Anterior Vertebral Body Growth-Modulation Tethering in Idiopathic Scoliosis: Surgical Technique.

The management of idiopathic scoliosis in the skeletally immature patient can be challenging. Posterior spinal fusion and instrumentation is indicated for severe scoliosis deformities. However, the skeletally immature patient undergoing posterior fusion and instrumentation is at risk for developing crankshaft deformities. Moreover, bracing treatment remains an option for patients who are skeletally immature, and although it was found to be effective, it does not completely preclude deformity progression. Recently, fusionless treatment options, such as anterior vertebral body growth modulation, have been developed to treat these patients while avoiding the complications of posterior rigid fusion. Good results have been shown in recent literature with proper indications and planning in the skeletally immature patient.

Intrathecal morphine combined with ropivacaine induces spinal myoclonus in cancer patients with an implanted intrathecal drug delivery system: Three case reports.

RATIONALE: Although intrathecal opioid infusion has been used for decades for the treatment of severe pain, myoclonus as one of the complications of this therapeutic modality is now beginning to be recognized more. PATIENTS CONCERNS: Here, we report three patients who developed myoclonus after dose adjustment in intrathecal drug delivery system for the treatment of refractory cancer pain. DIAGNOSIS: Spinal myoclonus is a sudden, brief, shock-like muscle contractions originating from the central nervous system. In our cases, it occurred after opioid administration via intrathecal delivery system with no abnormality found in laboratory or imaging examinations. INTERVENTIONS: Spinal myoclonus can be treated effectively by reducing the dose or infusion rate as described in case 1, or changing from an intrathecal to systemic administration in case 2, or correcting infusion and bolus parameters mistakes in case 3. OUTCOMES: All patients recovered quickly after stopping or decreasing the intrathecal drug infusion. LESSONS: Prevention is more important than treatment as for spinal myoclonus. Pain management teams should be aware of this distressing complication. Dose of intrathecal drugs should not exceed the recommended maximal daily doses by guidelines and patient education is important for successful intrathecal analgesic therapy.

Translation to Brazilian Portuguese and Cultural Adaptation of the Craniocervical Dysfunction Index

Abstract Introduction Functional disorders of the craniocervical region affect 77.78% of Brazilian teachers. Among the most common instruments used to assess craniocervical disorders in a detailed and objective way, none had been translated to Brazilian Portuguese and adapted to Brazilian culture. Objectives To translate to Brazilian Portuguese and to culturally adapt the Craniocervical Dysfunction Index (CDI). Method The first phase of the study consisted of the translation, synthesis, backtranslation, and review of the contents by a committee of experts, who developed a trial version and sent all the steps to the original author. The trial version was applied to 50 teachers of an institution. The reliability and internal consistency were evaluated by Cronbach α. For the validation, the Brazilian Portuguese version of the CDI was correlated with the Visual Analogue Scale (VAS) domains for cervicalgia and evaluated by Spearman ρ. Result Some expressions were adapted to the Brazilian culture. Among the participants who did not report neck pain in the VAS, 84.21% suffered from craniocervical dysfunction acording to the CDI. Among the participants who reported neck pain in the VAS, 100% suffered from craniocervical dysfunction according to the CDI. The CDI showed good internal consistency and satisfactory reliability measured by Cronbrach α (α = 0.717). There was a strong correlation between the CDI and the VAS score (ρ = 0.735). Conclusion No difficulties were encountered in the translation and back-translation of the CDI, and no problems were observed regarding the trial version developed; therefore, the Brazilian Portuguese version of the CDI is a valid and reliable instrument to evaluate the functional alteration of the craniocervical region.

Epidemiological panorama of orthopedic spine pathology in mexico / Panorama epidemiológico da patologia ortopédica da coluna espinal no méxico / Panorama epidemiológico de la patología ortopédica de columna vertebral en méxico

ABSTRACT Objective: To determine the epidemiology of orthopedic spine pathology in a national reference hospital in Mexico. Methods: Retrospective, observational and cross-sectional study, using the database and hospitalization census of the orthopedic spine service from January 2009 to December 2016. The data analysis was performed with SPSS version 22 measuring the central frequency and percentages. The demographic variables age and sex, and those related to the diagnosis, type of pathology, affected segment and degrees of affection were obtained. The sampling technique was non-probabilistic sampling by convenience of consecutive cases. Results: We analyzed 7,771 cases: 50.34% males, with a mean age of 53.51 years. The prevalence of the most frequent diseases in hospitalized patients was stenosis of the lumbar canal with 25.85% (1,834 patients), followed by lumbar disc herniation (23.12%), spondylolisthesis (22.63%), cervical spondylotic myelopathy (8.76%), lumbar pain and lumbosciatalgia (4.10%), cervical disc herniation (3.96%), primary infection (3.80%), loosening of material (3.16%), spinal tumors (2.53%) and cervical instability (2.04%). Conclusions: This is the largest series of cases of spinal pathology treated in a hospital in Latin America. The most frequent condition was the stenosis of the lumbar canal, the most affected segment was the lumbar, and the most affected age group was 51 to 60 years. The estimate is an increase in the incidence of spinal diseases, so it is necessary to identify the risk factors and the behavior of each disease for its prevention. Level of Evidence IV; Retrospective, observational and descriptive study.

RESUMO Objetivo: Determinar a epidemiología da patologia da coluna ortopédica em um hospital de referência nacional no México. Métodos: Um estudo retrospectivo, observacional e transversal, utilizando o banco de dados e o recenseamento hospitalar do serviço de orelha ortopédica de janeiro de 2009 a dezembro de 2016. A análise de dados foi realizada através da SPSS versão 22 usando medidas de frequência central e porcentagens. As variáveis demográficas idade e gênero, e aqueles relacionados ao diagnóstico, tipo de patologia, segmento afetado e graus de carinho foram obtidos. A técnica de amostragem foi por conveniência e não probabilística de casos consecutivos. Resultados: Analisamos 7771 casos: 50,34% do sexo masculino, com idade média de 53,51 anos. A prevalência das doenças mais frequentes em pacientes hospitalizados foi a conduta lombar estreita, com 25,85% (1834 pacientes), seguida de hérnia de disco lombar (23,12%), espondilolistese (22,63%), mielopatia espondilótica cervical (8,76%), lombo e lomossocialgia (4,10%), hérnia de disco e infecção primária cervical (3,96%, 3,80%), afrouxamento do material (3,16%), tumores espinhais (2,53%) e instabilidade cervical (2,04%). Conclusões: Este é o maior número de casos da patologia da coluna com tratamento hospitalar na América Latina. O estado mais comum era o canal lombar da coluna vertebral, o segmento lombar é o mais afetado e o grupo de idade mais afetado é de 51 a 60 anos. Um aumento na incidência de doenças da coluna vertebral está previsto, de modo que é necessário identificar os fatores de risco e o comportamento de cada condição para a prevenção. Nível de Evidência IV; Estudo retrospectivo, observacional e descritivo.

RESUMEN Objetivo: Conocer la epidemiologia de la patología ortopédica de columna vertebral en un hospital de referencia nacional en México. Métodos: Se realizó un estudio retrospectivo, observacional y transversal, utilizando la base de datos y censos de hospitalización del servicio de columna ortopédica de enero de 2009 a diciembre de 2016. Se realizó el análisis de datos mediante SPSS versión 22, utilizando medidas de frecuencia central y porcentajes. Se obtuvieron las variables demográficas edad y sexo, y las relacionadas con el diagnóstico, tipo de patología, segmento afectado y grados de afección. La técnica de muestreo fue por conveniencia y no probabilística de casos consecutivos. Resultados: Se analizaron 7.771 casos: 50,34% del sexo masculino, con un promedio de edad de 53,51 años. La prevalencia de las enfermedades más frecuentes en los pacientes hospitalizados fue el conducto lumbar estrecho con 25,85% (1.834 pacientes), seguido de hernia discal lumbar (23,12%), espondilolistesis (22,63%), mielopatía espondilótica cervical (8,76%), lumbalgias y lumbociatalgias (4,10%), hernia discal cervical (3,96%), infección primaria (3,80%), aflojamiento de material (3,16%), tumores espinales (2,53%) e inestabilidad cervical (2,04%). Conclusiones: Esta es la mayor serie de casos de patología de columna con tratamiento hospitalario en América Latina. El padecimiento más frecuente fue el conducto lumbar estrecho, el segmento más afectado el lumbar, y el grupo etario más aquejado el de 51 a 60 años. Se predice un incremento en la incidencia de las enfermedades de columna vertebral, por lo que es necesario identificar los factores de riesgo y el comportamiento de cada padecimiento para su prevención. Nivel de Evidencia IV; Estudio retrospectivo, observacional y descriptivo.

Prevalence, associated factors, and limitations related to chronic back problems in adults and elderly in Brazil. / Prevalência, fatores associados e limitações relacionados ao problema crônico de coluna entre adultos e idosos no Brasil.

The objective was to analyze the epidemiological characteristics of chronic back problems in Brazil and study the association between their prevalence and demographic and socioeconomic factors, lifestyle, and health conditions. The study used micro-data from the Brazilian National Health Survey (PNS), 2013. The epidemiological indicators were: prevalence, time with chronic back problems, life cycle (from young adults to the elderly), limitations in activities of daily living, and mean age at onset of symptoms, according to sex and age bracket. In order to analyze inequality in chronic back problems according to socioeconomic characteristics and risk factors, a multivariate logistic regression model was used, based on life cycle stages, with the presence of chronic back problems as the dependent variable and the following independent variables: sex, schooling, area of residence, race/color, self-rated health, types of chronic diseases, body mass index (BMI), and physical activity. Prevalence of chronic back problems in Brazil was 18.5%, and was higher in women than in men (21.1%; 95%CI: 20.2-21.9). Mean age at onset of chronic back problems was 35 years. There was an association between chronic back problems and lower schooling, poor self-rated health, and presence of the majority of the selected chronic diseases. Area of residence, BMI, age, and race/color were weakly associated or not associated with chronic back problems. Prevalence of chronic back problems stabilized at 50 years of age, but the severity of limitations increased at older ages. As in other countries, high prevalence and the impact on living conditions revealed the need for epidemiological studies on chronic back problems in Brazil. The results suggest that health promotion and the prevention of chronic back problems should be intensified, especially before 50 years of age, considering the on-going population aging in Brazil.

O objetivo foi analisar aspetos epidemiológicos do problema crônico de coluna no Brasil e estudar a associação entre a prevalência do problema crônico de coluna e fatores demográficos, socioeconômicos, estilo de vida e condições de saúde. Utilizam-se microdados da Pesquisa Nacional de Saúde (PNS) de 2013. Os indicadores epidemiológicos foram: prevalência, tempo vivido com problema crônico de coluna, ciclo vital (de adulto jovem até idoso), impacto nas limitações da Vida Diária e idade média do início dos sintomas, segundo sexo e faixa etária. Para analisar a desigualdade do problema crônico de coluna segundo características socioeconômicas e fatores de risco realiza-se modelo de regressão logística multivariada, por etapa do ciclo vital, tendo como variável dependente a presença de problema crônico de coluna e como independentes: sexo, escolaridade, área de residência, raça/cor, autoavaliação da saúde, tipo de doença crônica, ídice de massa corporal (IMC) e atividade física. A prevalência de problema crônico de coluna no Brasil foi de 18,5%, sendo maior entre mulheres do que entre homens (21,1%; IC95%: 20,2-21,9). A idade média de início do problema crônico de coluna é 35 anos. Encontrou-se associação entre problema crônico de coluna e menor nível educacional, má autoavaliação da saúde e presença da maioria das doenças crônicas consideradas. Local de residência, IMC, idade e raça/cor estiveram fracamente ou não associados. A prevalência de problema crônico de coluna estabiliza aos 50 anos, mas a severidade da limitação aumenta em idades mais avançadas. A alta prevalência, similar a outros países, e o impacto nas condições de vida revelam a necessidade de estudos epidemiológicos sobre problema crônico de coluna. Resultados sugerem que a promoção e prevenção do problema crônico de coluna devem ser intensificadas, especialmente antes dos 50 anos de idade, considerando-se o acentuado envelhecimento populacional do país.

El objetivo fue analizar aspectos epidemiológicos del problema crónico de columna en Brasil y estudiar la asociación entre la prevalencia del problema crónico de columna y factores demográficos, socioeconómicos, estilo de vida y condiciones de salud. Se utilizan microdatos de la Encuesta Nacional de Salud (PNS) de 2013. Los indicadores epidemiológicos fueron: prevalencia, tiempo vivido con problema crónico de columna, ciclo vital (desde la etapa de adulto joven a incluso anciano), impacto en las limitaciones de la vida diaria y edad media del inicio de los síntomas, según sexo y franja de edad. Para analizar la desigualdad del problema crónico de columna, según características socioeconómicas y factores de riesgo, se realiza un modelo de regresión logística multivariada, por etapa del ciclo vital, teniendo como variable dependiente la presencia de problema crónico de columna y como independientes: sexo, escolaridad, área de residencia, raza/color, autoevaluación de la salud, tipo de enfermedad crónica, índice de masa corporal (IMC) y actividad física. La prevalencia de problema crónico de columna en Brasil fue de un 18,5%, siendo mayor entre mujeres que entre hombres (21,1%; IC95%: 20,2-21,9). La edad media de inicio del problema crónico de columna es 35 años. Se encontró una asociación entre problema crónico de columna y un menor nivel educacional, mala autoevaluación de la salud y una presencia de la mayoría de las enfermedades crónicas consideradas. Lugar de residencia, IMC, edad y raza/color estuvieron escasamente o no asociados. La prevalencia de problema crónico de columna se estabiliza a los 50 años, pero la severidad de la limitación aumenta en edades más avanzadas. La alta prevalencia, similar a otros países, y el impacto en las condiciones de vida revelan la necesidad de estudios epidemiológicos sobre problema crónico de columna. Los resultados sugieren que la promoción y prevención del problema crónico de columna deben ser intensificadas, especialmente antes de los 50 años de edad, considerándose el acentuado envejecimiento poblacional del país.

Prevalência, fatores associados e limitações relacionados ao problema crônico de coluna entre adultos e idosos no Brasil / Prevalencia, factores asociados y limitaciones relacionadas con el problema crónico de columna entre adultos y ancianos en Brasil / Prevalence, associated factors, and limitations related to chronic back problems in adults and elderly in Brazil

O objetivo foi analisar aspetos epidemiológicos do problema crônico de coluna no Brasil e estudar a associação entre a prevalência do problema crônico de coluna e fatores demográficos, socioeconômicos, estilo de vida e condições de saúde. Utilizam-se microdados da Pesquisa Nacional de Saúde (PNS) de 2013. Os indicadores epidemiológicos foram: prevalência, tempo vivido com problema crônico de coluna, ciclo vital (de adulto jovem até idoso), impacto nas limitações da Vida Diária e idade média do início dos sintomas, segundo sexo e faixa etária. Para analisar a desigualdade do problema crônico de coluna segundo características socioeconômicas e fatores de risco realiza-se modelo de regressão logística multivariada, por etapa do ciclo vital, tendo como variável dependente a presença de problema crônico de coluna e como independentes: sexo, escolaridade, área de residência, raça/cor, autoavaliação da saúde, tipo de doença crônica, ídice de massa corporal (IMC) e atividade física. A prevalência de problema crônico de coluna no Brasil foi de 18,5%, sendo maior entre mulheres do que entre homens (21,1%; IC95%: 20,2-21,9). A idade média de início do problema crônico de coluna é 35 anos. Encontrou-se associação entre problema crônico de coluna e menor nível educacional, má autoavaliação da saúde e presença da maioria das doenças crônicas consideradas. Local de residência, IMC, idade e raça/cor estiveram fracamente ou não associados. A prevalência de problema crônico de coluna estabiliza aos 50 anos, mas a severidade da limitação aumenta em idades mais avançadas. A alta prevalência, similar a outros países, e o impacto nas condições de vida revelam a necessidade de estudos epidemiológicos sobre problema crônico de coluna. Resultados sugerem que a promoção e prevenção do problema crônico de coluna devem ser intensificadas, especialmente antes dos 50 anos de idade, considerando-se o acentuado envelhecimento populacional do país.

El objetivo fue analizar aspectos epidemiológicos del problema crónico de columna en Brasil y estudiar la asociación entre la prevalencia del problema crónico de columna y factores demográficos, socioeconómicos, estilo de vida y condiciones de salud. Se utilizan microdatos de la Encuesta Nacional de Salud (PNS) de 2013. Los indicadores epidemiológicos fueron: prevalencia, tiempo vivido con problema crónico de columna, ciclo vital (desde la etapa de adulto joven a incluso anciano), impacto en las limitaciones de la vida diaria y edad media del inicio de los síntomas, según sexo y franja de edad. Para analizar la desigualdad del problema crónico de columna, según características socioeconómicas y factores de riesgo, se realiza un modelo de regresión logística multivariada, por etapa del ciclo vital, teniendo como variable dependiente la presencia de problema crónico de columna y como independientes: sexo, escolaridad, área de residencia, raza/color, autoevaluación de la salud, tipo de enfermedad crónica, índice de masa corporal (IMC) y actividad física. La prevalencia de problema crónico de columna en Brasil fue de un 18,5%, siendo mayor entre mujeres que entre hombres (21,1%; IC95%: 20,2-21,9). La edad media de inicio del problema crónico de columna es 35 años. Se encontró una asociación entre problema crónico de columna y un menor nivel educacional, mala autoevaluación de la salud y una presencia de la mayoría de las enfermedades crónicas consideradas. Lugar de residencia, IMC, edad y raza/color estuvieron escasamente o no asociados. La prevalencia de problema crónico de columna se estabiliza a los 50 años, pero la severidad de la limitación aumenta en edades más avanzadas. La alta prevalencia, similar a otros países, y el impacto en las condiciones de vida revelan la necesidad de estudios epidemiológicos sobre problema crónico de columna. Los resultados sugieren que la promoción y prevención del problema crónico de columna deben ser intensificadas, especialmente antes de los 50 años de edad, considerándose el acentuado envejecimiento poblacional del país.

The objective was to analyze the epidemiological characteristics of chronic back problems in Brazil and study the association between their prevalence and demographic and socioeconomic factors, lifestyle, and health conditions. The study used micro-data from the Brazilian National Health Survey (PNS), 2013. The epidemiological indicators were: prevalence, time with chronic back problems, life cycle (from young adults to the elderly), limitations in activities of daily living, and mean age at onset of symptoms, according to sex and age bracket. In order to analyze inequality in chronic back problems according to socioeconomic characteristics and risk factors, a multivariate logistic regression model was used, based on life cycle stages, with the presence of chronic back problems as the dependent variable and the following independent variables: sex, schooling, area of residence, race/color, self-rated health, types of chronic diseases, body mass index (BMI), and physical activity. Prevalence of chronic back problems in Brazil was 18.5%, and was higher in women than in men (21.1%; 95%CI: 20.2-21.9). Mean age at onset of chronic back problems was 35 years. There was an association between chronic back problems and lower schooling, poor self-rated health, and presence of the majority of the selected chronic diseases. Area of residence, BMI, age, and race/color were weakly associated or not associated with chronic back problems. Prevalence of chronic back problems stabilized at 50 years of age, but the severity of limitations increased at older ages. As in other countries, high prevalence and the impact on living conditions revealed the need for epidemiological studies on chronic back problems in Brazil. The results suggest that health promotion and the prevention of chronic back problems should be intensified, especially before 50 years of age, considering the on-going population aging in Brazil.

Spine Conditions: Occupational Spine Conditions.

Neck and back conditions have significant effects on employee health and productivity. More than $7 billion in lost revenue in the United States annually can be attributed to workplace back pain among employees ages 40 to 65 years. According to the Bureau of Labor Statistics, in 2012 back pain was the most prevalent musculoskeletal condition resulting in workplace absenteeism. The incidence of these conditions is higher among individuals in certain professions, such as bus drivers, police officers, and correctional officers. Risk factors include obesity, depression, nicotine dependence, and alcohol abuse. There is limited evidence about whether modifying risk factors decreases the incidence of neck and back conditions. Specific efforts to reduce the burden in the workplace have shown mixed results. Use of simple interventions, such as braces and orthotics, has not consistently shown benefit. In addition, limited data show minimal or no evidence of effective prevention or management with back school programs and instruction on lifting techniques. The most consistent data support regular exercise as a method to prevent back pain. However, attempts to include exercise in workplace activities have shown mixed results. Lower rates of workplace absenteeism have been show to result from employee education on these issues.

The Impact of Cervical Musculoskeletal Disorders on UK Consultant Plastic Surgeons: Can We Reduce Morbidity With Applied Ergonomics?

BACKGROUND: Based on anecdotal and observational evidence, we hypothesized that the prevalence of cervical musculoskeletal disorder (C-MSD) would be high among plastic surgeons. A questionnaire review was undertaken to test this hypothesis. Ergonomic assessment was undertaken to assess causal factors of C-MSD. METHOD: An anonymous questionnaire recording demographics, physical symptoms and behavioral responses to C-MSD was distributed to UK Plastic Surgery consultants. The postural impact of wearing loupes was assessed using motion capture techniques and recording cervical muscular activity. RESULTS: The questionnaire response rate was 81%. The prevalence of cervical spine morbidity was recorded as 32%. Employment implications included 28% of the cohort requiring sick leave. The professional impact was 7% permanently modifying their practice. There were 2 factors significant for C-MSD, the surgeons' age and the duration in hours of wearing loupes per week. Ergonomic assessment of surgeons operating in loupes demonstrated: 1. increased forward and lateral cervical flexion; 2. increased cervical muscular activity to maintain the protracted "head forward" posture; and 3. prolonged static posturing to maintain head position for visual focus. Table height adjustment and variation of loupe working distance can reduce neck flexion. CONCLUSIONS: Cervical morbidity is a prevalent problem among plastic surgeons. Long procedures, static postures and neck flexion result in the "head forward" posture. This posture exaggerates when operating with loupe magnification. Early-middle-aged consultants are more prone to cervical morbidity hence afflicted when at the top of their game. The work force is diminished for a potentially avoidable morbidity. Rather than accept this morbidity, co-operation between plastic surgeons and ergonomist may help to reduce injury.

Iatrogenic Flatback and Flatback Syndrome: Evaluation, Management, and Prevention.

Flatback syndrome can be a significant source of disability, affecting stance and gait, and resulting in significant pain. Although the historical instrumentation options for thoracolumbar fusion procedures have been commonly regarded as the etiology of iatrogenic flatback, inappropriate selection, or application of modern instrumentation can similarly produce flatback deformities. Patients initially compensate with increased lordosis at adjacent lumbar segments and reduction of thoracic kyphosis. As paraspinal musculature fatigues and discs degenerate, maintaining sagittal balance requires increasing pelvic retroversion and hip extension. Ultimately, disc degeneration at adjacent levels overcomes compensatory mechanisms, resulting in sagittal imbalance and worsening symptoms. Nonoperative management for sagittally imbalanced (sagittal vertical axis>5 cm) flatback syndrome is frequently unsuccessful. Despite significant complication rates, surgical management to recreate lumbar lordosis using interbody fusions and/or osteotomies can significantly improve quality of life.

The M6-C Cervical Disk Prosthesis: First Clinical Experience in 33 Patients.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine the short-term clinical succesrate of the M6-C cervical disk prosthesis in primary and secondary surgery. SUMMARY OF BACKGROUND DATA: Cervical disk arthroplasty (CDA) provides an alternative to anterior cervical decompression and fusion for the treatment of spondylotic radiculopathy or myelopathy. The prevention of adjacent segment disease (ASD), a possible complication of anterior cervical decompression and fusion, is its most cited--although unproven--benefit. Unlike older arthroplasty devices that rely on a ball-and-socket-type design, the M6-C cervical disk prosthesis represents a new generation of unconstrained implants, developed to achieve better restoration of natural segmental biomechanics. This device should therefore optimize clinical performance of CDA and reduce ASD. MATERIALS AND METHODS: All patients had preoperative computed tomography or magnetic resonance imaging and postoperative x-rays. Clinical outcome was assessed using the Neck Disability Index, a Visual Analog Scale, and the SF-36 questionnaire. Patients were asked about overall satisfaction and whether they would have the surgery again. RESULTS: Thirty-three patients were evaluated 17.1 months after surgery, on average. Nine patients had a history of cervical interventions. Results for Neck Disability Index, Visual Analog Scale, and SF-36 were significantly better among patients who had undergone primary surgery. In this group, 87.5% of patients reported a good or excellent result and 91.7% would have the procedure again. In contrast, all 4 device-related complications occurred in the small group of patients who had secondary surgery. CONCLUSIONS: The M6-C prosthesis appears to be a valuable addition to the CDA armatorium. It generates very good results in patients undergoing primary surgery, although its use in secondary surgery should be avoided. Longer follow-up is needed to determine to what measure this device can prevent ASD.

Topping-off technique prevents aggravation of degeneration of adjacent segment fusion revealed by retrospective and finite element biomechanical analysis.

AIM: The aim of this study was to evaluate the effect of the Topping-off technique in preventing the aggravation of degeneration caused by adjacent segment fusion. METHODS: Clinical parameters of patients who underwent L5-S1 posterior lumbar interbody fusion + interspinous process at L4-L5 (PLIF + ISP) with the Wallis system (Topping-off group) were compared retrospectively with those of patients who underwent solely PLIF. Pre- and post-operative x-ray measurements, visual analogue scale (VAS) scores, and Japanese Orthopaedic Association (JOA) scores were assessed in all subjects. Normal L1-S1 lumbosacral finite element models were established in accordance with the two types of surgery in our study, respectively. Virtual loading was added to assess the motility, disc pressure, and facet joint stress of L4-L5. RESULTS: There were 22 and 23 valid cases included in the Topping-off and PLIF groups. No degeneration was observed in either group. Both VAS and JOA scores improved significantly post-operatively (P < 0.01). The intervertebral angle and lumbar lordosis of L4-L5 were both significantly increased (t = -2.89 and -2.68, P < 0.05 in the Topping-off group and t = -2.25 and -2.15, P < 0.05 in the PLIF group). In the Topping-off group, x-ray in dynamic position showed no significant difference in the angulation or distance of the anterior movement of the L4-L5 segment. The angle of hyper-extension and distance of the posterior movement of L4 were significantly decreased. In the PLIF group, both hyper-flexion and hyper-extension and posterior movement were increased significantly. In finite element analysis, displacement of the L4 vertebral body, pressure of the annulus fibrosus and nucleus pulposus, and stress of the bilateral facet joint were less in the Topping-off group under loads of anterior flexion and posterior extension. Facet joint stress on the left side of the L4-L5 segment was also less in the Topping-off group under left flexion loads. CONCLUSION: Short-term efficacy and safety between Topping-off and PLIF were similar, whilst the Topping-off technique could restrict the hyper-extension movement of adjacent segments, prevent back and forth movement of proximal vertebrae, and decrease loads of intervertebral disc and facet joints.

Health care associated hematogenous pyogenic vertebral osteomyelitis: a severe and potentially preventable infectious disease.

Although hematogenous pyogenic spinal infections have been related to hemodialysis (HD), catheter-related sepsis, and sporadically, to other nosocomial infections or procedures, in most recent studies and reviews the impact of nosocomial infection as a risk factor for vertebral osteomyelitis (VO) is not well established. The aim of our study was to describe the risk factors, infectious source, etiology, clinical features, therapy, and outcome of health care associated VO (HCAVO), and compare them with community-acquired VO (CAVO) cases.A retrospective cohort study of consecutive patients with hematogenous VO was conducted in our third-level hospital between 1987 and 2011. HCAVO was defined as onset of symptoms after 1 month of hospitalization or within 6 months after hospital discharge, or ambulatory manipulations in the 6 months before the diagnosis.Over the 25-year study period, among 163 hematogenous pyogenic VO, 41 (25%) were health care associated, a percentage that increased from 15% (9/61) in the 1987-1999 period to 31% (32/102) in the 2000-2011 period (P < 0.01). The presumed source of infection was an intravenous catheter in 14 (34%), cutaneous foci in 8 (20%), urinary tract in 7 (17%), gastrointestinal in 3 (7%), other foci in 3 (7%), and unknown in 6 (15%). Staphylococcus aureus was the most frequently isolated microorganism (14 cases, 34%), followed by coagulase-negative Staphylococci (CoNS) in 6 (15%), and Enterobacteriaceae in 6 (15%) cases.Compared with CAVO cases, patients with HCAVO were older (mean 66.0 SD 13.0 years vs 60.5 SD 15.5 years), had more underlying conditions (73% vs 50%, P < 0.05), neoplasm/immunosuppression (39% vs 7%, P < 0.005), chronic renal failure (19% vs 4%, P < 0.001), a known source of infection (85% vs 54% P < 0.05), Candida spp (7% vs 0%, P < 0.01) or CoNS infections (15% vs 2%, P < 0.05), higher mortality (15% vs 6%, P = 0.069), and a higher relapse rate in survivors (9% vs 1%, P < 0.05).Presently, in our setting, one-third of hematogenous pyogenic VO infections are health care associated, and a third of these are potentially preventable catheter-related infections. Compared with CAVO, in health care associated hematogenous VO, mortality and relapse rates are higher; hence, further prevention measures should be assessed.

Assessment of the outcomes associated with periprocedural anticoagulation management in children with acute lymphoblastic leukemia.

OBJECTIVE: To report the outcomes of an institutional protocol for periprocedural anticoagulant (AC) management in children with acute lymphoblastic leukemia (ALL). STUDY DESIGN: Children being treated for ALL who received full-dose (therapeutic) anticoagulation before undergoing at least 1 lumbar puncture (LP) were included in this retrospective cohort study. The main outcome was the risk of traumatic LP; exploratory analysis included the risks of symptomatic spinal hematoma and progression/recurrence of the thrombotic event. Analyses were conducted using logistic regression analysis with a generalized estimating equation approach. RESULTS: Twenty-two children with ALL receiving an AC underwent a total of 396 LPs. Although traumatic LP was associated with full-dose AC therapy in univariable analysis, a multiple logistic regression model controlling for other risk factors for traumatic LP showed that AC therapy was not significantly associated with the risk of traumatic LP when the ACs were held as per the institutional protocol. No patient developed symptomatic spinal hematoma. Exploratory analysis revealed that AC dose, a likely marker of thrombus burden, was significantly associated with progression/recurrence of the thrombotic event in univariable analysis. CONCLUSION: In our cohort, recent AC therapy was not statistically associated with an increased risk of bleeding after LP when following a specific protocol for periprocedural AC management. The risk associated with the progression/recurrence of thromboembolic events requires further evaluation.

[Complication analysis of spinal interventions in adult central movement disorders and scoliosis]. / Komplikationsanalyse von spinalen Eingriffen bei adulten zentralen Bewegungsstörungen und Skoliosen.

BACKGROUND: Adult central movement disorders, malpostures, and scolioses can have their cause in various neurological underlying diseases such as Morbus Parkinson, Pisa syndrome, or segmental dystonia. Important clinical characteristics are marked postural distortions such as camptocormia (bent spine) or laterocollis. In cases of these adult scolioses, surgical spine treatment puts high demands on the surgeon. Surgery in Parkinson's disease, for example, is associated with serious surgery-specific as well as general complications. The more rarely occurring Pisa syndrome is an entity primarily requiring medical therapy. PATIENTS AND METHODS: A series of ten case reports of patients with Morbus Parkinson and Pisa syndrome who underwent spinal surgery is presented and discussed. From these reports, treatment recommendations have been derived and complemented by references from the literature. An extensive MEDLINE search was performed for this purpose. RESULTS AND CONCLUSION: In patients suffering from Parkinson's disease, even minor surgical interventions can lead to instability of whole spine segments or even the entire spine. Implant loosening, adjacent segment instability, general perioperative complications, and progressive malposture due to disease progress can bring forth disastrous treatment courses. Spinal fixation should be performed long-segmented in combination with ventral stabilisation. Due to osteoporosis, pedicle screw cement augmentation is recommended in this collective. If the diagnosis of Pisa syndrome is established, an optimised preoperative preparation should be initiated in close cooperation with neurologists. In many cases medical therapy is sufficient and surgical interventions can be avoided.

[Utility of ligamentoplasty for the prevention of adjacent segment disease above 360 degree arthrodesis in degenerative lumbar spondylosis. Preliminary report]. / Utilidad de la ligamentoplastía para la prevención de la artrodesis en espondilolistesis lumbar degenerativa. Reporte preliminar.

BACKGROUND: Ligamentoplasty is a dynamic stabilization method used to treat lumbar stenosis and resect lumbar herniated discs with good results. The objective of this paper is to report preliminary results of the utility of ligamentoplasty to prevent adjacent segment disease above the arthrodesis. MATERIAL AND METHODS: Two groups of patients with degenerative lumbar spondylolisthesis who underwent circumferential arthrodesis. In 23 patients a dynamic stabilization system was placed in the segment above (group L), while this system was not used in 35 patients (group S). Degeneration and disease of the segment above were assessed. The statistical analysis was done with the SPSS 15.0 software. RESULTS: At the one-year follow-up, the incidence rate of adjacent segment degeneration was 11% for group L and 0% for group S; at the two-year follow-up it was 13% in both groups; at three years, 0% for group L and 19% for group S; at four years, 25% for group L and 0% for group S. At five years, 50% for group L and 0% for group S. Clinically significant radiculopathy occurred in two patients five years after surgery, one of whom also had adjacent segment disease. CONCLUSIONS: Based on the follow-up, at this moment it is not possible to show the utility of dynamic stabilization through ligamentoplasty to avoid adjacent segment disease above the arthrodesis.