Tramadol-paracetamol for postoperative pain after spine surgery - A randomized, double-blind, placebo-controlled study.

OBJECTIVES: Multimodal pain management is one component in enhanced recovery after surgery protocol. Here we evaluate the efficacy of tramadol-paracetamol in acute postoperative pain and pain outcome at 12 months after spine surgery in randomized, double-blind, placebo-controlled trial. METHODS: We randomized 120 patients undergoing spine surgery to receive, for add-on pain management, two tramadol-paracetamol 37.5 mg/325 mg (n = 61) or placebo tablets (n = 59) twice a day for 5 postoperative days. In the hospital, multimodal pain management consisted of dexketoprofen and oxycodone. After discharge, patients were prescribed ibuprofen 200 mg, maximum 1,200 mg/day. Pain, analgesic use, and satisfaction with pain medication were followed up with the Brief Pain Inventory questionnaire before surgery and at 1 and 52 weeks after surgery. The primary outcome was patients' satisfaction with pain medication 1 week after surgery. RESULTS: At 1 week after surgery, patients' satisfaction with pain medication was similarly high in the two groups, 75% [interquartile range, 30%] in the placebo group and 70% [40%] in the tramadol-paracetamol group (p = 0.949) on a scale: 0% = not satisfied, 100% = totally satisfied. At 1 week, ibuprofen dose was lower in the placebo group 200 mg [1,000] compared to the tramadol-paracetamol group, 800 mg [1,600] (p = 0.016). There was no difference in the need for rescue oxycodone. Patients in the tramadol-paracetamol group had more adverse events associated with analgesics during the first postoperative week (relative risk = 1.8, 95% confidence interval, 1.2-2.6). CONCLUSION: Add-on pain treatment with tramadol-paracetamol did not enhance patients' satisfaction with early pain management after back surgery.

A vertebra of a small species of Pachycetus from the North Sea and its inner structure and vascularity compared with other basilosaurid vertebrae from the same site.

In the Western Scheldt Estuary near the Belgian-Dutch border, middle to late Eocene strata crop out at the current seafloor. Most vertebrae of large Eocene basilosaurid taxa from this area were previously described in several papers. They represent three morphotypes: elongated vertebrae of a large species of Pachycetus (Morphotype 1b), a not-elongated vertebra of a large 'dorudontid' basilosaurid (Morphotype 2) and 'shortened' vertebrae of a new, unnamed taxon (Morphotype 3). This article deals with a still undescribed, smaller vertebra, NMR-16642, from this site. Our first aim was to date it by dinoflagellate cysts in adhering sediments. Yielding an age of about 38 Ma, it is one of the very few remains of basilosaurids from Europe, of which the age could be assessed with reasonable certainty. The vertebra, Morphotype 1a, is assigned to a small species of Pachycetus. High-quality CT scans are used to differentiate between NMR-16642, Morphotype 1a, and the large species of Pachycetus, Morphotype 1b. Another aim of this paper is to investigate the inner structure and vascularity of the study vertebra and that of the other morphotypes (1b, 2, 3) from this area by using high-quality CT scans. Notwithstanding differences in size, shape and compactness, the vertebral inner structure with a multi-layered cortex of periosteal bone, surrounding two cones of endosteal bone appears to be basically similar in all morphotypes. Apparently, this inner structure reflects the ontogenetic vertebral growth. An attempt to reconstruct the vascularity of the vertebrae reveals a remarkable pattern of interconnected vascular systems. From the dorsal and, if present, ventral foramina, vascular canals are running to a central vascular node. From this node a system of vascular canals goes to the epiphyseal ends, giving rise to separate systems for cortex and cones. It is the first time that the vascularity of vertebrae of archaeocetes is investigated.

[Small tidal volume hyperventilation relieves intraocular and intracranial pressure elevation in prone spinal surgery: a randomized controlled trial].

OBJECTIVE: To investigate the effects of different ventilation strategies on intraocular pressure (IOP) and intracranial pressure in patients undergoing spinal surgery in the prone position under general anesthesia. METHODS: Seventy-two patients undergoing prone spinal surgery under general anesthesia between November, 2022 and June, 2023 were equally randomized into two groups to receive routine ventilation (with Vt of 8mL/kg, Fr of 12-15/min, and etCO2 maintained at 35-40 mmHg) or small tidal volume hyperventilation (Vt of 6 mL/kg, Fr of18-20/min, and etCO2 maintained at 30-35 mmHg) during the surgery. IOP of both eyes (measured with a handheld tonometer), optic nerve sheath diameter (ONSD; measured at 3 mm behind the eyeball with bedside real-time ultrasound), circulatory and respiratory parameters of the patients were recorded before anesthesia (T0), immediately after anesthesia induction (T1), immediately after prone positioning (T2), at 2 h during operation (T3), immediately after supine positioning after surgery (T4) and 30 min after the operation (T5). RESULTS: Compared with those at T1, IOP and ONSD in both groups increased significantly at T3 and T4(P < 0.05). IOP was significantly lower in hyperventilation group than in routine ventilation group at T3 and T4(P < 0.05), and ONSD was significantly lower in hyperventilation group at T4(P < 0.05). IOP was positively correlated with the length of operative time (r=0.779, P < 0.001) and inversely with intraoperative etCO2 at T3(r=-0.248, P < 0.001) and T4(r=-0.251, P < 0.001).ONSD was correlated only with operation time (r=0.561, P < 0.05) and not with IOP (r=0.178, P>0.05 at T3; r=0.165, P>0.05 at T4). CONCLUSION: Small tidal volume hyperventilation can relieve the increase of IOP and ONSD during prone spinal surgery under general anesthesia.

Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists.

Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.

Do nutritional assessment tools (PNI, CONUT, GNRI) predict adverse events after spinal surgeries? A systematic review and meta-analysis.

BACKGROUND: Nutritional assessment tools are used to predict outcomes in cancer. However, their utility in patients undergoing spinal surgery is unclear. This review examined if prognostic nutritional index (PNI), controlling nutritional status (CONUT), and geriatric nutritional risk index (GNRI) can predict adverse events after spinal surgeries. METHODS: PubMed, CENTRAL, Scopus, and Embase were screened by two reviewers for relevant studies up to 26th January 2024. The primary outcome of interest was total adverse events after spinal surgery. Secondary outcomes were surgical site infections (SSI) and mortality. RESULTS: 14 studies were included. Meta-analysis showed that while reduced PNI was not associated with an increased risk of SSI there was a significant association between PNI and higher risk of adverse events. Meta-analysis showed that high CONUT was not associated with an increased risk of complications after spinal surgeries. Pooled analysis showed that low GNRI was associated with an increased risk of both SSI and adverse events. Data on mortality was scarce. CONCLUSIONS: The PNI and GNRI can predict adverse outcomes after spinal surgeries. Limited data shows that high CONUT is also associated with a non-significant increased risk of adverse outcomes. High GNRI was predictive of an increased risk of SSI. Data on mortality is too scarce for strong conclusions.

The Influencing Factors of Frailty and Quality of Life in Elderly Patients After Spinal Surgery.

Background: To study the related factors of frailty and quality of life in elderly patients after spinal surgery. Methods: The anxiety, depression, frailty, and quality of life of all patients were assessed by the Anxiety screening scale (GAD-7), Depression screening scale (PHQ-9), Frailty screening scale (FRAIL), and European five-dimensional health scale (EQ-5D-5L) 1 day before surgery (DAY-0). A numeric rating scale (NRS) was used to evaluate patients' pain during activities on the 1st day (POD-1), 3rd day (POD-3), and 30th day (POD-30) after operation. FRAIL scale and EQ-5D-5L were used to evaluate patients' frailty and quality of life on POD-30 and 90th day (POD-90) after the operation. Results: There were significant differences in age, body mass index (BMI), preoperative serum albumin level (ALB), and NRS score on POD-1 between the two groups (P<0.05). Age and PHQ-9 score were positively correlated with EQ-5D-5L score (P<0.05, r Age=0.245, rPHQ-9=0.217), and preoperative ALB level was negatively correlated with EQ-5D-5L score (P<0.05, r ALB=-0.274). Conclusion: The older the age, the larger the BMI and the higher the NRS score on the first day after surgery, the more prone to frailty in elderly patients after spinal surgery; The older age and the lower the preoperative ALB level, the worse the quality of life in elderly patients after spinal surgery.

Clinical applications of AI-prediction tools in spine surgery: a narrative review.

Spine surgery has grown into a wide, complex field encompassing trauma surgery to deformity to tumours. Artificial intelligence (AI) based technology has been particularly useful in improving imaging-reporting and detection of predictive patterns. The purpose of this narrative review is to present practical approaches towards implementing upcoming AI spine research for clinicians to help improve practices, clinical throughput, and surgical decision-making.

Cutting Edge Developments in Spine Surgery at the University of Missouri.

The treatment of spinal pathologies has evolved significantly from the times of Hippocrates and Galen to the current era. This evolution has led to the development of cutting-edge technologies to improve surgical techniques and patient outcomes. The University of Missouri Health System is a high-volume, tertiary care academic medical center that serves a large catchment area in central Missouri and beyond. The Department of Neurosurgery has sought to integrate the best available technologies to serve their spine patients. These technological advancements include intra-operative image guidance, robotic spine surgery, minimally invasive techniques, motion preservation surgery, and interdisciplinary care of metastatic disease to the spine. These advances have resulted in safer surgeries with enhanced outcomes at the University of Missouri. This integration of innovation demonstrates our tireless commitment to ensuring excellence in the comprehensive care of a diverse range of patients with complex spinal pathologies.

The impact of perioperative nonsteroidal anti-inflammatory drugs on the postoperative outcomes of spinal surgery: a meta-analysis of 23 randomized controlled trials.

In recent years, nonsteroidal anti-inflammatory drug (NSAIDs), which are considered to affect the prognosis of spinal surgery, have been widely used in perioperative analgesia in spinal surgery, but the relationship between these two factors remains unclear. The purpose of this study was to explore the effect of perioperative use of NSAIDs on the prognosis of patients treated with spinal surgery. We systematically searched PubMed, Embase, and Cochrane Library for relevant articles published on or before July 14, 2023. We used a random-effect model for the meta-analysis to calculate the standardized mean difference (SMD) with a 95% confidence interval (CI). Sensitivity analyses were conducted to analyze stability. A total of 23 randomized clinical trials including 1457 participants met the inclusion criteria. Meta-analysis showed that NSAIDs were significantly associated with postoperative morphine use (mg) (SMD = -0.90, 95% CI -1.12 to -0.68) and postoperative pain (SMD = -0.71, 95% CI -0.85 to -0.58). These results were further confirmed by the trim-and-fill procedure and leave-one-out sensitivity analyses. The current study shows that perioperative use of NSAIDs appears to be an important factor in reducing postoperative pain and morphine use in patients undergoing spinal surgery. However, well-designed, high-quality randomized controlled trials (RCTs) are still required.

A novel repair strategy using knotless squeeze anchors for lumbar disc herniation with endplate junction lesions under biportal endoscopic spinal surgery.

BACKGROUND: Annulus fibrosus-endplate (AF-EP) junction lesions are important determinants for lumbar disc herniation (LDH). Utilizing biportal endoscopic spinal surgery (BESS), we introduce a novel repair method using bioabsorbable PushLock anchors with suture fibers to stretch disconnected AF tissues to the vertebral cortex. METHODS: The viewing and working portals are established to excise herniated disc materials causing radiculopathy. Through the working portal, a suture strand is passed through the intact AF tissue near the lesion and retrieved using the Suture Crossing Device. Then, the knotless suture limbs are secured into the cortical bone socket of the vertebral body with a PushLock anchor. CONCLUSION: The procedure is a simple, safe, and feasible knotless suturing technique for the treatment of LDH with AF-EP junction lesions.

Post-operative bracing following adult spine deformity surgery: Results from the AO Spine surveillance of post-operative management of patients with adult spine deformity.

STUDY DESIGN: Cross-sectional international survey with a literature review. OBJECTIVES: While some surgeons favor spine bracing after surgery for adult spine deformity (ASD) to help prevent mechanical failures, there is a lack of evidence. The objective of the present study was to better understand the current trend in the use of bracing following ASD surgery based on an international survey. METHODS: An e-mail-based online survey was conducted among over 6000 international AO Spine members regarding the post-operative management of patients with ASD. The details of brace prescription, indications and influencing factors were solicited. Descriptive data were summarized based on different demographic groups and fusion levels for the responding surgeons who annually perform at least 10 long-segment fusions of >5 levels extending to the pelvis. RESULTS: A total of 116 responses were received, including 71 surgeons (61%) who used post-operative bracing for >5 levels of long fusion. The most common reason for bracing was pain management (55%) and bone quality was the strongest influencing factor (69%). Asia-Pacific surgeons had the highest rate of bracing (88%), while North American surgeons had the lowest (45%). The most common type of brace used were TLSO for cases with an uppermost instrumented vertebra (UIV) in the low- or mid-thoracic spine and a cervical brace for UIV at T1-3. The majority (56%) used bracing for 6-12 weeks after surgery. CONCLUSIONS: The present survey demonstrated significant interest in bracing following ASD surgery, however, there is substantial variability in post-operative bracing practice. A formal study on the role of bracing in ASD surgery is needed.

Percutaneous kyphoplasty through unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fracture with scoliosis.

PURPOSE: To assess the clinical safety, accuracy, and efficacy of percutaneous kyphoplasty (PKP) surgery using an enhanced method of unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fractures (P-OVCF) with scoliosis. METHODS: Clinical and radiographic data of P-OVCF patients with scoliosis who underwent PKP via unilateral puncture on the convex side from January 2018 to December 2021 were retrospectively analyzed. This technique's detailed surgical steps and tips were described. The local kyphosis angle (LKA), scoliosis Cobb angle (SCA), and local scoliosis Cobb angle (LSCA) were measured using X-ray and compared at pre-operation, post-operation, and the last follow-up. The width of pedicle (POW), inner inclination angle (IIA), lateral distance (LD), and puncture course length (PCL) were measured on the axial computed tomography image and compared between two sides. Postoperative computed tomography was employed to evaluate the condition of cement distribution and puncture. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back pain (BP). RESULTS: Thirty-six patients, 23 women and 13 men, with an average age of 76.31 ± 6.28 years were monitored for 17.69 ± 4.70 months. The median surgical duration of single vertebrae was 35 min. The volume of bone cement for single vertebrae was 3.81 ± 0.87 ml and the proportion of sufficient cement distribution of the patients was 97.22. LKA was considerably improved from pre-operation to post-operation and sustained at the last follow-up. SCA and LSCA were not significantly modified between these three-time points. IIA, PCL, and LD were lower on the convex side than on the concave side. POW was considerably wider on the convex side. The ODI and VAS-BP scores were significantly improved after surgery and sustained during the follow-up. CONCLUSIONS: Combining with the proper assessment of the pre-injured life status of patients, PKP surgery using unilateral puncture on the convex side for the treatment of P-OVCF with scoliosis can achieve safe, excellent clinical, and radiographic outcomes.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons.

BACKGROUND: Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS: The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS: Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS: Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

Comparison of Outcomes between Single-Level and Double-Level Corpectomy in Thoracolumbar Reconstruction: A Retrospective Study of 16 Patients Using Expandable Cages.

BACKGROUND Reconstruction surgery using titanium vertebral body replacements aids in spinal stability after damage. Functional evaluation includes Nurick and ASIA grading systems. This study compares outcomes of single and double-level corpectomy in patients treated with thoracolumbar reconstruction. MATERIAL AND METHODS Records of 16 patients who underwent vertebral reconstruction with expandable cages after single (n=9) and double (n=8) corpectomy were analyzed retrospectively. Thoracal and lumbar cases were approached posteriorly (n=14). Clinical evaluation was performed by neurological examination, Nurick Scale, American Spinal Injury Association (ASIA) Neurological Scores, and Visual Analog Scale (VAS). Preoperative and postoperative 3-month scores were recorded. Radiological evaluation was performed by calculation of regional angulation and postoperative recovery of vertebral body height. RESULTS Preoperatively, 2 patients had no motor or functional sensory deficits (ASIA grade E) and 6 patients were ASIA grade D. Immediately after surgery, 4 of the ASIA grade D patients improved to ASIA grade E, while 2 patients remained ASIA grade D during follow-up. Four patients were ASIA grade A; their conditions showed no improvement postoperatively. Preoperative and postoperative 3-month Nurick grade was statistically significant (P=0.022). Postoperative Cobb angle improved by a mean of 5.4° (P=0.001). Improvement by at least 1 grade in neurological recovery was observed in 6 (38%) of the cases. Pain scores analyzed using the VAS changed from a mean of 7 to a mean of 2.63 (P<0.001). CONCLUSIONS In our experience, expandable cages are useful in the restoration of different pathologies of the thoracolumbar trunk with low complication and revision rates. With expandable cages it is possible to achieve restoration of the Cobb angle, improvement in Nurick Grade and effective pain palliation.

[Frequency of spinopelvic alterations in postoperative total hip arthroplasty patients and their association with functional outcomes]. / Frecuencia de alteraciones espinopélvicas en pacientes postoperados de artroplastía total de cadera y su asociación con resultados funcionales.

INTRODUCTION: the analysis of spinopelvic imbalance in patients undergoing total hip arthroplasty has gained significance in recent years, being recognized as a risk factor for instability. Few reports exist regarding the prevalence of spinopelvic alterations in Latin American literature. The aim of this study is to determine the frequency of spinopelvic imbalance in our patients and to associate them with functional outcomes. MATERIAL AND METHODS: 29 patients who underwent total hip arthroplasty using a lateral approach (32 arthroplasties) were included. All patients completed clinical outcome questionnaires preoperatively. Twelve months after surgery, they underwent anteroposterior pelvic and lateral pelvic X-rays, both standing and sitting, and clinical outcome questionnaires were completed. The radiographic parameters examined were: pelvic incidence, lumbar lordosis, sacral slope, anterior pelvic plane and pelvic femoral angle. Functional outcome was assessed with the Harris Hip Score and WOMAC scales. Patients were classified according to their spinopelvic alteration and statistical analysis was performed to identify significant differences between the groups and the correlation with functional outcomes. RESULTS: there was a high frequency of spinopelvic balance alterations (46.8%); 6.2% (n = 2/32) presented isolated spinal stiffness (group 1B), 37.5% (n = 12/29) spinal deformity without spinal stiffness (group 2A) and 3.1% (n = 1/29) spinal deformity associated with stiffness (group 2B). We found no improvement in HHS and WOMAC scores in the groups with spinal stiffness (1B and 2B) (p = 0.98 y 0.15). There is association between spinal stiffness (SS < 10°) and poor functional outcomes (p = 0.02). CONCLUSIONS: the frequency of spinopelvic balance alterations was high. While there was no observed rise in prosthetic dislocations, the existence of spinal stiffness, defined by a SS of less than 10°, was associated to poor outcomes on functional scales.

INTRODUCCIÓN: el análisis de las alteraciones del balance espinopélvico en pacientes sometidos a artroplastía total de cadera ha adquirido importancia en años recientes, siendo reconocido como un factor de riesgo para inestabilidad. Existen pocos reportes de la prevalencia de alteraciones espinopélvicas en literatura latinoamericana. El objetivo de esta investigación es determinar la frecuencia de alteraciones del balance espinopélvico en nuestros pacientes y su asociación con los resultados funcionales. MATERIAL Y MÉTODOS: se incluyeron 29 pacientes intervenidos de artroplastía total de cadera mediante abordaje lateral (32 artroplastías). Todos los pacientes completaron escalas funcionales preoperatoriamente. A los 12 meses de la intervención, se valoró el balance espinopélvico mediante radiografías anteroposterior de pelvis y laterales de pelvis tanto de pie como en sedestación y completaron escalas funcionales. Los parámetros radiográficos valorados fueron: incidencia pélvica, lordosis lumbar, inclinación del sacro (sacral slope), plano pélvico anterior y ángulo pélvico femoral. El estado funcional se valoró con las escalas Harris Hip Score (HHS) y WOMAC. Se clasificó a los pacientes de acuerdo a su alteración espinopélvica y se realizó análisis estadístico para identificar diferencias significativas entre los grupos y la asociación con resultados funcionales. RESULTADOS: encontramos una elevada frecuencia de alteraciones del balance espinopélvico (46.8%); 6.3% (n = 2/32) presentaron rigidez espinal aislada (grupo 1B), 37.5% (n = 12/29) deformidad espinal sin rigidez espinal (grupo 2A) y 3.1% (n = 1/29) deformidad espinal asociada a rigidez (grupo 2B). En los grupos con rigidez espinal (1B y 2B) no hubo mejoría significativa en HHS y WOMAC (p = 0.98 y 0.15). Encontramos asociación entre la presencia de rigidez espinal (SS < 10°) y resultados funcionales subóptimos con valor de p = 0.02. CONCLUSIONES: la frecuencia de alteraciones en el balance espinopélvico fue elevada. A pesar de no verse reflejado en un aumento en la incidencia de luxaciones protésicas, la presencia de rigidez espinal caracterizada por un SS menor a 10° se asoció con resultados subóptimos en las escalas funcionales.

Vertebral metastasis of hepatocellular carcinoma secondary to viral hepatitis B: case report of 2 patients.

Bone metastases from liver cancer are rare. We report two cases of bone metastases revealing HBV-induced HCC. A 26-year-old african man presented with 4 months of low back pain in the context of general deterioration. Examination revealed a lumbar spinal syndrome and hepatomegaly. Abdominal ultrasound revealed a multinodular liver, and a CT scan of the spine revealed osteolytic lesions. Biological tests revealed a hepatic cytolysis syndrome, hepatic cholestasis and hepatocellular insufficiency. Alpha foetoprotein levels were elevated and hepatitis B serology was positive. We adopted the diagnosis of HCC of viral B origin with bone metastasis. The second case involved a 44-year-old African man admitted for 10 days with back pain. Examination revealed a spinal syndrome, paraplegia and hepatomegaly. A thoracic-abdominal-pelvic CT scan revealed typical HCC lesions and osteolytic lesions on the ribs, pelvis and vertebrae. The biology revealed a biological inflammatory syndrome, hepatic cytolysis, a hepatocellular insufficiency syndrome and a cholestasis syndrome. Alfa-feto proteins were elevated and HBV serology was positive. The diagnosis of bone metastasis of HCC secondary to HBV infection was accepted.

[Evaluation of spino-pelvic mobility; its importance in preventing total hip replacement dislocation]. / Evaluación de la movilidad espino-pélvica; su importancia para prevenir la luxación de prótesis total de cadera.

Recently, it has been recognized that changes in sagittal alignment and spinopelvic mobility due to alterations of the lumbosacral spine can influence the dislocation of a hip replacement. The biggest difficulties for this problem are: a) the bibliography related to this topic has been written in English and there is confusion in its terminology; b) there is no consensus on what parameters should be used to identify, measure, and estimate the risks of dislocation occurring; c) the basic concepts that interrelate spinal disorders and prosthetic dislocation are not clearly understood; and d) spine and hip surgeons pursue different goals. The objective of this narrative review is to overcome the aforementioned difficulties by using a strategy to answer some questions: Is hip dislocation really a problem? What is the interrelationship between alterations in the pelvic spinal balance and the dislocation of a prosthesis? How is sagittal balance and lumbosacral mobility defined and how can their alterations be measured? What are their compensatory mechanisms to achieve a good functioning and how these mechanisms can be used to correctly orient the acetabulum? To document this review, we consulted the databases of PubMed, Scopus, SciELO and Google Scholar with the keywords: Spinopelvic, Total Hip Arthroplasty, Hip Dislocation, Spine-Pelvis-hip Arthroplasty. The articles that, in the author's opinion, were the most objective and/or relevant for the study of this topic were selected.

Recientemente se ha reconocido que los cambios en alineación sagital y la movilidad espino-pélvica por alteraciones de la columna lumbosacra pueden ejercer influencia en la luxación de una prótesis de cadera. Las mayores dificultades para este problema son: a) que la bibliografía relacionada con este tema se ha escrito en idioma inglés y hay confusiones en su terminología; b) no hay consenso de cuáles son los parámetros que deben utilizarse para identificarla, medirla y para estimar los riesgos de que ocurra una luxación; c) no se conocen con claridad los conceptos básicos que interrelacionen los trastornos de la columna y la luxación protésica; y d) que los cirujanos de columna y artroplásticos de cadera persiguen diferentes objetivos. Esta revisión narrativa persigue como objetivo allanar las dificultades antes mencionadas, utilizando como estrategia contestar algunas preguntas: ¿la luxación de cadera es realmente un problema?; ¿cuál es la interrelación entre las alteraciones en el balance espino-pélvico y la luxación de una prótesis?; ¿cómo se define el balance sagital y la movilidad lumbosacra y cómo se pueden medir sus alteraciones?; ¿cuáles son sus mecanismos compensatorios para lograr un buen funcionamiento, y cómo se pueden aprovechar estos mecanismos para orientar correctamente el acetábulo? Para documentar esta revisión se consultaron las bases de datos de PubMed, Scopus, SciELO y Google Académico con las palabras clave: Spinopelvic, Total Hip Arthroplasty, Hip Dislocation, Spine-Pelvis-hip Arthroplasty. Se seleccionaron los artículos que a juicio del autor fueron los más objetivos y/o relevantes para el estudio de este tema.