no relacionados específicamente a un solo segmento de la columna vertebral. También se incluyeron artículos que determinaron valores límites considerados normales, ya que los cambios fueron considerados señales de degeneración o patología. No fue posible establecer la relación entre los cambios identificados en las imágenes y la historia clínica de los pacientes, tampoco definir orientaciones de tratamiento y pronóstico.

Patients with spinal metastasis submitted to neurological decompression and stabilization / Pacientes com metástases na coluna vertebral submetidos à descompressão neurológica e estabilização / Pacientes con metástasis espinal sometidos a descompresión neurológica y estabilización

ABSTRACT Objective: To analyze retrospectively the surgical outcomes of a group of patients with bone metastases and multiple myeloma in the spine, which underwent neurological decompression and arthrodesis using pedicle screws, by isolated posterior approach, to check whether the operated patients present clinical improvement regarding the pain and neurological deficit compared to the preoperative period. Methods: This is a retrospective, cross-sectional study of case series, that analyzed data from medical records of patients with bone metastases in the spine who underwent surgical treatment between January 2007 and February 2011. Results: Of the 42 patients in the sample, according to the Kolmogorov-Smirnov test (p=0.000) there was improvement in pain with respect to the preoperative, with 33 patients (78.6%) reporting improvement and only 9 (21.4%) maintaining the initial pain complaints. Of the 25 patients available for evaluation of neurological improvement (≠ Frankel E) 9 patients (36%) had some kind of improvement postoperatively, and no operated patient presented neurological worsening, indicating statistical significance according to the Kolmogorov-Smirnov test (p = 0.000). It was also observed statistical correlation (p=0.042) between Frankel functional score postoperatively and pain relief, using the chi-square test. Conclusions: Surgical treatment for patients with spinal metastasis through arthrodesis with pedicle instrumentation and decompression may have significant clinical benefits, especially as regards the improvement in pain symptoms and improved neurological function.

RESUMO Objetivo: Analisar retrospectivamente os resultados cirúrgicos de um grupo de pacientes com diagnóstico de metástases óssea e mieloma múltiplo na coluna vertebral, submetidos à descompressão neurológica e artrodese com instrumentação, utilizando parafusos pediculares por via posterior isolada, para verificar se os pacientes operados apresentam melhora clínica quanto à dor e ao déficit neurológico com relação ao pré-operatório. Métodos: Trata-se de um estudo retrospectivo, transversal do tipo série de casos, no qual foram analisados os dados dos prontuários dos pacientes portadores de metástase óssea na coluna vertebral, submetidos a tratamento cirúrgico, entre janeiro de 2007 e fevereiro de 2011. Resultados: Dos 42 pacientes da amostra, de acordo com teste de Kolmogorov-Smirnov (p = 0,000), houve melhora do quadro de dor com relação ao pré-operatório, com 33 pacientes (78,6%) relatando melhora e apenas 9 deles (21,4%) mantendo as queixas álgicas iniciais. Dos 25 pacientes disponíveis para avaliação de melhora neurológica (≠Frankel E) 9 pacientes (36%) apresentaram algum tipo de melhora no pós-operatório e nenhum paciente operado apresentou piora neurológica, indicando significância estatística de acordo com teste de Kolmogorov-Smirnov (p = 0,000). Observou-se também correlação estatística (p = 0,042) entre o escore funcional de Frankel no pós-operatório e a melhora da dor, usando o teste do qui-quadrado. Conclusões: O tratamento cirúrgico para os pacientes com metástases da coluna vertebral, por meio de artrodese com instrumentação pedicular e descompressão, pode trazer benefícios clínicos significativos, principalmente no que diz respeito a melhora do quadro álgico e melhora da função neurológica.

RESUMEN Objetivo: Evaluar retrospectivamente los resultados quirúrgicos de pacientes con metástasis ósea y mieloma múltiple en la columna vertebral, sometidos a descompresión neurológica y artrodesis con instrumentación con tornillos pediculares solamente por acceso posterior, para verificar si los pacientes muestran mejoría clínica con respecto al dolor y el déficit neurológico en relación con el período preoperatorio. Métodos: Se trata de un estudio transversal, retrospectivo, de serie de casos en el que se analizaron los datos de las historias clínicas de los pacientes con metástasis ósea en la columna vertebral, sometidos a cirugía entre enero de 2007 y febrero de 2011. Resultados: De los 42 pacientes de la muestra, de acuerdo con la prueba de Kolmogorov-Smirnov (p = 0,000), hubo una mejoría en el dolor con respecto al preoperatorio, con 33 pacientes (78,6%) reportando mejoría y sólo 9 de ellos (21,4%) manteniendo las quejas iniciales de dolor. De los 25 pacientes disponibles para evaluación de mejoría neurológica (≠ Frankel E) 9 pacientes (36%) tuvieron algún tipo de mejora en el postoperatorio y ningún paciente operado presentó empeoramiento neurológico, lo que indica la significación estadística de acuerdo con la prueba de Kolmogorov-Smirnov (p = 0,000). También se observó correlación estadística (p = 0,042) entre la puntuación funcional de Frankel después de la operación y el alivio del dolor, mediante la prueba de chi-cuadrado. Conclusiones: El tratamiento quirúrgico de los pacientes con metástasis en la columna vertebral por medio de artrodesis con instrumentación pedicular y descompresión puede tener beneficios clínicos significativos, sobre todo en lo que se refiere la mejora de los síntomas de dolor y mejora de la función neurológica.

Do benefits overcome the risks related to surgery for adult scoliosis? A detailed analysis of a consecutive case series.

PURPOSE: The surgical approach to adult spine deformities is complex and presents a high incidence of complications. METHODS: We report here a prospective consecutive case series analysis of 20 patients submitted to posterior correction and instrumented fusion for adult degenerative scoliosis. Clinical outcomes were assessed by self-reported measures. Pre-operative and post-operative complications were analysed during a mean 30-month follow-up period. RESULTS: Eleven patients (55 %) presented pre-operative or post-operative complications. Fifteen different complications occurred, six in the early pre-operative period and nine during follow-up period: ten of these complications occurred in patients who underwent a previous surgery for spine disease. CONCLUSIONS: The clinical improvement at the final follow-up resulted as statistically significant only for the group of patients exposed to posterior fusion without interbody fusion. The observations reported here have to be considered for a shared decision-making in the management of adult scoliosis.

Delayed presentation of a thoracic aortic injury with a vertebral pedicle screw.

Iatrogenic aortic injuries by pedicle screws are rare but serious complications of spinal fixation surgery. We report the case of a 55-year-old man who underwent surgical correction of traumatic thoracic vertebral fractures at another institution. At 6-month follow-up, computed tomography revealed a nonhealing of the fractures, and a T4 misplaced pedicle screw penetrating the descending thoracic aorta. The patient underwent open aortic repair associated with the anterior vertebral column reconstruction and posterior arthrodesis revision by a vascular and orthopedic surgery team simultaneously.

Influence of a thread wire saw guide and spinal cord protector device in "en bloc" vertebrectomies.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of the study was to describe and compare the surgical outcomes between the use of a new auto static spinal cord and thread wire guiding device and the traditional scalpel technique for en bloc vertebrectomies using only the posterior approach. SUMMARY OF BACKGROUND DATA: As en bloc vertebrectomy has become more accepted as the ideal treatment for selected cases of spine tumors, its high morbidity has to be kept in mind. Uneven cutting surfaces and high risk of spinal cord lesions are among the problems. Although some modifications of the technique and development of new devices to minimize the risks have been reported, there are still some pitfalls associated with them. METHODS: Twenty-five patients, divided into 2 groups, were retrospectively reviewed. Patients in group 1 (G1) were operated using the device, and the patients in group 2 (G2) underwent en bloc vertebrectomy by the traditional scalpel technique. The surgical time, amount of blood loss based on the total volume of blood transfusion during surgery, and the rate of complication were compared. RESULTS: No differences regarding sex, age, and preoperative status occurred. The mean operative time was 294 and 388 minutes and the mean volume of transfused blood was 37 and 53 mL/kg for G1 and G2, respectively. These differences were not statistically significant. CONCLUSIONS: Patient selection and surgical experience are the best outcome predictors. However, methods to reduce the risks of neural lesions, surgical time, and blood loss should always be applied, specially dealing with highly morbid and demanding procedures in the spine.

Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening: a review of 21 cases.

BACKGROUND: This prospective mixed cohort study was designed to evaluate the middle- to long-term purchase of cement-augmented pedicular screws in patients with poor bone quality. The growing number of surgical procedures performed in the spine has highlighted the problem of screws loosening in patients with poor bone stock due to osteoporosis and/or tumors. Different methods of increasing screw purchase have been reported in the literature, including polymethylmethacrylate (PMMA) augmentation. MATERIALS AND METHODS: From September 2006 to April 2008, 21 patients with a poor bone stock condition due to osteoporosis or tumor underwent posterior stabilization by fenestrated pedicle screws and PMMA augmentation. Pain improvement and long-term clinical outcome were assessed by visual analogue scale (VAS) score and SF-36 health survey (SF-36) questionnaire. Implant stability was evaluated by plain radiography and CT scans performed three days after surgery and every three months thereafter. After the first 12 months, radiologic controls were taken once a year in all surviving patients. Complications were evaluated in all cases. RESULTS: All patients were clinically and radiographically followed up for a mean of 36 months. VAS scores and SF-36 questionnaires showed a statistically significant reduction in pain and improvement in the quality of life. No radiological loosening or pulling out of screws was observed. In two cases, cement leakage occurred intraoperatively: one patient who suffered from a transitory nerve root palsy improved spontaneously, while the surgeon immediately removed the excess cement before setting in the other case. In three cases, the post-op CT scan revealed a small amount of cement in the canal without clinical relevance. CONCLUSIONS: Fenestrated screws for cement augmentation provided effective and lasting purchase in patients with poor bone quality due to osteoporosis or tumors. No case of loosening was recorded after a mean follow-up of 36 months. The only clinical complication strictly related to PMMA screw augmentation did not require further surgery.

Fratura diafisária do fêmur: reprodutibilidade das classificações AO-ASIF e Winquist / Femoral shaft fracture: reproducibility of AO-ASIF and Winquist classifications

OBJETIVO: Avaliar a reprodutibilidade interobservadores das classificações AO/ASIF e de Winquist para as fraturas diafisárias do fêmur no adulto. MÉTODOS: foram selecionadas aleatoriamente 50 radiografias de pacientes adultos portadores de fratura diafisária do fêmur nas incidências em antero-posterior e perfil. As radiografias foram analisadas por 5 observadores, sendo um membro da Sociedade Brasileira de Trauma Ortopédico, um radiologista, um residente do terceiro ano de Ortopedia e Traumatologia, um do segundo e um do primeiro. Para avaliar a concordância interobservadores destas classificações, foi utilizado o índice estatístico Kappa (K). RESULTADOS: Em todas as análises, observou-se um coeficiente de concordância entre observadores estatisticamente significativo (valor p < 0,05) e classificado como bom (valores de 0,61 a 0,80) ou muito bom (valores acima de 0,80), segundo os critérios de Landis e Koch. CONCLUSÃO: As classificações AO e Winquist apresentam alto índice de concordância interobservadores para as fraturas diafisárias do fêmur no adulto.

OBJECTIVE: To evaluate inter-observer reproducibility of AO / ASIF and Winquist-Hansen classifications for shaft fractures of the femur in adults. METHODS: 50 anterior-posterior and profilelateral radiographs were randomly selected, of adult patients awith diaphyseal fracture of the femur. The radiographs were analyzed by 5 observers-a member of the Brazilian Society of Orthopedic Trauma, a radiologist and 3 residents. To assess the concordance between these classifications, we used the statistical index Kappa (K). RESULTS: In all analyses, we observed a statistically significant correlation coefficient between observers (p <0.05) and according to the criteria of Landis and Koch, they were ranked them as good (values of 0.61 to 0.80) or very good (values above 0.80). CONCLUSION: The AO rating and Winquist present a high rate of concordance between observers for shaft fractures of the femur in adults.