Improved diagnosis of infection associated with osteosynthesis by use of sonication of fracture fixation implants.

Previous studies have shown that sonication fluid cultures from removed orthopedic devices improved the microbiological diagnosis of orthopedic implant-associated infections; however, few of these investigations have applied sonication to the removed fracture fixation devices to evaluate its utility for the diagnosis of osteosynthesis-associated infection (OAI). We compared sonication fluid to conventional tissue cultures from 180 subjects with different sizes of plates and screws (n = 156), spinal implants (n = 26), and intramedullary nails (n = 3), of whom 125 and 55 subjects had OAI and noninfected osteosynthesis (NIO), respectively. The sensitivity for detecting OAI was 90.4% for sonication fluid culture and 56.8% for periprosthetic tissue cultures (P < 0.05), and the specificities were 90.9% and 96.4%, respectively. Sonication fluid culture detected more pathogens than peri-implant tissue culture (113 versus 71; P < 0.001), while polymicrobial infections were diagnosed by sonication fluid cultures and tissue cultures in 20.8% and 8% (P < 0.001), respectively. Microbiological diagnosis was achieved exclusively by sonication fluid cultures for 47 (90.4%) subjects, and among them, 18 (38.3%) had previously received antibiotics, whereas in five (9.6%) infected subjects, tissue culture was positive and the sonication fluid culture was negative. Among 39 (31.2%) OAI cases receiving antibiotics, the identification of the organisms occurred in 38.5% and 82.1% of the tissue and sonication fluid cultures, respectively (P < 0.049). We demonstrated that sonication fluid culture from removed osteosyntheses has the potential for improving the microbiological diagnosis of OAI.

Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To assess patient quality of life before and after surgical treatment of adolescent idiopathic scoliosis (AIS) and determine whether an association exists between quality of life and curve magnitude, curve correction, and type of instrumentation. SUMMARY OF BACKGROUND DATA: Assessment of AIS surgery outcomes has always been based on analysis of radiographic measurements and postoperative curve correction. However, there is a current trend toward greater emphasis on patient-centered outcomes. Assessment of treatment success on the basis of these outcomes requires prospective use of quality-of-life surveys before and after AIS treatment. METHODS: Prospective study of 33 patients undergoing surgical treatment of AIS. Mean age was 15.6 years and mean Cobb angle was 70.5 degrees. Patients were randomly allocated into one of 2 instrumentation groups (hybrid and pedicle screws alone), and the Scoliosis Research Society-30 questionnaire (SRS-30) and Short Form-36 Health Survey (SF-36) questionnaires were administered preoperatively and at 3-, 6-, and 12-month follow-up. Statistical testing was performed to determine whether survey scores correlated with Cobb angle, curve correction, or type of instrumentation. RESULTS: SRS-30 and SF-36 scores improved significantly. The greatest changes occurred in the self-image and satisfaction with management domains of the SRS-30 survey. SRS-30 and SF-36 scores showed worsening pain and decreased function at 3-month follow-up, but significant improvement from baseline at 12 months. Total SRS-30 scores were significantly improved at 6- and 12-month follow-up, as were subscores in the general health, vitality, and social functioning domains of SF-36. Curve magnitude, percent curve correction, and type of instrumentation had no significant influence on final SRS-30 and SF-36 scores. CONCLUSIONS: Surgical treatment of AIS improved patient quality of life, as shown by significant improvement on all SRS-30 and SF-36 domains. Questionnaire scores did not correlate with Cobb angle, curve correction, or type of instrumentation.

Medial patellofemoral ligament anatomy: is it a predisposing factor for lateral patellar dislocation?

PURPOSE: Because the medial patellofemoral ligament (MPFL) is the primary restraint to lateral dislocation of the patella, we aimed, in this controlled study, to verify whether the MPFL with different measurements could be considered another predisposing factor for patellar dislocation. METHODS: A group of 100 consecutive individuals without the criteria for patellar dislocation (trochlear dysplasia, patella alta and lateral patellar tilt) was recruited as a control group and underwent magnetic resonance imaging (MRI) study and another group of 50 patients with patellar instability. Femoral condyles, interepicondylar distance, length and thickness of the MPFL were measured. RESULTS: In the control group, the MPFL was 38-60 mm long. Individuals with patellar instability who had no episode of patellar dislocation had a 4.11-mm longer ligament than controls (p = 0.032), while patients with instability with a previous history of dislocation had a 13.54-mm longer MPFL than controls (p < 0.001). Thickness of the MPFL at the patellar insertion was lower in individuals with patellar instability with a history of dislocation (p < 0.001). An instability coefficient (IC) less than 1.3 indicates that the MPFL is insufficient. CONCLUSIONS: Individuals with patellar instability and previous patellar dislocation present with longer MPFL when compared to controls, and an associated IC less than 1.3 can be considered a predisposing factor for patellar dislocation. Treatment of patellar instability is a challenge, and it is difficult to identify what is the predisposing factor. This study has verified the measurements of the MPFL for the first time and presents values of thickness and length that can be considered as indications for surgical reconstruction. LEVEL OF EVIDENCE: III.

Combined aerobic and resistance training improves respiratory and exercise outcomes more than aerobic training in adolescents with idiopathic scoliosis: a randomised trial.

QUESTION: In adolescents with idiopathic scoliosis, does combined aerobic and resistance training improve respiratory function, perceived exertion and functional exercise capacity more than aerobic training only? DESIGN: Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Forty adolescents with idiopathic scoliosis and formal indication for surgical correction (spinal curvature ≥ 45 deg). INTERVENTION: Both groups undertook three 60-minute training sessions per week for 12 weeks. The experimental group performed combined aerobic and resistance training and the control group performed only aerobic training. OUTCOME MEASURES: At baseline and upon completion of treatment, participants completed: a 6-minute walk test with Borg scale (0 to 10) rating of exertion, spirometry, maximal respiratory pressures and peak expiratory flow measurement. RESULTS: After 12 weeks of training, the experimental group improved more than the control group on the 6-minute walk test (MD 22 m, 95% CI 4 to 40), with lower perceived exertion at the end of the test (MD -1.2, 95% CI -1.9 to -0.4). The experimental group also improved more than the control group on several respiratory measures, including: FEV1 (MD 270 ml, 95% CI 30 to 510), maximal inspiratory pressure (MD 4 cmH2O, 95% CI 1 to 8) and peak expiratory flow (MD 33 l/minute, 95% CI 7 to 58). CONCLUSION: In adolescents with idiopathic scoliosis, combined aerobic and resistance training improves functional exercise capacity and several respiratory outcomes more than a similar training regimen with aerobic training only. It is unclear whether the magnitude of the benefits is large enough to be worthwhile. TRIAL REGISTRATION: NCT02413788.

A systematic review of randomised clinical trials using posterior discectomy to treat lumbar disc herniations.

The focus of this study was to examine the safety and effectiveness of three different discectomy techniques using a posterior approach for the treatment of herniated lumbar discs. There are only a small number of prospective randomised studies comparing posterior lumbar discectomy techniques, and no recent systematic review has been published on this matter. Using the Cochrane Collaboration guidelines, all randomised or "quasi-randomised" clinical trials, comparing classic, microsurgical, and endoscopic lumbar discectomies using a posterior approach were systematically reviewed. No statistically significant differences were found between these techniques regarding improvement in pain, sensory deficits, motor strength, reflexes, and patient satisfaction. Current data suggest that the microsurgical and endoscopic techniques are superior to the classic technique for the treatment of single level lumbar disc herniations with respect to volume of blood loss, systemic repercussions, and duration of hospital stay. All three surgical techniques were found to be effective for the treatment of single level lumbar disc herniations in patients without degenerative vertebral deformities. No conclusions could be drawn from the clinical randomised studies reviewed regarding the safety of the three techniques studied due to insufficient data on postoperative complications.

Balloon Kyphoplasty in the Treatment of Neoplastic Spine Lesions: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: To assess the efficacy of kyphoplasty in controlling pain and improving quality of life in oncologic patients with metastatic spinal disease and pathologic compression fractures of the spine. METHODS: A literature search through medical database was conducted (using PubMed, EMBASE, Cochrane, and LILACS) for randomized controlled trials comparing balloon kyphoplasty versus the traditional treatment for compression fractures of the spine due to metastatic disease. Two investigators independently assessed all titles and abstracts to select potential articles to be included. Inclusion criteria consisted of randomized controlled trials involving patients with pathologic compression fractures due to spinal metastasis or multiple myeloma treated with balloon kyphoplasty procedure as one of the study interventions, while the control group was any other treatment modality. The risk of bias in individual studies was assessed. RESULTS: Two studies, with a combined total of 181 patients, met inclusion criteria. Because of data heterogeneity, the meta-analysis was not possible, and individual analysis of studies was performed. There is moderate evidence that patients treated with balloon kyphoplasty displayed better scores for pain (Numeric Rating Scale), disability (Roland-Morris Disability Questionnaire), quality of life (Short Form-36 Health Survey), and functional status (Karnofsky Performance Status) compared with those undergoing the conventional treatment. Patients treated with kyphoplasty also have better recovery of vertebral height. CONCLUSIONS: This study concluded that balloon kyphoplasty could be considered as an early treatment option for patients with symptomatic neoplastic spinal disease, although further randomized clinical trials should be performed for improvement of the quality of evidence.

Predictors for Postoperative Shoulder Balance in Lenke 1 Adolescent Idiopathic Scoliosis: A Prospective Cohort Study.

STUDY DESIGN: Prospective cohort. OBJECTIVES: To determine the predictors of the shoulder balance after main thoracic (MT) fusion in patients with Lenke 1 adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Imbalanced shoulders are a major cause of dissatisfaction in AIS patients. In Lenke 1 curves, MT curve fusion is supposed to lead to spontaneous correction of the proximal thoracic (PT) curve and thereby promote shoulder balance. However, this is not always observed. METHODS: Fifty-two Lenke 1 AIS patients who underwent MT fusion by a posterior approach were prospectively evaluated preoperatively, immediately postoperatively and two years after the surgical procedure. The shoulder balance was determined using the biacromial angle. The clinical results were examined for their correlation with several radiographic measurements. RESULTS: Spontaneous correction of the PT Cobb angle after MT fusion was noted in 52% of cases, similar to that observed on preoperative bending films. A total of 51% of patients had unbalanced shoulders before surgery (right side higher). Two years after surgery, 30.77% showed unbalanced shoulders (p < .001). However, 17.1% of patients presented with a higher left shoulder, a reversion of the initial deformity. This phenomenon was more common among the patients with mild or no shoulder asymmetry (biacromial angle inferior to 1°) before surgery (p < .001). It was also determined that for each degree measured for the clavicle angle, there was an elevation of 0.14° for the ipsilateral shoulder. CONCLUSIONS: In Lenke 1 cases with higher right shoulder and absence of abnormalities in the sagittal plane view, the correction of the main right thoracic curve could be enough to balance the shoulders. No correlation was found between shoulder balance and the amount of correction of the PT and MT curves.

Impact of a physical rehabilitation program on the respiratory function of adolescents with idiopathic scoliosis.

BACKGROUND: Idiopathic adolescent scoliosis (AIS) causes not only spinal deformities but rib cage abnormalities that lead to abnormal volumes and pulmonary capacity on pulmonary function testing (PFT). The objective of this study was to analyze the impact of a physical rehabilitation program on respiratory function in surgical patients with AIS. METHODS: From October 2003 to October 2004, a total of 34 patients (age range, 10 to 18 years) presenting with AIS and a thoracic curvature between 45 degrees and 88 degrees were studied prospectively at a tertiary academic hospital. The patients underwent clinical and radiographic evaluations of the vertebral deformity, chest radiographs, PFT, evaluation of peak expiratory flow, and 6-min walk tests (6MWTs) before and after joining a physical rehabilitation program for 4 months. RESULTS: An improvement in FVC, inspiratory capacity, FEV(1), expiratory reserve volume, and performance assessed by 6MWT were observed after rehabilitation. CONCLUSIONS: Global conditioning improved after the rehabilitation program. This was expressed by both PFT and 6MWT results.

RESPIRATORY MUSCLE STRENGTH IN IDIOPATHIC SCOLIOSIS AFTER TRAINING PROGRAM.

OBJECTIVE: To analyze the impact of a physiotherapy protocol in maximum inspiratory and expiratory pressure in patients with adolescent idiopathic scoliosis (AIS) by manovacuometry. AIS may change the respiratory dynamics and the performance of inspiratory and expiratory muscles, affecting ventilatory capacity. METHODS: Patients with AIS aged 10 to 20 years old were randomly assigned to receive an aerobic exercise-training program or no treatment. They were evaluated for respiratory muscle strength before and after the treatment period by means of manovacuometry, thorax and spine radiographs. Physical therapy exercising protocol comprised three weekly sessions including stretching and aerobic exercises during four months. RESULTS: Forty five patients received physical therapy and 45 patients received no treatment (control group). The mean maximum inspiratory pressure (Pimax) was -52.13 cm H20 and the maximum expiratory pressure (Pemax) was 62.38 cm H20. There was a significant increase of Pimax and Pemax (p=0,000) in the group receiving physical therapy. There were no drop-outs and no adverse events in this study. Respiratory muscle strength, scoliosis and kyphosis degrees were not statistically correlated. CONCLUSION: Exercising is beneficial to patients with AIS, who have shown significant increases in respiratory muscle strength after physical therapy. There was no correlation between respiratory pressure and spine deformity. Level of Evidence I, High quality randomized trial.

Percutaneous instrumentation without arthrodesis for thoracolumbar burst fractures (a3/a4, b): a retrospective study / Instrumentação percutânea sem artrodese em fraturas toracolombares do tipo explosão (a3/a4, b): estudo retrospectivo / Instrumentación percutánea sin artrodesis en fracturas toracolumbares del tipo explosión (a3/a4, b): estudio retrospectivo

ABSTRACT Objective: There is still no consensus as to the treatment options for thoracolumbar burst fractures, although these fractures are widely described in the literature. The aim of this study was to evaluate the clinical and radiological outcomes of percutaneous instrumentation without arthrodesis as a method of fixation of these lesions. Methods: This retrospective, cross-sectional study evaluated 16 patients by measuring regional kyphosis using the Cobb method and the scores for quality of life and return to work (Oswestry Disability Index, VAS, SF-36 and Denis). Results: Six months after surgical treatment, 62.5% of all patients showed minimal disability according to the Oswestry Disability Index, maintenance of regional kyphosis correction and no synthesis failure. Conclusions: The clinical and radiological outcomes of the study suggest that minimally invasive fixation is indicated for the treatment of thoracolumbar burst fractures. Level of evidence IV; Observational study: retrospective cohort.

RESUMO Objetivo: As fraturas toracolombares do tipo explosão, embora amplamente descritas na literatura, permanecem sem consenso quanto às modalidades de tratamento. O objetivo do presente estudo foi avaliar os resultados clínicos e radiológicos da instrumentação percutânea sem artrodese como método de fixação dessas lesões. Métodos: O estudo transversal retrospectivo avaliou 16 pacientes por meio da aferição da cifose regional pelo método de Cobb e dos escores de qualidade de vida e retorno ao trabalho (Índice de Incapacidade de Oswestry, EVA, SF-36 e Denis). Resultados: Seis meses depois do tratamento cirúrgico, verificou-se 62,5% dos pacientes com incapacidade mínima segundo o Índice de Incapacidade Oswestry, manutenção da correção da cifose regional e ausência de falha da síntese. Conclusões: Os desfechos clínicos e radiológicos do estudo sugerem que a fixação minimamente invasiva é relevante para o tratamento das fraturas toracolombares do tipo explosão. Nível de evidência IV; Estudo observacional: coorte retrospectiva.

RESUMEN Objetivo: Las fracturas toracolumbares del tipo explosión, aunque están ampliamente descritas en la literatura, siguen sin tener consenso en cuanto a las modalidades de tratamiento.. El obetivo del presente estudio fue evaluar los resultados clínicos y radiológicos de la instrumentación percutánea sin artrodesis como método de fijación de estas lesiones. Métodos: El estudio transversal retrospectivo evaluó a 16 pacientes, midiendo la cifosis regional mediante el método de Cobb y las puntuaciones de calidad de vida y reincorporación al trabajo (Índice de Discapacidad de Oswestry, VAS, SF-36 y Denis). Resultados: Seis meses después del tratamiento quirúrgico, el 62,5% de los pacientes presentaron discapacidad mínima según el Índice de Discapacidad de Oswestry, mantenimiento de corrección de cifosis regional y ausencia de fallo de síntesis. Conclusiones: Los resultados clínicos y radiológicos del estudio sugieren que la fijación mínimamente invasiva es pertinente para el tratamiento de fracturas toracolumbares del tipo explosión. Nivel de evidencia IV; Estudio observacional: estudio de cohorte retrospectivo.

[Treatment of discitis in the child]. / Tratamento da discite na criança.

BACKGROUND: The authors reviewed nine patients presenting with discitis during infancy, demonstrating that its diverse forms of presentation lead to a delayed and difficult diagnosis. METHODS: This study reports that initial radiographs may not show any alterations, enhancing the importance of scintillography or magnetic resonance for these cases. RESULTS AND CONCLUSIONS: One patient was submitted to surgical treatment for lumbar canal decompression due to the presence of a disk abscess. The remaining patients were treated conservatively only with an appropriate antibiotic therapy, immobilization and restriction of physical activity. All of the young patients had a satisfactory evolution and stated no complaints about sequels during their final evaluation.

Toracolombar burst fractures and spinopelvic balance / Fratura toracolombar do tipo explosão e equilíbrio espinopélvico / Fractura toracolumbar del tipo explosión y equilibrio espinopélvico

ABSTRACT Objective To describe the spinopelvic parameters in patients with conservatively treated thoracolumbar burst fractures. Methods Twenty-six patients with thoracolumbar burst fractures treated conservatively between 2008 and 2017 participated in the study. Inclusion criteria were acute burst-type fractures, located between T11 and L2, which compromised a single vertebral segment, did not present a neurological deficit, and had a minimum of 6 months of follow-up, excluding injuries that presented distraction or rotation, pathological fractures, and surgically treated cases. The sagittal and spinopelvic alignment parameters, including vertical sagittal axis, sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, and regional kyphosis, were analyzed. Results The values obtained for the sample showed that there was an increase in regional kyphosis and that the mean sagittal parameters and lumbar lordosis were within the values considered normal in the literature. Conclusion Patients with thoracolumbar burst fractures treated conservatively had no alterations in the spinopelvic parameters. Level of Evidence II; Retrospective study.

RESUMO Objetivo Descrever os parâmetros espinopélvicos de pacientes com fratura toracolombar tipo explosão tratados de modo conservador. Métodos Participaram do estudo 26 pacientes com fratura toracolombar do tipo explosão tratados conservadoramente entre 2008 e 2017. Os critérios de inclusão consistiam em: fraturas tipo explosão agudas, localizadas entre T11 e L2, as quais comprometiam um único segmento vertebral, não apresentavam déficit neurológico e tinham no mínimo seis meses de acompanhamento, excluídas as lesões que apresentavam componente de distração, rotação, fraturas patológicas e casos tratados cirurgicamente. Foram analisados os parâmetros do alinhamento sagital e espinopélvico, incluindo o eixo sagital vertical, a inclinação sacral, a versão pélvica, a incidência pélvica, lordose lombar e cifose regional. Resultados Os valores obtidos na amostra demonstraram que houve aumento da cifose regional e que a média total dos parâmetros sagitais e de lordose lombar estão dentro dos valores considerados normais na literatura. Conclusões Os pacientes com fraturas toracolombares tipo explosão, tratados de modo conservador, não apresentaram alterações nos parâmetros espinopélvicos. Nível de evidência II; Estudo retrospectivo.

RESUMEN Objetivo Describir los parámetros espinopélvicos de pacientes con fractura toracolumbar tipo explosión tratados de modo conservador. Métodos Participaron en el estudio 26 pacientes con fractura toracolumbar del tipo explosión, tratados conservadoramente entre 2008 y 2017. Los criterios de inclusión consistían en: fracturas tipo explosión agudas, localizadas entre T11 y L2, las cuales comprometían un único segmento vertebral, no presentaban déficit neurológico y tenían como mínimo 6 meses de acompañamiento,, excluidas las lesiones que presentaban componente de distracción, rotación, fracturas patológicas y casos tratados quirúrgicamente. Fueron analizados los parámetros de la alineación sagital y espinopélvica, incluyendo el eje sagital vertical, la inclinación sacral, la versión pélvica, la incidencia pélvica, lordosis lumbar y cifosis regional. Resultados Los valores obtenidos en la muestra demostraron que hubo aumento de la cifosis regional y que el promedio total de los parámetros sagitales y de lordosis lumbar están dentro de los valores considerados como normales en la literatura. Conclusiones Los pacientes con fracturas toracolumbares tipo explosión, tratados de modo conservador, no presentaron alteraciones en los parámetros espinopélvicos. Nivel de evidencia II; Estudio retrospectivo.

Effect of a preoperative protocol of aerobic physical therapy on the quality of life of patients with adolescent idiopathic scoliosis: a randomized clinical study.

Patients with adolescent idiopathic scoliosis (AIS) have lower potential for physical activity because of lung dysfunction and lower muscle strength, which can be reversed by the cardiorespiratory and musculoskeletal conditioning provided by standardized physical activities. We conducted a study to determine if a preoperative protocol of aerobic exercise would improve quality of life (QoL) both before and after training and if there would be any differences between patients who received the therapy and those who did not. Patients with the indication of surgical correction of AIS were randomized to receive or not receive a 4-month preoperative course of aerobic physical training. At baseline and after 4 months, they were evaluated with the Short Form-36 questionnaire (SF-36). QoL scores improved for the study group but did not change for the control group. In all QoL domains, the study group's mean score increased significantly between baseline and 4 months. We concluded that the proposed preoperative physical therapy protocol improved the QoL of patients with AIS.

Evaluation of patients with subaxial cervical fractures by the new aospine classification / Avaliação de pacientes com fratura cervical subaxial por meio da nova classificação aospine / Evaluación de pacientes con fractura cervical subaxial por medio de la nueva clasificación aospine

ABSTRACT Objective: To evaluate the profile of patients with fracture and / or dislocation of the subaxial cervical spine using the new AOSpine classification and to correlate it with the trauma mechanism and the type of neurological deficit. Methods: Analyses were performed of the medical records of patients admitted to a tertiary hospital with fracture and / or subaxial cervical dislocation during the period from 2009 to 2016. For the evaluation of the association between the two categorical variables, the Chi-square test was used with a significance level of p <0.05. Results: A total of 67 medical records were analyzed, in which a higher prevalence of type C fractures (49.3%) was observed. The neurological subclassification N4 (35.8%) was the most prevalent type found, followed by subtype N0 (26.9%). Among the main injury mechanisms found, the most prevalent was the motorcycle accident (29.9%). There was no statistically significant association between the injury mechanism and the AOSpine morphological classification (p> 0.05) or neurological deficit (p> 0.05). Conclusion: Cervical fractures of type C, due to automobile accidents were the most prevalent. It was not possible to determine an association between the degree of neurological involvement and the morphology of the injury. Level of Evidence II; Retrospective study.

RESUMO Objetivo: Avaliar o perfil dos pacientes com fratura e/ou luxação da coluna cervical subaxial por meio da nova classificação AOSpine e correlacionar com o mecanismo de trauma e o tipo de déficit neurológico. Métodos: Foram realizadas análises dos prontuários médicos dos pacientes admitidos em um hospital terciário com fratura e/ou luxação cervical subaxial entre o período de 2009 a 2016. Para a avaliação da associação entre as duas variáveis categóricas, utilizou-se o teste Qui-quadrado com nível de significância de p<0,05. Resultados: Foram analisados 67 prontuários, em que se obteve maior prevalência para as fraturas do tipo C (49,3%). A subclassificação neurológica N4 (35,8%) foi o tipo mais prevalente encontrado, seguido pelo subtipo N0 (26,9%). Entre os principais mecanismos de lesão encontrados, o mais prevalente foi o acidente motociclístico (29,9%). Não foi observada associação estatisticamente significativa entre o mecanismo de lesão com a classificação morfológica AOSpine (p > 0,05) ou com o déficit neurológico (p > 0,05). Conclusão: As fraturas cervicais do tipo C, devido a acidentes automobilísticos, foram as mais prevalentes. Não foi possível obter associação entre o grau de acometimento neurológico e a morfologia da lesão. Nível de evidência II; Estudo Retrospectivo.

RESUMEN Objetivo: Evaluar el perfil de los pacientes con fractura y / o luxación de la columna cervical subaxial por medio de la nueva clasificación AOSpine y correlacionar con el mecanismo de trauma y el tipo de déficit neurológico. Métodos: Se realizaron análisis de los historiales médicos de los pacientes admitidos en un hospital terciario con fractura y/o luxación cervical subaxial entre el período de 2009 a 2016. Para la evaluación de la asociación entre dos variables categóricas, se utilizó el test Chi-cuadrado, con nivel de significancia de p <0,05. Resultados: Se analizaron 67 historiales, en que se obtuvo mayor prevalencia para las fracturas del tipo C (49,3%). La subclasificación neurológica N4 (35,8%) fue el tipo más prevalente encontrado, seguido del subtipo N0 (26,9%). Entre los principales mecanismos de lesión encontrados, el más prevalente fue el accidente motociclístico (29,9%). No se observó asociación estadísticamente significativa entre el mecanismo de lesión con la clasificación morfológica AOSpine (p> 0,05) o con el déficit neurológico (p> 0,05). Conclusión: Las fracturas cervicales del tipo C, debido a accidentes automovilísticos, fueron las más prevalentes. No fue posible obtener asociación entre el grado de afectación neurológica y la morfología de la lesión. Nivel de evidencia II; Estudio retrospectivo.

Randomized Clinical Study on Surgical Techniques With Different Pedicle Screw Densities in the Treatment of Adolescent Idiopathic Scoliosis Types Lenke 1A and 1B.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To analyze the impact of surgical techniques with different pedicle screw densities on clinical, functional, and radiographic outcomes, and on costs for patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The use of pedicle screws to correct spinal deformities has grown. However, there is no scientific evidence that higher-density screws offer better results for AIS treatment. METHODS: Patients with Lenke 1A/1B AIS and main thoracic curves to the right, 45° to 70°, were operated on using a posterior approach and free-hand technique. Group 1 was treated with 10 screws in strategically determined vertebrae: 4 in the base, 3 in central vertebrae, and 3 in superior vertebrae. In Group 2, the principles of segmental instrumentation were followed, treating all pedicles on the concavity side, except for the apical vertebra, and alternate pedicles on the convexity side, using 10 to 14 screws. Screw density was calculated as the ratio between the number of screws and pedicles fused. RESULTS: Groups were homogeneous regarding preoperative clinical and functional variables, surgery time, and intraoperative bleeding volume. Group 2 had a higher number of screws, average density of pedicle screws, and cost of treatment (p = .000). The number of fused levels was similar between groups. Two years postoperatively, all radiographic variables were homogeneous between groups (mean correction of main thoracic curve was 68.5% in Group 1 and 67.9% in Group 2), but Group 2 achieved better clinical correction of the thoracic hump (p = .000). Both presented significant improvement in the 5 domains of Scoliosis Research Society Score-30. CONCLUSIONS: In AIS patients with Lenke 1A/B curves of 45° to 70°, treatment with a higher pedicle screw density construct was significantly more expensive but had statistically similar functional results and radiographic correction. The denser construct achieved better correction of the thoracic hump 2 years after surgery.

Can the interpedicular distance reliably assess the severity of thoracolumbar burst fractures?

STUDY DESIGN: Retrospective analysis of 260 patients with acute spine fractures treated at a tertiary trauma center from 1989 to 2009. OBJECTIVE: To correlate the Interpedicular distance (IPD) to the percentage of narrowing of the spinal canal and to the presence of neurological deficit and laminar fracture in thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA: Several reports use radiographic findings such as severity of vertebrae collapse, comminution of the vertebral body, and grade of localized kyphosis to determine the severity of spinal traumas and establish appropriate management. However, the importance of the IPD in burst fractures has rarely been mentioned, and no report specifically describes the correlation between an increased IPD and the severity of the lesion or a higher occurrence of lamina fractures. METHODS: Plain radiographs of 260 patients with acute thoracolumbar burst fractures were studied. The percentage of widening between the pedicles of the fractured vertebra (IPD) was established by comparing this distance with that of the vertebrae immediately above and below. Data concerning neurological status, percentage of narrowing of the spinal canal, and the presence of laminar fracture were correlated to the IPD. RESULTS: A significant correlation between IPD and the percentage of narrowing of the spinal canal was found (r = 0.39; t = 6.78; P = 0.00). IPD was significantly increased in patients with neurological deficit (24.7% ± 12.6%) and in patients with lamina fractures (24.6% ± 16.2%). CONCLUSION: IPD measured from plain radiographs proved to be a reliable instrument to assess narrowing of the spinal canal, neurological deficits, and laminar fractures.

Cross-cultural adaptation and validity of an adapted Brazilian Portuguese version of Scoliosis Research Society-30 questionnaire.

STUDY DESIGN: Prospective clinical study developed at a tertiary teaching facility to test an adapted Brazilian Portuguese version of the Scoliosis Research Society-30 (SRS-30) questionnaire. OBJECTIVE: To perform cross-cultural adaptation and evaluate the validity of the adapted Brazilian Portuguese version of SRS-30 questionnaire. SUMMARY OF BACKGROUND DATA: Quality-of-life measurement is a common practice to assess spine diseases. The SRS questionnaires have been proven to be a valid tool in the clinical evaluation of patients diagnosed with idiopathic scoliosis in United States. However, adaptation into languages other than the source language is necessary to allow multinational use respecting cultural and lingual differences. METHODS: A translation/retranslation of the English version of the SRS-30 into Brazilian Portuguese was conducted, and all steps for cross-cultural adaptation process were performed, including a pretest with 20 patients. Sixty-four postoperative patients were submitted to the final version of the Brazilian SRS-30 questionnaire, through oral interviews. The average age of all patients who joined the study was 18.5 years. Internal consistency of the instrument was determined with Cronbach α coefficient. RESULTS: The study demonstrated high Cronbach α values for 4 of the corresponding domains (pain, 0.68; self-image, 0.75; mental health, 0.78; and function/activity, 0.57). However, the Cronbach α value for satisfaction domain (0.28) was considerably lower than the original English questionnaire. The overall Cronbach α values achieved 0.85 for all domains. CONCLUSION: The adapted Brazilian version of the SRS-30 questionnaire can be used to assess the outcome of treatment for Brazilian Portuguese-speaking patients with idiopathic scoliosis.

Correlation between persistent neurological impairment and clinical outcome after microdiscectomy for treatment of lumbar disc herniation.

BACKGROUND: Outcome of lumbar disc herniation is often based on clinical scores and less frequently on the neurological examination. However, even when clinical outcome measures are favorable, patients may still experience motor or sensory impairment. OBJECTIVE: To evaluate the percentage of patients with persistent neurological deficits after lumbar disc surgery and whether these correlate with clinical outcome. METHODS: A total of 150 patients with sciatica and lumbar disc herniation with neurological impairment underwent microdiscectomy and were prospectively followed for 24 months. Patients were assessed pre- and postoperatively with neurological examination, the Oswestry Disability Index (ODI), and the visual analog scale (VAS) for pain. RESULTS: Twenty-four months after surgery, 25% of patients who presented with motor deficits, 40% of patients with sensory deficits, and 48% of patients with reflex abnormalities remained unchanged. The VAS and the ODI showed significant improvement in both patients with and without persistent neurological impairment immediately after surgical repair of the herniated disc with progressive improvement over the follow-up period. However, when calculating the area under the receiver operating characteristics curve, no statistically significant correlation could be established between the presence and persistence of neurological impairment and the 2 clinical scores. CONCLUSION: There seems to be no correlation between clinical results and neurological impairment when assessed by the VAS and ODI.

THORACOLUMBAR BURST FRACTURE: CORRELATION BETWEEN KYPHOSIS AND FUNCTION AFTER SURGICAL TREATMENT.

OBJECTIVE: To assess the correlation between post-traumatic kyphosis in patients with thoracolumbar burst fractures undergoing surgical treatment and the functional result from treatment. METHODS: A retrospective study was conducted on 27 patients with thoracolumbar burst fractures according to Denis and A3 to Margerl's classification who met the inclusion criteria for this sample and underwent surgical treatment with a minimum follow-up of six months. The patients' mean age was 46.96, with a range from 16 to 73 years. The treatment outcome was evaluated based on applying the short-form 36 (SF-36) quality of life questionnaire, Denis pain and work scale and visual pain scale. The kyphosis was measured according to the Cobb method at the end of the follow-up. RESULTS: The residual kyphosis was found not to correlate with the SF-36, Denis pain and work scale or visual pain score (p > 0.05). CONCLUSION: There is no correlation between the final clinical result and residual kyphosis in patients with thoracolumbar burst fractures who undergo surgical treatment.

Thoracolumbar burst fracture: radiographic evaluation on differences between Magerl's A and B.

OBJECTIVE: Evaluate incidence of Magerl's A and B group in thoracolumbar burst fracture (Denis) according to independent examiners. METHOD: According to the posterior spinous process split on the anterior posterior radiography, three independent examiners have analyzed the patients admitted from 2000 to 2009 with thoracolumbar burst fractures (according to Denis) to differentiate between Magerl's type A3 and B1.2. Statistical evaluation was descriptive and by using Kappa's method. RESULTS: From the 72 patients, 11 patients compose the Magerl's type B group according to examiner 1; 10 according to examiner 2; and 17 according to examiner 3. Posterior lesion concordance was satisfactory (good, κ=0.7) between the examiners. CONCLUSION: 14 to 24% patients with thoracolumbar fractures show posterior lesion (B1.2) by using radiographic criteria. Level of evidence III, Diagnostic Studies Investigating a Diagnostic Test.