Is endoscopic technique an effective and safe alternative for lumbar interbody fusion? A systematic review and meta-analysis.

Study design: Systematic review; meta-analysis. Purpose: Lumbar degenerative disease is frequent and has a tremendous impact on patients' disability and quality-of-life. Open and minimally invasive procedures have been used to achieve adequate decompression and fusion. Endoscopic lumbar interbody fusion (Endo-LIF) is emerging as an alternative, trying to reduce morbidity, while achieving comparable to superior clinical outcomes. The aim of this work is to perform a systematic review and meta-analysis to investigate how Endo-LIF compares to open or minimally invasive procedures. Methods: Electronic databases (MEDLINE, Scopus, Web of Science, Cochrane) were systematically reviewed using the query: '(percutaneous OR endoscop*) AND (open OR minimal* invasive) AND lumbar AND fusion'. PRISMA guidelines were followed. Results: Twenty-seven articles were included (25 cohort study, 1 quasi-experimental study, and 1 randomized control trial; for meta-analytical results, only observational studies were considered). Endo-LIF conditioned longer operative time, with significantly lower blood loss, bedtime, and hospital length of stay. Early post-operative back pain favored endoscopic techniques. Endo-LIF and non-Endo-LIF minimally invasive surgery displayed comparable results for most back and leg pain or disability outcomes, despite Endo-LIF having been associated with higher disability at late follow-up (versus Open-LIF). No differences were found regarding fusion rates, cage subsidence, or adverse events. Definitive conclusions regarding fusion rate cannot be drawn due to low number of studies and unstandardized fusion definition. Conclusion: Endo-LIF is an effective and safe alternative to conventional lumbar interbody fusion procedures. Evidence shortcomings may be addressed, and future randomized control trials may be performed to compare techniques and to validate results.

Spondylectomy for Primary Ewing Lumbar Sarcoma in Children.

Primary Ewing sarcoma in the spine is very rare, and the treatment for it is multidisciplinary. There is no consensus regarding the optimal method of local control; however, en bloc resection is associated with an improvement in survival rates. The authors report a case of a 5-year-old girl who initially presented low back pain, and was diagnosed with Ewing sarcoma after being submitted to imaging studies by radiography, magnetic resonance and bone biopsy. A spondylectomy was performed in accordance with the Euro Ewing protocol. At the three-year follow-up, the patient had no restrictions regarding her daily activities, and there has been no evidence of recurrence to date.

Azole-resistant Candida albicans Spondylodiscitis After Bariatric Surgery: A Case Report.

CASE: We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up. CONCLUSION: Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.

Cervical Osteoblastoma: A Case Report.

Osteoblastoma is a rare benign primary bone tumor. It accounts for 3% of benign and 1% of all primary bone tumors. The treatment goal is complete surgical resection. This treatment limits the risk of recurrence. As osteoblastoma is a highly vascular tumor, complete resection is often difficult. This report describes the case of a 19-year-old male patient who presented severe right-sided neck and shoulder pain. The computed tomography scan revealed a mass lesion on C7 compatible with osteoblastoma. Preoperative embolization and tumor resection were performed. At the 3-year follow-up, the patient had no restrictions on daily activities, and, to date, there has been no evidence of recurrence.

Anterior fixation of odontoid fractures: results.

OBJECTIVE: To evaluate the clinical and radiological outcomes of the surgical treatment in patients diagnosed with odontoid fracture who underwent open reduction and internal fixation (ORIF) with screws. METHODS: This was a retrospective study with nine patients. Pain (visual analog scale [VAS]) and neurological status (Frankel scale) were assessed. The neck disability index (NDI) and the post-operative cervical range of motion were calculated. The cervical spine was radiologically evaluated (X-ray and CT) pre- and postoperatively. RESULTS: The mean age of patients was 70 years. All patients presented type IIb (Grauer classification) fractures, with a mean deviation of 2.95 mm. Two patients had subaxial lesions. The mean follow-up was 30 months. The mean time from trauma to surgery was seven days. The pre-operative Frankel score was E in all except one patient (B), in whom a post-operative improvement from B to D was observed. Post-operative pain was 2/10 (VAS). A total of 77% of patients presented a mild or moderate disability (NDI). Six patients regained full range of cervical movement, and bone union required approximately 14 weeks. Pseudarthrosis complications were observed in two patients (77% union rate), one patient presented screw repositioning and one case, dysphonia. CONCLUSION: Delayed diagnosis is still an issue in the treatment of odontoid fractures, especially in elderly patients. Concomitant lesions, especially in younger patients, are not uncommon. The literature presents high fusion rates with ORIF (≥80%), which was also observed in the present study. However, surgical success depends on proper patient selection and strict knowledge of the technique. This pathology presents a reserved functional prognosis in the medium-term, especially in the elderly.

OBJETIVO: Avaliar os resultados clínicos e radiológicos do tratamento cirúrgico em pacientes com diagnóstico de fratura do processo odontoide submetidos a redução aberta e fixação interna (RAFI) com parafusos. MÉTODOS: Estudo retrospectivo com nove pacientes. Avaliada a dor (escala visual analógica [EVA]) e o estado neurológico (escala de Frankel). O Neck Disability Index (NDI) e a amplitude de movimento cervical pós-operatória foram calculados. A coluna cervical foi avaliada radiologicamente (Raios X e TC) nos períodos pré- e pós-operatório. RESULTADOS: A idade média dos pacientes foi de 70 anos. Todos os pacientes apresentaram fraturas do tipo IIb (classificação de Grauer), com desvio médio de 2,95 mm. Dois pacientes apresentaram lesões subaxiais. O seguimento médio foi de 30 meses. O tempo médio entre trauma e cirurgia foi de sete dias. O escore pré-operatório de Frankel foi E em todos, exceto em um paciente (B), no qual se observou uma melhora pós-operatória de B para D. A dor pós-operatória foi 2/10 (EVA). Um total de 77% dos pacientes apresentou incapacidade leve ou moderada (NDI). Seis pacientes recuperaram toda a amplitude de movimento cervical; a consolidação óssea levou aproximadamente 14 semanas. Foram observadas complicações de pseudartrose em dois pacientes (taxa de consolidação: 77%), um paciente necessitou reposicionamento do parafuso e um paciente, disfonia. CONCLUSÃO: O diagnóstico tardio ainda é um problema no tratamento de fraturas do odontoide, especialmente em pacientes idosos. As lesões concomitantes, especialmente em pacientes mais jovens, não são incomuns. A literatura apresenta altas taxas de consolidação com RAFI (≥ 80%), o que também foi observado no presente estudo. No entanto, o sucesso cirúrgico depende da seleção adequada do paciente e do conhecimento rigoroso da técnica. Esta patologia apresenta um prognóstico funcional reservado no médio prazo, especialmente em idosos.

Spondylectomy for Primary Ewing Lumbar Sarcoma in Children / Espondilectomia para sarcoma lombar primário de Ewing em crianças

Abstract Primary Ewing sarcoma in the spine is very rare, and the treatment for it is multidisciplinary. There is no consensus regarding the optimal method of local control; however, en bloc resection is associated with an improvement in survival rates. The authors report a case of a 5-year-old girl who initially presented low back pain, and was diagnosed with Ewing sarcoma after being submitted to imaging studies by radiography, magnetic resonance and bone biopsy. A spondylectomy was performed in accordance with the Euro Ewing protocol. At the three-year follow-up, the patient had no restrictions regarding her daily activities, and there has been no evidence of recurrence to date.

Resumo O sarcoma de Ewing da coluna vertebral é raro, e seu tratamento é multidisciplinar. Não há consenso sobre o método ideal de controle local do tumor; no entanto, a ressecção em bloco com margens negativas está associada a uma melhora da sobrevida. Os autores relatam um caso de uma paciente de 5 anos do sexo feminino que inicialmente se apresentou com dor lombar, tendo sido diagnosticada com sarcoma de Ewing de acordo com o estudo imagiológico por radiografia, ressonância magnética e biópsia óssea. A paciente foi submetida a vertebrectomia após quimioterapia, de acordo com o protocolo Euro Ewing. Aos três anos de seguimento, não apresentou restrições nas atividades da vida diária, e, até o momento, não houve evidência de recidiva.

Cervical Osteoblastoma: A Case Report / Osteoblastoma cervical: relato de caso

Abstract Osteoblastoma is a rare benign primary bone tumor. It accounts for 3% of benign and 1% of all primary bone tumors. The treatment goal is complete surgical resection. This treatment limits the risk of recurrence. As osteoblastoma is a highly vascular tumor, complete resection is often difficult. This report describes the case of a 19-year-old male patient who presented severe right-sided neck and shoulder pain. The computed tomography scan revealed a mass lesion on C7 compatible with osteoblastoma. Preoperative embolization and tumor resection were performed. At the 3-year follow-up, the patient had no restrictions on daily activities, and, to date, there has been no evidence of recurrence.

Resumo Osteoblastoma é um tumor primário benigno raro. Constitui cerca de 3% dos tumores benignos e 1% de todos os tumores ósseos. O objetivo do tratamento é a ressecção completa, que limita o risco de recidiva. Por se tratar de um tumor vascularizado, a ressecção completa é, muitas vezes, difícil. Os autores descrevem um caso clínico de um paciente do sexomasculino de 19 anos que apresentava queixas de cervicalgia direita com irradiação para o ombro. O exame por tomografia computadorizada indicou uma lesão em C7 compatível com osteoblastoma. O paciente foi submetido a resseção cirúrgica após embolização pré-operatória e artrodese anterior. Aos 3 anos de seguimento, o paciente encontra-se assintomático e, até a data, sem evidência de recidiva.

Anterior fixation of odontoid fractures: results / Fixação anterior de fraturas do processo odontoide: resultados

ABSTRACT Objective: To evaluate the clinical and radiological outcomes of the surgical treatment in patients diagnosed with odontoid fracture who underwent open reduction and internal fixation (ORIF) with screws. Methods: This was a retrospective study with nine patients. Pain (visual analog scale [VAS]) and neurological status (Frankel scale) were assessed. The neck disability index (NDI) and the post-operative cervical range of motion were calculated. The cervical spine was radiologically evaluated (X-ray and CT) pre- and postoperatively. Results: The mean age of patients was 70 years. All patients presented type IIb (Grauer classification) fractures, with a mean deviation of 2.95 mm. Two patients had subaxial lesions. The mean follow-up was 30 months. The mean time from trauma to surgery was seven days. The pre-operative Frankel score was E in all except one patient (B), in whom a post-operative improvement from B to D was observed. Post-operative pain was 2/10 (VAS). A total of 77% of patients presented a mild or moderate disability (NDI). Six patients regained full range of cervical movement, and bone union required approximately 14 weeks. Pseudarthrosis complications were observed in two patients (77% union rate), one patient presented screw repositioning and one case, dysphonia. Conclusion: Delayed diagnosis is still an issue in the treatment of odontoid fractures, especially in elderly patients. Concomitant lesions, especially in younger patients, are not uncommon. The literature presents high fusion rates with ORIF (≥80%), which was also observed in the present study. However, surgical success depends on proper patient selection and strict knowledge of the technique. This pathology presents a reserved functional prognosis in the medium-term, especially in the elderly.

RESUMO Objetivo: Avaliar os resultados clínicos e radiológicos do tratamento cirúrgico em pacientes com diagnóstico de fratura do processo odontoide submetidos a redução aberta e fixação interna (RAFI) com parafusos. Métodos: Estudo retrospectivo com nove pacientes. Avaliada a dor (escala visual analógica [EVA]) e o estado neurológico (escala de Frankel). O Neck Disability Index (NDI) e a amplitude de movimento cervical pós-operatória foram calculados. A coluna cervical foi avaliada radiologicamente (raios X e TC) nos períodos pré- e pós-operatório. Resultados: A idade média dos pacientes foi de 70 anos. Todos apresentaram fraturas do tipo IIb (classificação de Grauer), com desvio médio de 2,95 mm. Dois apresentaram lesões subaxiais. O seguimento médio foi de 30 meses. O tempo médio entre trauma e cirurgia foi de sete dias. O escore pré-operatório de Frankel foi E em todos, exceto em um paciente (B), no qual se observou uma melhoria pós-operatória de B para D. A dor pós-operatória foi 2/10 (EVA). Apresentaram incapacidade leve ou moderada (NDI) 77% pacientes. Seis pacientes recuperaram toda a amplitude de movimento cervical; a consolidação óssea levou aproximadamente 14 semanas. Foram observadas complicações de pseudartrose em dois pacientes (taxa de consolidação: 77%), um paciente necessitou reposicionamento do parafuso e um paciente, disfonia. Conclusão: O diagnóstico tardio ainda é um problema no tratamento de fraturas do odontoide, especialmente em pacientes idosos. As lesões concomitantes, especialmente em pacientes mais jovens, não são incomuns. A literatura apresenta altas taxas de consolidação com RAFI (≥ 80%), o que também foi observado no presente estudo. No entanto, o sucesso cirúrgico depende da seleção adequada do paciente e do conhecimento rigoroso da técnica. Essa patologia apresenta um prognóstico funcional reservado em médio prazo, especialmente em idosos.

Os odontoideum: case report / Os odontoideum: relato de caso / Os odontoideum: reporte de caso

OBJECTIVE: To report the difficulties in managing a case of os odontoideum. METHODS: Female patient, 12 years old who developed a quadiparesis after minor cervical trauma in October 2005. In the emergency department a congenital cervical anomaly was identified. The patient was placed in a Stryker® frame and, few days later, in a halo bracing. After 3 months, an infection around the pins emerged and the halo vest had to be removed. A severe C1-2 instability persisted and a C1-C2 Gallie procedure was attempted. In the following weeks the bone disappeared and another procedure was attempted in June 2006 - C1 laminectomy and occiput-C3 fusion. In the following months the neurological status of the patient improved and a complete mass of occiput-C3 fusion was observed. RESULTS: We choose a posterior cervical arthrodesis of C1-C2 using the Gallie technique. Since the condition was not resolved we performed a second surgery, C1 laminectomy (determined by SAC of 8, 3 mm in MRI) followed by posterior occiput-C3 fusion. In our case, until now, there is no evidence of axial decompensation, but a more prolonged follow-up is needed. CONCLUSIONS: The treatment of os odontoideum has many considerations but the essential that in the presence of instability and neurological deficit a solid fusion is achieved. In case of failure of posterior atlantoaxial wiring, the occiput-C2 or C3 fusion with rods seems to be an excellent option with a high rate of success, avoiding the need for additional support.

OBJETIVO: Relatar as dificuldades no tratamento de um caso de os odontoideum. MÉTODOS: Paciente do sexo feminino com 12 anos de idade que desenvolveu tetraparesia após trauma cervical discreto em outubro de 2005. No departamento de emergência, constatou-se uma anomalia cervical congênita. A paciente foi colocada em cama Stryker® e alguns dias depois, em colete Halo Vest. Depois de 3 meses, ocorreu infecção em torno dos pinos e foi preciso remover o colete. Houve persistência de instabilidade C1-C2 grave, tentando-se a resolução com a técnica de Gallie C1-C2. Nas semanas seguintes, o enxerto desapareceu e outro procedimento foi tentado em junho de 2006 - laminectomia de C1 e fusão occipital-C3. Nos meses posteriores, o estado neurológico da paciente melhorou e verificou-se massa de fusão completa occipital-C3. RESULTADOS: Escolhemos a artrodese cervical posterior C1-C2 usando a técnica de Gallie. Uma vez que o problema não se resolveu, realizamos uma segunda cirurgia, laminectomia de C1 (determinada por SAC de 8, 3 mm na RM) seguida de fusão occipital-C3. Em nosso caso, até agora, não há evidência de descompensação axial, mas é necessário um período maior de acompanhamento. CONCLUSÕES: o tratamento de os odontoideum tem muitas considerações, mas é essencial, na presença de instabilidade e déficit neurológico, obter fusão sólida. Em caso de falha de amarrilho atlanto-axial posterior, a fusão occipital-C2 ou C3 com hastes parece ser uma opção excelente, com alta taxa de sucesso, evitando a necessidade de suporte complementar.

OBJETIVO: Informe sobre las dificultades para tratar un caso de os odontoideum. MÉTODOS: Paciente, una adolescente, de 12 años de edad, que desarrolló una cuadriparesia después de un traumatismo cervical leve en octubre de 2005. En el Departamento de Primeros Auxilios, se identificó una anomalía cervical congénita. La paciente fue colocada en un marco de Stryker®, unos días después, en un braguero de halo. Cuando transcurrieron 3 meses, surgió una infección alrededor de los pernos y se tuvo que retirar el chaleco de halo. Persistió una grave inestabilidad C1-2 y se intentó un procedimiento de Gallie C1-C2. En las semanas siguientes, el alambre desapareció y, en junio de 2006, se intentó otro procedimiento - laminectomía C1 y fusión de occipucio-C3. En los meses siguientes, el estado neurológico de la paciente mejoró y se observó una masa completa de fusión occipucio-C3. RESULTADOS: Elegimos una artrodesis cervical posterior de C1-C2 usando la técnica de Gallie. Como la condición no se solucionó, realizamos una segunda cirugía, laminectomía C1 (determinada por SAC de 8, 3 mm en Imágenes de Resonancia Magnética), seguida por una fusión posterior occipucio-C3. En nuestro caso, hasta la fecha, no hay evidencia de descompensación axial, pero se necesita de un seguimiento más prolongado. CONCLUSIONES: El tratamiento de os odontoideum tiene muchas consideraciones, pero lo esencial es que, en la presencia de inestabilidad y de déficit neurológico, se obtiene una fusión sólida. En el caso de falla del sistema de alambres posteriores atloidoaxoideos, la fusión occipucio-C2 o C3, con bastoncillos, parece ser una opción excelente que tiene una tasa alta de éxito, evitando la necesidad de apoyo adicional.