Comparison Between Surgical and Conservative Treatment for AOSpine Type A3 and A4 Thoracolumbar Fractures without Neurological Deficit: Prospective Observational Cohort Study / Comparação entre tratamento cirúrgico e conservador para fraturas toracolombares AOSpine tipo A3 e A4 sem déficit neurológico: Estudo de coorte prospectivo observacional

Abstract Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit. Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up. Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p> 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p> 0.05), quality of life (EQ-5D), and return to work (DWS). Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.

Resumo Objetivo Comparar os resultados clínicos entre os tratamentos conservador (CS) e cirúrgico (CXS) das fraturas A3 e A4 sem déficit neurológico. Métodos Estudo prospectivo observacional de paciente com fraturas toracolombares tipo A3 e A4. Esses pacientes foram separados entre os grupos cirúrgico e conservador e avaliados sequencialmente através da escala numérica de dor (NRS), do questionário de incapacidade de Roland-Morris (RMDQ), do EuroQol-5D (EQ-5D) e da escala de trabalho de Denis (DWS) até 2,5 anos de acompanhamento. Resultados Ambos os grupos apresentaram melhora significante, sem diferença estatística nos questionários de dor (NRS: CXS 2,4 ± 2,6; CS 3,5 ± 2,6; p> 0,05), funcionalidade (RMDQ: CS 7 ± 6,4; CXS 5,5 ± 5,2; p> 0,05), qualidade de vida (EQ-5D) e retorno ao trabalho (DWS). Conclusão Ambos os tratamentos são opções viáveis e com resultados clínicos equivalentes. Há uma tendência a melhores resultados no tratamento cirúrgico das fraturas A4.

Spinal Cord Alignment in Patients with Thoracolumbar Burst Fracture / Alinhamento espinopélvico em pacientes com fratura toracolombar explosão

Abstract Objective To evaluate the spinopelvic alignment in patients with thoracolumbar burst fracture (TBF) without neurological deficit treated nonsurgically and surgically in a tertiary reference trauma hospital. Method Retrospective cross-sectional study of patients with single level, type A3 and A4 AOSpine TBF only of the thoracolumbar region. Analysis of clinical data, low back pain (visual analogue scale [VAS]), Denis Pain Scale, quality of life (SF-36), sagittal (TC, TLC, LL, SVA) and spinopelvic (IP, PV, SI, PI-LL) radiographic parameters of patients treated surgically and nonsurgically. Results A total of 50 individuals with an average age of 50 years old with a mean follow-up of 109 months (minimum of 19 and maximum of 306 months) were evaluated. There was a significant difference between treatments for the Denis Work Scale (p= 0.046) in favor of nonsurgical treatment. There was no significant difference between the treatments for lower back pain VAS and Denis Pain Scale (p= 0.468 and p= 0.623). There was no significant difference between treatments in any of the domains evaluated with the SF-36 (p> 0.05). Radiographic parameters were not different between the analyzed groups; however, all radiographic parameters showed significant difference between the population considered asymptomatic, except for pelvic incidence (p< 0.005). Conclusions The spinopelvic alignment was normal in patients with TBF without neurological deficit treated nonsurgically and surgically after a minimum follow-up of 19 months. However, they presented a higher mean pelvic version and discrepancy between lumbar lordosis and pelvic incidence when compared with the reference values of the Brazilian population.

Resumo Objetivo Avaliar o alinhamento espinopélvico em pacientes com fratura toracolombar do tipo explosão (FTE) sem déficit neurológico tratados de forma não operatória e operatória em um hospital terciário de referência em trauma. Método Estudo transversal retrospectivo de pacientes com FTE apenas da região toracolombar, de nível único, do tipo A3 e A4 AOSpine. Análise de dados clínicos, dor lombar (escala visual analógica [EVA]), Escala de Denis, qualidade de vida (SF-36), parâmetros radiográficos sagitais (cifose torácica [CT], cifose toracolombar [CTL], lordose lombar [LL] e eixo vertical sagital [EVS]) e espinopélvicos (incidência pélvica [IP], versão pélvica [VP], inclinação sacral [IS] e a discrepância entre incidência pélvica e lordose lombar [IP-LL]) de pacientes tratados de forma operatória e não operatória. Resultados O presente estudo avaliou um total de 50 indivíduos com uma média de 50 anos de idade com acompanhamento médio de 109 meses (mínimo de 19 e máximo de 306 meses). Houve diferença significativa entre os tratamentos para Denis trabalho (p= 0,046) a favor do tratamento não operatório. Não houve diferença significativa entre os tratamentos para EVA dor lombar e Denis dor (p= 0,468 e p= 0,623). Não houve diferença significante entre os tratamentos em nenhum dos domínios avaliados do SF-36 (p> 0,05). Parâmetros radiográficos não se mostraram diferentes entre os grupos analisados; contudo, todos os parâmetros radiográficos mostraram diferença significante entre a população considerada assintomática, com exceção da incidência pélvica (p< 0,005). Conclusões O alinhamento espinopélvico foi normal em pacientes com FTE sem déficit neurológico tratados de forma não operatória e operatória, após acompanhamento mínimo de 19 meses. Entretanto, estes pacientes apresentaram maior média de versão pélvica e de discrepância entre lordose lombar e incidência pélvica quando comparados com os valores de referência da população brasileira.

Experiencia en patología cervical alta en el Hospital Guillermo Almenara Irigoyen 2016 - 2021

Introducción : El complejo C0-C1-C2 es responsable de la transición de la carga axial, con función biomecánica única, siendo afectada por múltiples patologías, que por lo general la literatura no las considera como un solo ítem, sino que lo desarrolla según su etiología, pero en nuestro estudio se ha considerado en 5 grupos: traumática, congénita, inflamatoria reumática, neoplásica y degenerativa. Objetivo : Determinar las características epidemiológicas, clínicas y del tratamiento en la patología cervical alta. Materiales y métodos : Se incluyeron a todos los pacientes con diagnóstico clínico radiológico de alguna patología cervical alta que hayan sido sometidos a tratamiento quirúrgico entre 2016 y 2021 en el Hospital Almenara. Se usó el test "t" de student y de chi cuadrado. Se dividió a los pacientes en alguno de los 5 grupos antes mencionados. Resultados : Se consideraron 31 pacientes, con una edad media de 51.16 años. La patología cervical alta más frecuente fue la traumática con el 35.48%. El déficit motor se presentó en el 51.61% y el déficit sensitivo se presentó en el 54.84%. La cirugía más frecuente fue la fijación cervical alta con el 43.89%. La tasa de complicaciones fue del 16.13% con una mortalidad del 0%. Conclusiones : La patología cervical alta es rara, siendo la del tipo traumática la más frecuente, pero un manejo oportuno y adecuado permite un mejor pronóstico funcional del paciente.

Introduction : The C0-C1-C2 complex is responsible of axial load transition, and its biomechanical function is unique, it is affected by multiple pathological conditions; and generally speaking, the literature does not consider these conditions as a single item, it describes them according to etiology. For our study we considered five groups: trauma-related, congenital, rheumatic-inflammatory, neoplastic, and degenerative. Objective : To determine epidemiological, clinical, and therapy-related characteristics in upper cervical pathological conditions. Materials and methods : All patients with a clinical-radiological diagnosis of any upper cervical pathological condition that had undergone surgery between 2016 and 2021 in Guillermo Almenara Hospital were included. Student's t test and chi square methods were used. patients were divided into one of the five aforementioned groups. Results : Thirty-one patients were included in the study; their mean age was 51.16 years. The most frequent upper cervical pathological condition was trauma-related, with 35.48%. Motor deficit occurred in 51.61% of all patients, and sensitive deficit occurred in 54.84%. The most frequently surgical procedure performed was upper cervical fixation, in 43.89% of all patients. Complication rate was 16.13%, and mortality was 0%. Conclusions : Upper cervical pathological conditions are rare, trauma-related conditions are most frequent, but timely and adequate management allow us to achieve better functional prognosis for these patients.

Analysis of 5 cases of Waveflex semi-rigid internal fixation in treatment of thoracolumbar fracture / 国际外科学杂志

Objective:To investigate various clinical treatment measures for thoracolumbar fractures and provide new diagnosis and treatment methods.Methods:The case data of 5 patients(3 males, 2 females, and the age ranged from 39 to 59 years with an average of 51 years) with thoracolumbar fractures were treated with Waveflex semi-rigid internaI fixation system from May 2020 to December 2021 were retrospectively analyzed, imaging indexes and clinical effects were followed up, and analyzed and summarized in combination with relevant literatures.Results:The operations of all 5 patients were successfully completed, and the follow-up period was 6 months. At the last follow-up, the internal fixation position was good, the height of the injured vertebra was maintained satisfactorily, and the clinical effect was satisfactory.Conclusion:Waveflex semi-rigid internal fixation system combines the advantages of fusion and non-fusion, providing a new idea for the treatment of thoracolumbar fractures, but its long-term effect still needs further follow-up.

Treatment of spinal burst fractures with pedicle screw fixation at high altitude area / 中国骨伤

OBJECTIVE@#According to the characteristics of spinal burst fractures in high-altitude areas and the local medical conditions, to explore the clinical efficacy of short-segment fixation with pedicle screws combined with screw placement in injured vertebrae in the treatment of thoracolumbar burst fractures.@*METHODS@#From August 2018 to December 2021, 12 patients with single-vertebral thoracolumbar burst fractures without neurological symptoms were treated with injured vertebral screw placement technique, including 7 males and 5 females;aged 29 to 54 years old, with an average of(42.50±7.95) years old;6 cases of traffic accident injury, 4 cases of high fall injury, 2 cases of heavy object injury;2 cases of T11, 4 cases of T12, 3 cases of L1, 2 cases of L2, and 1 case of L3. In the operation, screws were first placed in the upper and lower vertebrae of the fracture, pedicle screws were placed in the injured vertebra, and connecting rods were installed, and the fractured vertebral body was reset by positioning and distraction. Visual analogue scale (VAS) and Japanese Orthopedic Association (JOA) scoring were used to evaluate the changes in pain and quality of life of patients, and the kyphotic correction rate and correction loss rate of the injured segment were measured by X-ray.@*RESULTS@#All operations were successful without significant intraoperative complications. All 12 patients were followed up, the duration ranged from 9 to 27 months, with an mean of (17.75±5.79) months. VAS at 3 days after operation was significantly higher than that at admission (t=6.701, P=0.000). There was significant difference in JOA score between 9 months after operation and at admission (t=5.085, P=0.000). Three days after operation, Cobb angle was (4.42±1.16)°, and the correction rate was (82±5)% compared with (25.67±5.71)° at admission. Cobb angle was (5.08±1.24) °at 9 months after operation, with a corrected loss rate of (16±13)%. No loosening or breakage of internal fixation was found.@*CONCLUSION@#Under the high-altitude hypobaric and hypoxic environment, the effect of the operation should be ensured while reducing the trauma. The application of the technique of placing screws on the injured vertebra can effectively restore and maintain the height of the injured vertebra, with less bleeding and shorter fixed segments, which is an effective method.

Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries: A prospective analysis of the National Spinal Column/Cord Injury Registry of Iran (NSCIR-IR) data / 中华创伤杂志(英文版)

PURPOSE@#To identify risk factors for developing pressure ulcers (PUs) in the acute care period of traumatic spinal fracture patients with or without spinal cord injuries (SCIs).@*METHODS@#Data were collected prospectively in participating the National Spinal column/Cord Injury Registry of Iran (NSCIR-IR) from individuals with traumatic spinal fractures with or without SCIs, inclusive of the hospital stay from admission to discharge. Trained nursing staff examined the patients for the presence of PUs every 8 h during their hospital stay. The presence and grade of PUs were assessed according to the European Pressure Ulcer Advisory Panel classification. In addition to PU, following data were also extracted from the NSCIR-IR datasets during the period of 2015 - 2021: age, sex, Glasgow coma scale score at admission, having SCIs, marital status, surgery for a spinal fracture, American Spinal Injury Association impairment scale (AIS), urinary incontinence, level of education, admitted center, length of stay in the intensive care unit (ICU), hypertension, respiratory diseases, consumption of cigarettes, diabetes mellitus and length of stay in the hospital. Logistic regression models were used to estimate the unadjusted and adjusted odds ratio (OR) with 95% confidence intervals (CI).@*RESULTS@#Altogether 2785 participants with traumatic spinal fractures were included. Among them, 87 (3.1%) developed PU during their hospital stay and 392 (14.1%) had SCIs. In the SCI population, 63 (16.1%) developed PU during hospital stay. Univariate logistic regression for the whole sample showed that marital status, having SCIs, urinary incontinence, level of education, treating center, number of days in the ICU, age, and Glasgow coma scale score were significant predictors for PUs. However, further analysis by multiple logistic regression only revealed the significant risk factors to be the treating center, marital status, having SCIs, and the number of days in the ICU. For the subgroup of individuals with SCIs, marital status, AIS, urinary incontinence, level of education, the treating center, the number of days in the ICU and the number of days in the hospital were significant predictors for PUs by univariate analysis. After adjustment in the multivariate model, the treating center, marital status (singles vs. marrieds, OR = 3.06, 95% CI: 1.55 - 6.03, p = 0.001), and number of days in the ICU (OR = 1.06, 95% CI: 1.04 - 1.09, p < 0.001) maintained significance.@*CONCLUSIONS@#These data confirm that individuals with traumatic spinal fractures and SCIs, especially single young patients who suffer from urinary incontinence, grades A-D by AIS, prolonged ICU stay, and more extended hospitalization are at increased risk for PUs; as a result strategies to minimize PU development need further refinement.

Application of different puncture techniques to inject bone cement in osteoporotic vertebral compression fractures / 中国骨伤

OBJECTIVE@#To study the application of different puncture techniques to inject bone cement in osteoporotic vertebral compression fractures (OVCFs).@*METHODS@#The clinical data of 282 patients with OVCFs treated from January 2017 to December 2019 were collected for a retrospective study. According to the surgical plan the patients were divided into group A and B, with 141 cases in each group. In group A, extreme lateral puncture was used to inject bone cement through unilateral puncture and bilateral puncture. In group B, bone cement was injected through unilateral pedicle puncture through pedicle approach. The operation status(operation time, radiation exposure time, bone cement injection volume, hospital stay) and complications were observed between two groups. Before operation and 6, 12 months after operation, the pain mediators such as serotonin 5-hydroxytryptamine (5-HT), prostaglandin E2(PGE2), substance P(SP) were compared, bone mineral density, anatomical parameters of the injured vertebrae (height of the anterior edge of the vertebral body, height of the posterior edge of the vertebral body, Cobb angle), visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated between two groups.@*RESULTS@#There were no significant difference in operation time, radiation exposure time, hospital stay between two groups (P>0.05). The amount of bone cement injected in group A was greater than that in group B (P<0.05). The serum 5-HT, SP and PGE2 levels of group A were lower than those of group B at 12 months after operation (P<0.05). The height of anterior edge and height of the posterior edge of vertebral body in group A were greater than those of group B at 12 months after operation, Cobb angle of group A was smaller than that of group B, VAS and ODI were lower than those of group B(P<0.05). There was no significant difference in bone mineral density between two groups at 6 and 12 months postoperatively(P<0.05). There was no significant difference between two groups in postoperative complications (P>0.05).@*CONCLUSION@#Compared with unilateral puncture of the pedicle approach, unilateral puncture and bilateral cement injection technique is more conducive to the recovery of the injured vertebral anatomy and function, and do not prolong operation time, radiation exposure time, hospital stay, nor do increase the risk of nerve damage and bone cement leakage, and postoperative bone metabolism and bone mineral density are improved well, which is a safe and reliable surgical method for the treatment of OVCFs.

Treatment of thoracolumbar fractures by closed reduction via a percutaneous solid pedicle screw / Tratamento de fraturas toracolombares por redução fechada com parafuso de pedículo percutâneo

ABSTRACT Objectives: Investigate the effect of closed reduction and per- cutaneous pedicle screw fixation in treating thoracolumbar fractures. Methods: This retrospective study analyzed 12 cases of single-segment thoracolumbar spine fractures without spinal cord and nerve injury at our department from March 2016 to September 2017. Patients were treated with closed reduction, percutaneous reduction, and internal fixation with solid pedicle screws. The operation time, intraoperative blood loss, anterior vertebral body height ratio (AVHR), Cobb angle (CA) of sagittal kyphosis, and VAS of back pain were determined and statistically compared. Results: The average operation time was 147.2 ± 45.6 min, and the average intraoperative bleeding was 67.8 ± 34.2 mL. All fractured vertebrae were completely reduced, their height was restored, and kyphosis was corrected. The average follow-up period was 10.6 ± 2.7 months, with significant improvements seen in the AVHR, CA of sagittal kyphosis, and VAS score (P < 0.01). One case had a broken rod after three months, and another had a postoperative infection. All the patients achieved bony healing. Conclusion: The treatment of thoracolumbar fractures by closed reduction and internal fixation with a percutaneous solid pedicle screw is simple, effective, and economical. Level of Evidence VI; Therapeutic Study, Case Series.

RESUMO Objetivo: Investigar o efeito da redução incruenta e da fixação com parafuso de pedículo percutâneo no tratamento das fraturas toraco- lombares. Métodos: Este estudo retrospectivo analisou 12 casos de fraturas toracolombares com segmento único sem lesão medular ou neural, encontrados no departamento dentro do período de março de 2016 a setembro de 2017. Os pacientes foram tratados com redução fechada e fixação interna com parafusos de pedículo percutâneo. O tempo de operação, a perda sanguínea intra-operatória, a relação da altura do corpo vertebral anterior (AVHR), o ângulo de Cobb (CA) da cifose sagital e a EVA relativa à dor nas costas foram determinados e comparados estatisticamente. Resultados: O tempo médio da operação foi de 147,2±45,6 min, com sangramento intraoperatório médio de 67,8±34,2 mL. Todas as vértebras fraturadas foram com- pletamente reduzidas, suas alturas foram restauradas e a cifose foi corrigida. O período médio de acompanhamento foi de 10,6±2,7 meses, apresentando melhorias significativas observadas no AVHR, CA da cifose sagital e pontuação VAS (P <0,01). Um caso teve uma haste quebrada após 3 meses, e outro paciente apresentou uma infecção pós-operatória. Todos os pacientes alcançaram a recuperação óssea. Conclusão: O tratamento das fraturas toracolombares por redução fechada com fixação interna pelo parafuso de pedículo percutâneo é simples, eficaz e econômico. Nível de Evidência IV; Estudos Terapêuticos, Série de Casos

Agreement on mri diagnosis in compressive malignant vertebral fractures / Concordância no diagnóstico por rm em fraturas vertebrais malignas compressivas

ABSTRACT Objective: Verify interobserver and intraobserver agreement of malignant compressive vertebral fractures (MCVF) diagnosis using magnetic resonance imaging (MRI). Methods: We retrospectively included a lumbar spine MRI of 63 patients with non-traumatic compressive vertebral fracture diagnoses. Each lumbar vertebra was classified as: without fracture, with fracture of benign characteristics, or with fracture of malignant characteristics. Two medical residents in radiology, one musculoskeletal radiologist fellow, one musculoskeletal radiologist, and two spine surgeons evaluated MRI exams, independently and blindly. Each observer performed two readings, with a 15-day interval between evaluations. A simple Kappa coefficient was used to calculate the intra and interobserver agreement. The reference standard classification was based on bone biopsy or clinical, and imaging follow-up of at least two years, for diagnostic performance analysis. Diagnostic performance was assessed by calculating sensitivity, specificity, accuracy, and positive and negative predictive values with a 95% confidence interval (CI). Results: We observed substantial to perfect intraobserver agreement (kappa: 0.80 to 1.00) and substantial interobserver agreement (kappa 0.64 to 0.77). In general, the sensitivity for the detection of MCVF was moderate, except for the second-year radiology resident that achieved a lower sensitivity. The specificity, accuracy, and negative predictive value were high for all observers. Conclusion: MCVF diagnosis using MRI showed substantial interobserver agreement. The second-year medical resident achieved lower sensitivity but high specificity for MCVF. Regarding the seniors, there was no statistical significance between spine surgeons and the musculoskeletal radiologist. Level of Evidence III; Diagnostic.

RESUMO Objetivo: Verificar a concordância interobservador e intraobservador no diagnóstico de fraturas vertebrais compressivas malignas (MCVF) por meio de ressonância magnética (MRI). Métodos: Incluiu-se retrospectivamente a ressonância magnética da coluna lombar de 63 pacientes com diagnóstico de fratura vertebral compressiva não traumática. Cada vértebra lombar foi classificada da seguinte forma: sem fratura, com fratura de características benignas ou com fratura de características malignas. Dois médicos residentes em radiologia, um pesquisador radiologista musculoesquelético, um radiologista musculoesquelético e dois cirurgiões da coluna vertebral avaliaram os exames de ressonância magnética, independentemente e cegamente. Cada observador realizou duas leituras, com um intervalo de 15 dias entre as avaliações. O coeficiente Kappa simples foi utilizado para calcular o acordo intra e interobservador. A classificação padrão de referência foi baseada em biópsia óssea ou clínica, e acompanhamento por imagem de pelo menos dois anos, para análise de desempenho diagnóstico. O desempenho diagnóstico foi avaliado através do cálculo de sensibilidade, especificidade, precisão, valores preditivos positivos e negativos com um intervalo de confiança de 95% (IC). Resultados: Foi observada concordância substancial a perfeita intraobservador (kappa: 0,80 a 1,00) e concordância substancial interobservador (kappa 0,64 a 0,77). Em geral, a sensibilidade para a detecção de MCVF foi moderada, exceto para o segundo ano de residência radiológica que alcançou uma sensibilidade menor. A especificidade, precisão e valor preditivo negativo foram altos para todos os observadores. Conclusão: O diagnóstico de MCVF por ressonância magnética mostrou uma concordância substancial entre observadores. O residente médico do segundo ano alcançou uma sensibilidade menor, mas alta especificidade para MCVF. Com relação aos veteranos, não houve significância estatística entre os cirurgiões da coluna vertebral e o radiologista músculo-esquelético. Nível de Evidencia III; Diagnóstico.

Retrospective analysis of spinal fracture cases in a tertiary hospital / Análise retrospectiva dos casos de fratura de coluna em um hospital terciário / Análisis retrospectivo de casos de fractura de columna en un hospital terciario

ABSTRACT: Objective: To evaluate the clinical and epidemiological profile of patients diagnosed with spinal fractures treated at Hospital Regional de São José Dr. Homero de Miranda Gomes (HRSJ), from the municipality of São José/SC, from March 2020 to March 2021. Methods: An observational study was carried out with a cross-sectional design and analysis of secondary data obtained by reviewing electronic medical records of patients diagnosed with spinal fractures treated during the study period. Associations of categorical variables were tested using Pearson's chi-square test. The statistical significance level adopted was 5% (p<0.05). Results: 173 individuals participated in the study. There was a predominance of males, with 120 (70.5%) cases. The most frequent trauma was falling from a height (43.4%), followed by trauma from traffic accidents (37.6%). In the AO Classification, A1 was attributed in 35.8% of the cases, and the Frankel Scale had mostly E (90.8%). The approach to fractures was predominantly conservative (70.5%). The most injuries were in the lumbar spine (93). Conclusion: The risk group for spine fractures consists of young men, with a predominance of falls as a mechanism of trauma and lumbar involvement. It is necessary to establish preventive measures aimed at the public at risk. Since spine fractures are important determinants of morbidity and mortality in the population. Level of Evidence II; Type of study: Prognostic study.

RESUMO: Objetivo: Avaliar o perfil clínico e epidemiológico dos pacientes com diagnóstico de fratura de coluna atendidos no Hospital Regional de São José Dr. Homero de Miranda Gomes (HRSJ), do município de São José/SC, no período de março de 2020 a março de 2021. Métodos: Foi realizado um estudo observacional com delineamento transversal e análise de dados secundários obtidos por meio da revisão de prontuários eletrônicos, dos pacientes com diagnóstico de fratura de coluna atendidos no período de estudo. As associações das variáveis categóricas foram testadas pelo teste de Qui-quadrado de Pearson. O nível de significância estatística adotado foi de 5% (valor de p<0,05). Resultados: Participaram do estudo 173 indivíduos. Obteve-se predomínio do sexo masculino com 120 (70,5%) dos casos. O trauma mais frequente foi o de queda de altura (43,4%), seguido por traumas provenientes de acidentes de trânsito (37,6%). Na Classificação AO, a A1 foi atribuída em 35,8% dos casos e a Escala de Frankel teve em sua maioria E (90,8%). A abordagem das fraturas teve predomínio por conduta conservadora (70,5%). Os maiores acometimentos de lesão foram em coluna lombar (93). Conclusão: O grupo de risco para fraturas de coluna constitui-se por homens jovens, com predomínio de quedas como mecanismo de traumas e acometimento lombar. É necessário que se estabeleçam medidas de prevenção voltadas para o público de risco. Nível de Evidência II; Tipo de estudo: Estudo prognóstico.

RESUMEN: Objetivo: Evaluar el perfil clínico y epidemiológico de los pacientes con diagnóstico de fractura de columna atendidos en el Hospital Regional de São José Dr. Homero de Miranda Gomes (HRSJ), del municipio de São José/SC, de marzo de 2020 a marzo de 2021. Métodos: Se realizó un estudio observacional con diseño transversal y análisis de datos secundarios obtenidos a través de la revisión de historias clínicas electrónicas de pacientes con diagnóstico de fractura de columna atendidos durante el periodo de estudio. Las asociaciones de variables categóricas se probaron mediante la prueba de chi-cuadrado de Pearson. El nivel de significancia estadística adoptado fue del 5% (p<0,05). Resultados: 173 personas participaron en el estudio. Hubo predominio del sexo masculino con 120 (70,5%) de los casos. El traumatismo más frecuente fue la caída de altura (43,4%), seguido del traumatismo por accidente de tráfico (37,6%). En la Clasificación AO se atribuyó A1 en el 35,8% de los casos y la Escala de Frankel tuvo mayoritariamente E (90,8%). El abordaje de las fracturas fue predominantemente conservador (70,5%). La mayoría de las lesiones fueron en la columna lumbar (93). Conclusión: El grupo de riesgo para las fracturas de columna está formado por hombres jóvenes, con predominio de caídas como mecanismo de traumatismo y afectación lumbar. Es necesario establecer medidas preventivas dirigidas al público en riesgo. Nivel de Evidencia II; Tipo de estudio: Estudio pronóstico.

Conservative treatment and vitamin d levels in patients with spinal fractures / Tratamento conservador e níveis de vitamina d em pacientes com fraturas toracolombares / Tratamiento conservador y niveles de vitamina d en pacientes con fracturas toracolumbares

ABSTRACT Objectives: Evaluate the evolution of pain, functional capacity, and vitamin D levels in conservatively treated patients with low-energy spinal fractures. Methods: Between January 2017 and March 2021, patients older than 40 years old affected by these fractures were selected and treated conservatively for six months. Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores and Cobb angle were evaluated pre- and post-treatment. Serum vitamin D levels were also measured at the first outpatient visit, and it was investigated whether the patient had a previous diagnosis of osteoporosis or previous fractures. Results: A total of 105 patients were analyzed, 70.5% of whom were women, with a mean age of 73.1 years. The average vitamin D level was 25.3 ng/mL, and hypovitaminosis was found in 75% of patients. Eight patients (7.62%) had a previous diagnosis of osteoporosis, and ten (9.52%) reported the occurrence of previous fractures. Regarding the VAS score, there was a mean reduction of 5.5 points of pain; for ODI, there was an average increase of 1 percentage point and an average increase of 4.3º of kyphosis in the fractured segment between pre- and post-treatment. Conclusion: The treatment improved pain, and patients maintained their functional capacity. Low levels of vitamin D were associated with more complex fractures. Level of evidence III; Retrospective Study.

Resumo: Objetivos: Avaliar a evolução da dor, capacidade funcional e níveis de vitamina D em pacientes com fraturas toracolombares por trauma de baixa energia tratados conservadoramente. Métodos: No período de janeiro de 2017 a março de 2021, pacientes com mais de 40 anos acometidos por estas fraturas foram selecionados e tratados conservadoramente durante 6 meses. As pontuações da Escala Visual Analógica (VAS), do Índice de Incapacidade de Oswestry (ODI) e o ângulo de Cobb foram avaliados no pré e pós tratamento. Dosagem sérica de vitamina D no primeiro retorno ambulatorial também foi realizada e o paciente foi questionado se tinha diagnóstico prévio de osteoporose ou fraturas prévias. Resultados: Foram avaliados 105 pacientes, sendo 70,5% mulheres, cuja idade média foi de 73,1 anos. O nível sérico médio de vitamina D foi de 25,3 ng/mL, sendo que uma hipovitaminose foi encontrada em 75% dos pacientes. Oito pacientes (7,62%) tinham diagnóstico prévio de osteoporose e dez (9,52%) relataram a ocorrência de fraturas prévias. Em relação à pontuação de VAS, observou-se uma redução média de 5,5 pontos da dor, para ODI houve um aumento médio de 1 ponto percentual e um aumento médio de 4,3º de cifose no segmento fraturado entre o pré e pós tratamento. Conclusão: O tratamento se mostrou eficaz na melhora da dor e os pacientes mantiveram sua capacidade funcional. Baixos níveis de vitamina D estavam associados a fraturas mais complexas. Nível de evidência III; Estudo Retrospectivo.

Resumen: Objetivos: Evaluar la evolución del dolor, capacidad funcional y los niveles de vitamina D en los pacientes con fracturas toracolumbares por trauma de baja energía tratados conservadoramente. Métodos: Entre enero de 2017 y marzo de 2021, los pacientes con más de 40 años afectados por estas fracturas fueran seleccionados y tratados de forma conservadora por 6 meses. Las puntuaciones de la escala analógica visual (VAS), el índice de discapacidad de Oswestry (ODI) y el ángulo de Cobb antes y después del tratamiento fueron evaluados. También se realizó la determinación del nivel sérico de vitamina D en la primera consulta y se preguntó al paciente si tenía diagnóstico previo para la osteoporosis o fracturas previas. Resultados: 105 pacientes fueran evaluados, de los cuales 70,5% eran mujeres, con edad promedio de 73,1 años. La media del nivel sérico de vitamina D fue de 25,3 ng/mL y la hipovitaminosis fue encontrada en 75% de los pacientes. Ocho pacientes (7,62%) tenían diagnóstico previo de osteoporosis y diez (9.52%) reportaron la ocurrencia de fracturas previas. Cuanto a la puntuación VAS, hubo una reducción promedio de 5,5 puntos en el dolor, para ODI hubo un aumento promedio de 1 punto porcentual y un aumento promedio de 4,3º de cifosis en el segmento fracturado entre pre y post tratamiento. Conclusión: El tratamiento demostró ser efectivo para mejorar el dolor y los pacientes mantuvieron su capacidad funcional. Los niveles bajos de vitamina D se asociaron con fracturas más complejas. Nivel de evidencia III; Estudio Retrospectivo.

Epidemiology of vertebral fractures evaluated at iot-fmusp from 2019 to 2022 / Epidemiologia das fraturas vertebrais avaliadas no iot-fmusp de 2019 a 2022 / Epidemiología de fracturas vertebrales evaluadas en iot-fmusp del2019 al 2022

ABSTRACT: Objective: To determine the epidemic profile of patients with spinal fractures referred for evaluation by Spine Group of IOT-HCFMUSP between 2019 and 2022. To enable the effect of the Covid-19 Pandemic on these epidemic profiles. Methods: We retrospectively analyzed the medical records of patients with spinal fractures referred by the São Paulo Center for the Regulation of Health Offers and Services (CROSS) to the Spine Group of IOT-HCFMUSP between 2019 and 2022. The epidemiological profile between the pre-pandemic Covid-19 period and the period of the Covid-19 pandemic until December 2022 in the city of São Paulo was compared. Results: The medical records of 427 patients were analyzed between March 2019 and December 2022. During the period, males accounted for 71.9% of cases, and the mean age was 46.7 years. Falls from heights were the most frequent trauma mechanism (63.7%), followed by motorcycle accidents (14.3%). The absence of neurological deficit occurred in 76.8% of the cases, and the most injured region was the lumbar region (39.3%). There were changes in the epidemiological profile during the Covid-19 pandemic compared to the pre-pandemic. Conclusions: A predominance of middle-aged males was observed, in addition to the trauma mechanism of falling from a height, as well as the absence of a neurological deficit in the initial evaluation. The lumbar and cervical regions were the most frequent sites of injury. The pandemic period interfered with the epidemiological profile presented and in the time interval between the injury and the evaluation at the IOT-HCFMUSP. Level of Evidence IV; Case Series.

RESUMO: Objetivos: Determinar o perfil epidemiológico dos pacientes com fraturas na coluna vertebral encaminhados para avaliação pelo Grupo de Coluna do IOT-HCFMUSP entre 2019 e 2022. Avaliar o efeito da Pandemia de Covid-19 sobre esse perfil epidemiológico. Métodos: Foram analisados retrospectivamente os prontuários dos pacientes com fratura na coluna encaminhados pela Central de Regulação de Ofertas e Serviços de Saúde (CROSS) de São Paulo ao Grupo de Coluna do IOT-HCFMUSP entre os anos de 2019 e 2022. Foi comparado o perfil epidemiológico entre o período pré-pandemia Covid-19 e o período de pandemia Covid-19 até dezembro de 2022 na cidade de São Paulo. Resultados: Analisou-se o prontuário médico de 427 pacientes entre março de 2019 e dezembro de 2022. No período o sexo masculino correspondeu a 71,9% dos casos, a média da idade foi de 46,7 anos. Queda de altura foi o mecanismo de trauma mais frequente (63,7%), seguido de acidentes de motocicleta (14,3%). A ausência de déficit neurológico ocorreu em 76,8% dos casos, bem como a região mais lesada foi a lombar (39,3%). Houveram mudanças no perfil epidemiológico durante a pandemia de Covid 19 em relação à pré-pandemia. Conclusões: Observado predomínio do sexo masculino de meia idade, além do mecanismo de trauma de queda de altura, bem como ausência de déficit neurológico a avaliação inicial. A região lombar e cervical foram os locais mais frequentes de lesão. O período pandêmico interferiu no perfil epidemiológico apresentado e nos intervalos de tempo entre a lesão e a avaliação no IOT-HCFMUSP. Nível de Evidência IV; Série de Casos.

RESUMEN: Objetivos: Determinar la epidemiología de los pacientes con fracturas vertebrales evaluadas por el Grupo de Columna IOT-HCFMUSP entre 2019 y 2022. Evaluar el efecto de la Pandemia Covid-19 sobre esta epidemiología. Métodos: Análisis retrospectivo de historias clínicas de pacientes con fracturas de columna remitidos por el Central de Regulação de Ofertas e Serviços de Saúde (CROSS) de São Paulo al Grupo de Columna IOT-HCFMUSP entre 2019 y 2022. Se comparó el perfil epidemiológico entre el periodo de la pre-pandemia de Covid-19 y el período de pandemia de Covid-19 hasta diciembre de 2022. Resultados: Serie de casos de 427 pacientes entre marzo de 2019 y diciembre de 2022. En el período, el sexo masculino representó el 71,9% de los casos, la edad promedio fue de 46,7 años. La caída de altura fue el mecanismo traumático más común (63,7%), seguido de los accidentes de motocicleta (14,3%). La ausencia de déficit neurológico se presentó en el 76,8% de los casos, siendo la región lumbar (39,3%) la región más lesionada. Hubo cambios en el perfil epidemiológico durante la pandemia de Covid-19 con relación a la prepandemia. Conclusiones: Hubo predominio del sexo masculino, caídas de altura como mecanismo traumático y ausencia de déficit neurológico en la evaluación inicial. La región lumbar y cervical fueron los sitios de lesión más frecuentes. El período pandémico interfirió con el perfil epidemiológico presentado y los intervalos de tiempo entre la lesión y la evaluación en el IOT-HCFMUSP.

Evaluation of kyphosis measurement in thoracolumbar spine fractures / Avaliação da mensuração da cifose nas fraturas da coluna toracolombar / Evaluación de la medición de cifosis en fracturas de la columna toracolumbar

ABSTRACT Objectives: Evaluate the reliability and reproducibility of the kyphosis measurement in thoracolumbar spine traumatic fractures by different assessment methods in different types of fractures. Methods: Fifteen fractures of the thoracolumbar spine, previously classified into types A, B, and C according to Magerl's classification, were evaluated. The value of kyphosis was measured using five different methods: (1) Cobb angle; (2) Gardner's method; (3) back wall method; (4) angle of adjacent endplates; and (5) wedge angle. The measurements were performed by five independent observers and repeated five times with a minimum interval of two weeks between each evaluation. Results: Intraobserver reliability was excellent among the five observers, evidencing good reproducibility of the methods. The five methods used also showed great intraobserver reliability in the global analysis, with methods one and four being more consistent. Conclusion: Although there is no universal agreement on measuring kyphosis in thoracolumbar fractures, our study concluded that method 1 (Cobb angle) and method 4 (adjacent endplate angle) presented the best interobserver reliabilities. Furthermore, the use of digitized radiographs and a simple computer program allowed the performance of highly reliable and reproducible measurements by all methods, given the high intraobserver reliability. Level of Evidence II; Comparative study.

Resumo: Objetivos: Avaliar a confiabilidade e reprodutibilidade da mensuração da cifose nas fraturas traumáticas da coluna toracolombar por diferentes métodos de avaliação nos diferentes tipos de fraturas. Métodos: Foram avaliadas 15 fraturas na coluna toracolombar previamente classificadas em tipo A, B e C de acordo com a classificação de Magerl. Em cada caso, foi medido o valor da cifose através de cinco diferentes métodos: (1) ângulo de Cobb; (2) método de Gardner; (3) método das paredes posteriores; (4) ângulo das placas terminais adjacentes; e (5) ângulo de cunha. As mensurações foram realizadas por cinco avaliadores independentes e repetidas cinco vezes com intervalo mínimo de duas semanas entre cada avaliação. Resultados: A confiabilidade intraobservador mostrou-se excelente entre os cinco avaliadores, evidenciando boa reprodutibilidade dos métodos. Os cinco métodos utilizados também apresentaram grande confiabilidade intraobservador na análise global, sendo mais consistentes o método 1 e o método 4. Conclusão: Apesar de não haver concordância universal em como medir a cifose nas fraturas toracolombares, nosso estudo concluiu que o método 1 (ângulo de Cobb) e o método 4 (ângulo das placas terminais adjacentes) apresentaram as melhores confiabilidades interobservadores. Além disso, o uso de radiografias digitalizadas e um programa computadorizado simples permitiram a realização de medidas altamente confiáveis e reprodutíveis por todos os métodos, visto pela elevada confiabilidade intraobservador. Nível de evidência II; Estudo Comparativo.

Resumen: Objetivos: Evaluar la fiabilidad y reproducibilidad de mensuración de cifosis en fracturas traumáticas de la columna toracolumbar por diferentes métodos de valoración en diferentes tipos de fracturas. Métodos: Se evaluaron quince fracturas de columna toracolumbar, previamente clasificadas en los tipos A, B y C según la clasificación de Magerl. En cada caso, el valor de la cifosis se midió utilizando cinco métodos diferentes: (1) ángulo de Cobb; (2) método de Gardner; (3) método de la pared posterior; (4) ángulo de placas de extremo adyacentes; y (5) ángulo de cuña. Las mediciones fueron realizadas por cinco evaluadores independientes y repetidas cinco veces con un intervalo mínimo de dos semanas entre cada evaluación. Resultados: La confiabilidad intraobservador fue excelente entre los cinco evaluadores, evidenciando una buena reproducibilidad de los métodos. Los cinco métodos utilizados también mostraron una gran fiabilidad intraobservador en el análisis global, siendo el método 1 y el método 4 más consistentes. Conclusión: Aunque no existe un acuerdo universal sobre cómo medir la cifosis en las fracturas toracolumbares, nuestro estudio concluyó que el método 1 (ángulo de Cobb) y el método 4 (ángulo de la placa terminal adyacente) presentaron las mejores confiabilidades entre observadores. Además, el uso de radiografías digitalizadas y un programa informático simple permitieron realizar mediciones altamente fiables y reproducibles por todos los métodos, dada la alta fiabilidad intraobservador. Nivel de evidencia II; Estudio Comparativo.

Radiographic evaluation of surgical correction of scoliosis due to cerebral palsy using intra-operative traction and new correction technique with 3rd provisional rod / Avaliação radiográfica de correção cirúrgica de escoliose devido a paralisia cerebral usando tração intraoperativa e nova técnica de correção com terceira haste provisória / Evaluación radiográfica de corrección quirúrgica de escoliosis debido a paralisia cerebral mediante tracción intraoperativa y nueva técnica de corrección con tercera barra provisoria

ABSTRACT Objective: Evaluate the radiographic results of patients with cerebral palsy and Lonstein and Akbarnia type II scoliosis who underwent intraoperative halofemoral traction (IFAT) and correction with a 3rd provisional nail. Methods: Retrospective case series study. Were evaluated preoperative (PRE), traction (TR), immediate (POI), and late (POT) total spine radiographs. Were verified the angular value of the main curve (COBB), pelvic obliquity (OP), trunk balance in the coronal plane (CSVA), vertical sagittal alignment (SVA), curve flexibility, and percentage of correction in the final PO. Friedam and Wilcoxon tests were performed (p<0.05). Results: Twenty-one patients were included in the study, with a mean age of 16 (±4.13). There was a statistical difference when comparing COBB PRE with TRACTION to POI and POT (p=0.0001), OP in PRE with TRACTION, and between PRE and POT (p=0.0001). There was a statistical difference in coronal (CSVA) and sagittal (SVA) balance concerning PRE and POT. The percentage of correction for the main curve was 55.75% (± 11.11), and for the O P, 64.86% (± 18.04). Conclusion: The correction technique using the 3rd provisional nail technique and intraoperative traction presents a correction power of 55.75% of the proximal curve and 64% of the pelvic obliquity. In addition, it is easy to assemble, has a short surgical time, and causes little loss of correction during follow-up. Level of Evidence III B; I study a series of retrospective cases.

Resumo: Objetivo: Avaliar os resultados radiográficos de pacientes com paralisia cerebral e escoliose tipo II de Lonstein e Akbarnia submetidos à tração halo-femoral intra-operatória (THFI) e correção com 3ª haste provisória. Métodos: Estudo série de casos retrospectivo. Foram avaliadas radiografias de coluna total pré-operatórias (PRÉ), sob tração (TR), pós-operatória imediata (POI) e tardia (POT). Verificou-se valor angular da curva principal (COBB), obliquidade pélvica (OP), equilíbrio do tronco no plano coronal (CSVA), alinhamento sagital vertical (SVA), flexibilidade da curva e percentual de correção no PO final. Foram realizados os testes de Friedam e Wilcoxon (p<0,05). Resultados: Vinte e um pacientes foram incluídos no estudo, com idade média de 16 (±4,13) anos. Houve diferença estatística quando se comparou: COBB PRÉ com TRAÇÃO em relação ao POI e POT (p=0,0001), OP no PRÉ com TRAÇÃO e entre o PRÉ e POT (p=0,0001). Houve diferença estatística em relação ao equilíbrio coronal (CSVA) e sagital (SVA) em relação ao PRE e POT. O percentual de correção da curva principal foi de 55,75% (± 11,11) e da OP de 64,86% (± 18,04). Conclusão: A técnica de correção utilizando a técnica da 3° haste provisória e tração intra-operatória apresenta poder de correção de 55,75% da curva proximal e 64% da obliquidade pélvica. Além disso, apresenta facilidade de montagem, tempo cirúrgico pequeno e pouca perda de correção ao longo do seguimento. Nível de Evidência III B; Estudo de série de casos retrospectivos.

Resumen: Objetivo: Evaluar los resultados radiográficos de pacientes con parálisis cerebral y escoliosis tipo II de Lonstein y Akbarnia a quienes se les realizó tracción halofemoral intraoperatoria (THFI) y corrección con una tercera barra provisoria. Métodos: Estudio retrospectivo de serie de casos. Se evaluaron radiografías totales de columna preoperatorias (PRE), de tracción (TR), post-operatorias inmediatas (POI) y tardías (POT). Se verificó el valor angular de la curva principal (COBB), la oblicuidad pélvica (OP), el equilibrio del tronco en el plano coronal (CSVA), la alineación sagital vertical (SVA), la flexibilidad de la curva y el porcentaje de corrección en el PO final. Se realizaron las pruebas de Friedam y Wilcoxon (p<0,05). Resultados: Se incluyeron en el estudio 21 pacientes, con una edad media de 16 (±4,13) años. Hubo diferencia estadística al comparar: COBB PRE con TRACCIÓN en relación a POI y POT (p=0,0001), OP en PRE con TRACCIÓN y entre PRE y POT (p=0,0001). Hubo diferencia estadística en relación al equilibrio coronal (CSVA) y sagital (SVA) en relación a PRE y POT. El porcentaje de corrección para la curva principal fue del 55,75% (± 11,11) y para la OP del 64,86% (± 18,04). Conclusión: La técnica de corrección mediante la técnica de la tercera barra provisoria y tracción intraoperatoria presenta un poder de corrección del 55,75% de la curva proximal y del 64% de la oblicuidad pélvica. Además, es de fácil montaje, tiene un tiempo quirúrgico corto y poca pérdida de corrección durante el seguimiento. Nivel de evidencia III B; Estudio una serie de casos retrospectivos.

Expandable intravertebral implants in post-traumatic vertebral necrosis - new classification suggestion / Implantes intravertebrais expansíveis no tratamento de necrose vertebral pós-traumática - proposta de nova classificação

ABSTRACT The progressive evolution of post-traumatic vertebral necrosis and consequent loss of structural integrity of the vertebral body along with neurological risk, makes it one of the most feared and unpredictable pathologies in spine traumatology. Several studies have addressed the role of vertebroplasty, kyphoplasty, and corpectomy in its treatment; however, it remains a controversial concept without a defined therapeutic algorithm. The recent emergence of expandable intravertebral implants, which allow, by a percutaneous transpedicular application, the capacity for intrasomatic filling and maintenance of the height of the vertebral body, makes them a viable option, not only in the treatment of acute vertebral fractures, but also in non-union cases. In this study, we present a review of the current evidence on the application of expandable intravertebral implants in cases of post-traumatic vertebral necrosis. Based on the available scientific literature, including previous classifications of post-traumatic necrosis, and on the mechanical characteristics of the main expandable intravertebral implants currently available, we propose a simplified classification of this pathology, considering parameters that influence surgical therapeutic guidance, the morphology and the dynamics of the necrotic vertebra's mobility. According to its stages and based on authors' experience and on the scarce literature, we propose an initial therapeutic algorithm and suggest preventive strategies for this disease, considering its main risk factors, that is, fracture comminution and impairment of vertebral vascularity. Therefore, expandable intravertebral implants have a promising role in this condition; however, large prospective studies are needed to confirm their efficacy, to clarify the indications of each of these devices, and to validate the algorithm suggestion regarding treatment and prevention of post-traumatic vertebral necrosis. Level of Evidence III, Systematic Review/Actualization.

RESUMO A evolução progressiva da necrose vertebral pós-traumática e consequente perda da integridade estrutural do corpo vertebral, juntamente com o risco neurológico, a torna uma das patologias mais temidas e imprevisíveis na traumatologia da coluna. Vários estudos têm abordado o papel da vertebroplastia, cifoplastia e corpectomia no tratamento da necrose vertebral, no entanto, o tratamento ainda é controverso sem um algoritmo terapêutico definido. O recente surgimento dos implantes intravertebrais expansíveis, que permitem através duma aplicaçao transpedicular percutânea a capacidade de preenchimento intrassomático e de manutenção da altura do corpo vertebral, torna-os uma opção viável não só no tratamento das fraturas vertebrais agudas, mas também em situações de não consolidação óssea. Neste estudo, apresentamos uma revisão das evidências atuais sobre a aplicação de implantes intravertebrais expansíveis em casos de necrose vertebral pós-traumática. Com base na literatura científica disponível, incluindo classificações prévias de necrose vertebral pós-traumática, e nas características mecânicas dos principais implantes intravertebrais expansíveis disponíveis, propomos uma classificação simplificada desta patologia, considerando parâmetros que influenciam a orientação terapêutica cirúrgica, a morfologia e a dinâmica da mobilidade da vértebra. De acordo com seus estágios e com base na experiência dos autores e na escassa literatura, propomos um algoritmo terapêutico inicial e sugerimos estratégias preventivas para esta doença, considerando seus principais fatores de risco, ou seja, cominução da fratura e lesão da vascularização vertebral. Portanto, os implantes intravertebrais expansíveis têm um papel promissor nessa condição; no entanto, estudos prospectivos de grande dimensão são necessários para confirmar sua eficácia, esclarecer as indicações de cada um desses dispositivos e validar a presente proposta do algoritmo de tratamento e prevenção da necrose vertebral pós-traumática. Nível de Evidência III, Revisão Sistemática/Atualização.

Progress in open surgical treatment of thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fractures / 中华骨科杂志

Osteoporotic vertebral compression fracture (OVCF) is the most common complication of spinal osteoporosis, mostly occurring in thoracolumbar segment, which can cause acute and chronic pain at the fracture site and loss of vertebral height, and can lead to progressive kyphosis. For kyphosis caused by old OVCF, open surgery such as anterior or posterior decompression and fusion, internal fixation and osteotomy can improve local sequence and achieve satisfactory kyphotic correction which is difficult to complete in percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP), and reconstruct the sagittal balance. Due to the older age of OVCF patients, some of them have poor general conditions. In addition, osteoporosis leads to increased vertebral fragility, which increases the risk of surgery and postoperative internal fixation failure. The anterior approach presents some problems including a complex approach and poor mechanical stability. At present, most studies focus on posterior surgery. Due to the limitation of kyphosis correction by decompression and fixation alone, osteotomy is often required to correct kyphosis. In cases of old OVCF with kyphosis, the screw holding capability decreases due to the decrease of bone mineral density. Additionally, once the screw loosens, the orthopedic effect is inevitably affected. To enhance pedicle screws, most studies have utilized bone cement to increase the axial pullout force of the vertebral body and improve screw stability. The selection from different osteotomy methods is a critical determinant in achieving favorable surgical outcomes for patients.

Distribution pattern and related factors of single osteoporotic vertebral compression fractures / 中华骨科杂志

Objective:To identify the anatomical distribution of and factors related to single-segment osteoporotic vertebral compression fractures (OVCF).Methods:The radiology and clinical data of 944 patients with single-segment OVCF hospitalized in Zhongda Hospital Southeast University between June 2016 and October 2020 were retrospectively analyzed, including 175 males and 769 females, aged 72.1±9.6 years (range, 45-97 years). The anatomical distribution of OVCF was quantified. The demographics, comorbidity profile, spine trauma, back pain duration, vertebral compression degree, and bone mineral density of the OVCF patients in different anatomical segments were summarized and compared.Results:Of the 944 single-segment OVCF, 864 were located in the lower thoracic and lumbar spine that peaked at L 1 (Modal-1 group), and 80 were located in the middle and upper thoracic spine (Modal-2 group) that peaked at T 7, demonstrating an asymmetric bimodal distribution. The difference in the female/male ratio between the two groups was insignificant (χ 2=0.06, P=0.803). Patients in Modal-2 were aged 75.0±9.8 years and on average older than the patients (aged 71.8±9.6 years) in Modal-1 ( t=2.78, P=0.005). The female patients in Modal-2 (aged 75.0±9.6 years) were significantly older than that (aged 71.2±9.3 years) in Modal-1 ( t=3.17, P=0.002). The ratio of back pain duration for <1 week in Modal-2 (43.8%) was lower than that in Modal-1 (60.2%), and the ratio of back pain for 1-weeks (28.8%) was significantly higher than that (15.5%) in Modal-1 (χ 2=11.50, P=0.009). The most frequently reported spine traumas in Modal-2 (50.0%) were heavy lifting injury, lumbar sprain, and strenuous cough, which were significantly different from and less apparent than the fall on ground or crush injury to the spine (64.1%) in Modal-1 (χ 2=60.71, P<0.001). The anterior to posterior height ratio of the fractured vertebrae in Modal-2 was 0.78±0.13, 0.83±0.14, 0.84±0.13, and 0.78±0.18 in the OVCF patients complaining of back pain for <1 week, 1-weeks, 2-weeks, and >4 weeks respectively, showing no significant difference between groups ( F=1.01, P=0.009). In Modal-1, the anterior to posterior height ratio of the fractured vertebrae was lower in the OVCF patients complaining of back pain for 2-weeks (0.80±0.15) and >4 weeks (0.77±0.19) than in those with back pain for <1 week (0.85±0.11) and 1-weeks (0.86±0.14), with sinificant differences ( P<0.05). 32.4% (306/944) of the OVCF patients had one of the following geriatric comorbidities: hypertension, diabetes mellitus, coronary heart disease, cerebral infarction, and chronic obstructive pulmonary disease. The OVCF patients in Model-2 had higher comorbidity of coronary heart disease (21.3%) and cerebral infarction (36.3%) than those in Model-1 (11.6% and 20.3%). Bone mineral density information was available from 371 patients (308 females). In the age groups of <70, 70-, and >80 years, no significant difference was detected in the T-score values of the lumbar spine or hip joint between the OVCF patients in Model-1 and Model-2 ( F=0.13, P=0.880; F=0.62, P=0.538). Conclusion:Single-segment OVCF feature an asymmetric bimodal distribution that is demarcated by the T 10 vertebrae. The distribution pattern is not determined by gender or baseline bone mineral density but highlights the risk of mechanical stress and vertebral fragility within a specific segment. OVCF in the middle and upper thoracic spine is less frequent but common in older patients with higher comorbidity of coronary heart disease and cerebral infarction, which tend to be caused by less apparent spine trauma and maintain vertebral compression but complain of long back pain duration.

Posterior vertebral column resection combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column for stage Ⅲ Kümmell's disease with very severe collapse of fractured vertebra / 中华创伤骨科杂志

Objective:To investigate the feasibility and clinical efficacy of posterior vertebral column resection (PVCR) combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column for stage Ⅲ Kümmell's disease with very severe collapse of fractured vertebra.Methods:From January 2017 to September 2021, 9 patients with stage Ⅲ Kümmell's disease with very severe collapse of fractured vertebra underwent PVCR combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column. Their medical records were retrospectively analyzed. There were 1 male and 8 females, aged (66.9±5.8) years. The injured vertebra was located at T 11 in 2 patients, at T 12 in 4, at L 1 in 2 and at L 2 in 1. X-ray, CT and MRI were performed before operation. The posterior intervertebral heights of adjacent vertebral bodies of the fractured vertebra in the median sagittal position were measured on CT or MRI to evaluate the shortening of the spinal column before PVCR. Recorded were intraoperative bleeding volume, operation time, complications, bone graft fusion, and American Spinal Injury Association (ASIA) grading at preoperation and the last follow-up. The visual analogue scale (VAS) pain scores, Oswestry disability index (ODI) scores, and kyphotic cobb angles at preoperation, 1 week and 3 months postoperation, and the last follow-up were compared to evaluate the clinical efficacy of PVCR. Results:All patients underwent surgery successfully, with tight closure of adjacent vertebrae after resection of the injured vertebra and bone grafting. Operation time was (240.6±23.2) min and intraoperative bleeding (505.6±95.0) mL. The 9 patients were followed up for (17.3±5.6) months. No worsening symptoms of nerve injury, cerebrospinal fluid leakage, or other serious complications were found after operation, nor such complications as loosening or breakage of internal fixation or adjacent vertebral fractures. Bone fusion was achieved at the bone graft sites in all patients by the last follow-up. The VAS and ODI scores and cobb angles at 1 week and 3 months postoperation and at the last follow-up were significantly decreased compared with preoperation ( P<0.05). There were no significant differences in VAS scores or cobb angles among postoperative 1 week and 3 months and the last follow-up ( P>0.05), but pairwise comparisons between different time points after operation showed significant differences in ODI, with postoperative 1 week > postoperative 3 months > the last follow-up ( P<0.05). The ASIA grading at the last follow-up was improved from preoperative grade C to grade D in 2 cases, from preoperative grade C to grade E in 1 case and from preoperative grade D to grade E in 5 cases. Conclusion:PVCR combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column is a feasible and effective surgical treatment for stage Ⅲ Kümmell's disease with very severe collapse of fractured vertebra, leading to good clinical efficacy.

Percutaneous kyphoplasty through transverse pedicle approach for osteoporotic vertebral compression fractures / 中华创伤骨科杂志

Objective:To investigate the clinical efficacy of percutaneous kyphoplasty (PKP) through the transverse process-pedicle approach (TPPA) by comparing with PKP through the conventional transpedicle approach (CTA).Methods:A retrospective study was conducted to analyze the data of 101 patients with single-segment osteoporotic vertebral compression fracture (OVCF) who had been treated at Department of Spine Surgery, The Fourth Hospital of Wuhan from August 2020 to August 2021. There were 31 males and 70 females, with an age of (70.3±7.6) years. Their T values of bone mineral density averaged (-3.0±0.3). They were divided into a TPPA group of 52 cases in which PKP was performed through the TPPA and a CTA group of 49 cases in which PKP was performed through the CTA. The clinical efficacy was evaluated by comparing the 2 groups in terms of operation time, frequency of intraoperative fluoroscopy, excellent to good rate of bone cement distribution, rate of bone cement leakage, refractures, and visual analogue scale (VAS), Oswestry disability index (ODI) and Beck index at preoperation, 24 hours, 3 months and 6 months postoperation.Results:There was no significant difference in the preoperative general data between the 2 groups, showing they were comparable ( P>0.05). All the patients were followed up for (9.8±1.5) months. Operations were completed successfully in all patients with no complications like nerve injury or pedicle fracture. There were no significant differences in operation time, frequency of intraoperative fluoroscopy or rate of bone cement leakage between the 2 groups ( P>0.05). In the TPPA group, the excellent to good rate of bone cement distribution [92.3% (48/52)] was significantly higher than that in the CTA group [61.2% (30/49)], the VAS score [3.0 (2.0, 4.0)] and ODI (57.2±4.6) at 24 hours postoperation were significantly lower than those in the CTA group [4.0 (3.0, 4.0) and 59.2±5.3] ( P<0.05). There were no significant differences in VAS or ODI between the 2 groups at preoperation, 3 months or 6 months postoperation ( P>0.05). The VAS and ODI improved steadily within each group, showing significant differences between every 2 time points ( P<0.05). The Beck indexes [0.81 (0.69, 0.86) and 0.76 (0.67, 0.81)] at 24 hours and 6 months postoperation in the TPPA group were significantly higher than those in the CTA group [0.75 (0.71, 0.79) and 0.72 (0.68, 0.77)] ( P<0.05). The Beck indexes at 24 hours and 6 months postoperation improved significantly in all patients compared with the preoperative values ( P<0.05). Conclusions:In the treatment of OVCF with PKP, the TPPA shows the same surgical safety as CTA does, but leads to better cement distribution, better pain relief at immediate postoperation and an advantage in restoring and maintaining the height of the injured vertebral body.

Feasibility of using cortical bone trajectory screws in osteoporotic thoracolumbar fixation based on evaluation of bone CT values at bone-screw interface / 中华创伤骨科杂志

Objective:To evaluate the feasibility of using cortical bone trajectory (CBT) screws in the osteoporotic thoracolumbar fixation by comparing the bone CT values at the bone-screw interface between traditional trajectory (TT) screws and CBT screws in patients with different bone densities.Methods:The high-resolution CT imaging data of thoracolumbar segments following thoracic or lumbar spine fractures from April 2020 to October 2022 were collected at The Second Hospital Affiliated to Wenzhou Medical University for retrospective analysis. They were divided into 3 groups: a normal bone mass group, an osteopenia group and an osteoporosis group. From each group 30 cases were chosen (90 cases in total, 36 males and 54 females). All the data were imported into Mimics 18.0 for three-dimensional bone reconstruction in which placement of TT and CBT screws was simulated on the vertebrae from T10 to L2 (non-fractured vertebrae). Regions of interest (ROI) where each simulated screw intersected the bone were segmented to measure their CT bone values. For each vertebra in each group, the relative difference percentage in average CT value of ROI between TT and CBT screws was calculated. The CT values of ROI were compared in the same group between TT and CBT screws from T10 to L2; the CT values of ROI were compared in the same screws among the 3 groups from T10 to L2; the CT values of ROI were compared between the CBT screws in the osteopenia and osteoporosis groups and the TT screws in the normal bone mass group; the relative difference percentages in average CT value of ROI between CBT and TT screws were compared between the 3 groups from T10 to L2.Results:The average CT value of ROI for CBT screws was significantly higher than that for TT screws from T10 to L2 in every group ( P< 0.001); as for the CT values of ROI for CBT and TT screws from T10 to L2, the osteoporosis group<the osteopenia group<the normal bone mass group ( P<0.001); from T10 to L2, the CT value of ROI for CBT screws in the osteopenia group was significantly higher than that for TT screws in the normal bone mass group ( P<0.001); the CT value of ROI for CBT screws in the osteoporosis group was not significantly different from that for TT screws in the normal bone mass group ( P>0.05). At T10, T12, and L1, the relative difference percentage in average CT value of ROI between CBT and TT screws was significantly higher in the osteopenia and osteoporosis groups than that in the normal bone mass group ( P<0.05), but there was no such a difference between the osteopenia and the osteoporosis groups ( P>0.05). At T11 and L2, there was no significant difference between the 3 groups in the relative difference percentage in average CT value of ROI between CBT and TT screws ( P>0.05). Conclusions:As bone mass decreases, both CBT and TT screws lead to a significant decrease in the bone density at the bone-screw interface. In patients with osteoporosis, CBT screws can still lead to a higher bone density at the bone-screw interface than TT screws, thus providing a higher strength at the bone-screw interface.