Cervical dorsal rhizotomy for upper limbs spasticity. Case report.

Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.

Development and validation of an instrument for measuring parkinsonian motor impairment: TRAPS-D.

BACKGROUND: Parkinson's disease is incurable, idiopathic, degenerative, and progressive, and affects about 1% of the elderly population. Multidisciplinary clinical treatment is the best and most adopted therapeutic option, while surgical treatment is used in less than 15% of those affected. In practice, there is a lack of reliable and validated scales for measuring motor impairment, and monitoring and screening for surgical indications. OBJECTIVE: To develop and validate an instrument for measuring parkinsonian motor impairment in candidates for neurosurgical treatment. METHOD: The development and validation methods followed published guidelines. The first part was the choice of domains that would make up the construct: cardinal signs of disease (tremor, rigidity (stiffness), posture/balance/gait, hypokinesia/akinesia, and speech), along with pain and dyskinesia. A multi-professional working group prepared an initial pilot instrument. Ten renowned specialists evaluated, judged, and suggested modifications to the instrument. The second phase was the evaluation of the content of each domain and the respective ability to classify commitment intensity. The third phase was the correction of the main flaws detected and new submission to the board. The instrument was applied to 41 candidates for neurosurgical treatment in two situations: with and without medication RESULTS: The final form received 100% agreement from the judges. Its average time for application was 8 min. It was very responsive (p = 0.001, Wilcoxon) in different situations (On-Off). CONCLUSION: TRASP-D is a valid instrument for measuring motor impairment in patients with Parkinson's disease who are candidates for neurosurgical treatment. It allows measurement in multiple domains with reliability and sensitivity.

The surgical treatment of subaxial acute cervical spine facet dislocations in adults: a systematic review and meta-analysis.

Adult cervical spine traumatic facet joint dislocations occur when excessive traumatic forces displace the vertebrae's facets, leading to loss of joint congruence. Reduction requires either cranial traction or open surgical procedures. This study aims to appraise the effects of different surgical techniques in the treatment of subaxial cervical spine acute traumatic facet blocks in adults. This study was based on a systematic literature review and meta-analysis, registered in Prospero (CRD42021279249). The PICO question was composed of adults with acute cervical spine traumatic facet dislocations submitted to anterior or posterior surgical approaches, associated or not with cranial traction for reduction. Each surgical technique was compared to the other. The primary clinical outcomes included neurological improvement or worsening and surgical success/failure rates. The anterior approach without cranial traction was efficient in reducing facet displacements. Skull traction was an efficient and immediate method to achieve spine dislocation reductions. Differences were not present among techniques regarding neurological improvement. There were no surgical failures in patients operated on via the posterior approach. The need to decompress and stabilize the cervical spine can be achieved by anterior or posterior surgical approaches, and there is no clear answer as to which initial approach is superior to the other.

The impact of traumatic herniated discs in cervical facets dislocations treatments: systematic review and meta-analysis.

BACKGROUND: Traumatic facet dislocations in the subaxial cervical spine, also known as locked facets, are commonly associated with neurological deficits. The fear of the presence of an associated traumatic disc herniation and consequent neurological worsening usually causes a delay in the spinal realignment. This study's aim is an analysis of safety and efficacy when treating acute cervical traumatic facet dislocations using cranial-cervical traction or posterior open reduction and fixation in the presence of disc herniations. METHODS: Inclusion criteria addressed the following patient groups: (1) MRI diagnosis of traumatic cervical facet dislocations with disc herniation, (2) intervention: either cranial-cervical traction or posterior open reduction and fixation, (4) neurological outcomes after treatment, (5) adult 18 plus years of age, (6) sample sizes greater than 20 patients, (7) English language publication. The following databases and search tools were analyzed: MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and the clinical trial registries (ClinicalTrials.gov), October 2021. RESULTS: Six studies were found, 2 with posterior open reduction and fixation and 4 with cranial-cervical traction, totalizing 197 patients. Neurological worsening was reported only in 1 case (0.5%). CONCLUSIONS: Traumatic disc herniation in cervical facet dislocations is not an absolute contraindication of cranial-cervical traction or posterior open reduction. Early realignment of the spine could bring more neurological benefits than waiting for an MRI or surgical discectomy. However, caution is needed in this review's data interpretation until prospective and well-designed studies are performed.

The effect of filum terminale sectioning for Chiari 1 malformation treatment: systematic review.

PURPOSE: Symptomatic Chiari type I malformation (CM) is treated with posterior fossa decompression with/ without duroplasty. Few authors suggested cerebellar tonsil caudal migration due to a supposed "caudal traction" of cranial nerve structures in a so-called occult tethered cord syndrome. For these authors, filum terminale (FT) sectioning may improve CM symptoms. The objective of this review is to evaluate the effect of FT sectioning on the treatment of CM. METHODS: Using the PRISMA guidelines for systematic reviews, we reviewed studies to evaluate patient's outcomes with CM who underwent FT sectioning. The MINORS instrument was used for methodological quality assessment. The included studies' levels of evidence (LOE) were classified according to the Oxford Centre of Evidence-Based Medicine. RESULTS: Two studies from the same group of authors were included. We cannot assure if the cited cases in the first study were also included in their latter published study. The described results suggest that outcomes were not collected in a standardized fashion. Outcomes are described vaguely as a percentage of improvement. Case series samples were small and included not only patients with CM but also patients with scoliosis and syringomyelia. The MINORS score reported that both studies had low methodological quality. Both included studies were classified as level 4 of evidence. CONCLUSION: There is no scientific support for filum terminale sectioning in patients with CM without evidence of tethered cord. This procedure may be considered experimental and should be validated in a strict criterion of inclusion clinical trial comparing outcomes in posterior fossa decompression.

The effect of posterior fossa decompression in adult Chiari malformation and basilar invagination: a systematic review and meta-analysis.

Chiari malformation (CM) and basilar invagination (BI) are mesodermal malformations with disproportion between the content and volume of posterior fossa capacity and overcrowding of neural structures at the level of foramen magnum. Several alternatives for posterior approaches are available, including extradural (ED), extra-arachnoidal, and intradural (ID) approaches. The objectives are to evaluate the effect of several surgical techniques for posterior fossa decompression (PFD) in the outcomes of patients with CCJM and to evaluate complications in the techniques reported. A systematic review of the literature on the effects of PFD surgery was performed using the MEDLINE (via PubMed) database and the Cochrane Central Register of Controlled Trials. The PRISMA statement and MOOSE recommendations were followed. Five hundred and thirty-nine (539) articles were initially selected by publication title. After abstract analysis, 70 articles were selected for full-text analysis, and 43 were excluded. Ultimately, 27 studies were evaluated. The success rate (SR) with ED techniques was 0.76 versus 0.81 in EA technique and 0.83 in IA technique. All posterior fossa decompression techniques were very successful. Results from observational studies were similar to that of the randomized trial. The main complications were CSF fistulas, most common in patients with IA approach. The overall mortality rate was 1%.

Is there a relationship between spinal instability in neoplastic disease and Tokuhashi scoring system?

Spinal instability neoplastic score (SINS) classification evaluates spinal stability by adding together six radiographic and clinical components. The objective of this study was to verify the association between SINS and Tokuhashi scoring system (TSS) score. Fifty-eight patients with vertebral metastases were admitted from 2010 to 2014 at Hospital do Servidor Público Estadual de São Paulo. They were evaluated according to their SINS and Tokuhashi SS score. Fourteen patients (24.13 %) scored from 0 to 6 points (stable spine), 37 (63.79 %) scored from 7 to 12 (potentially unstable), and 7 (12.06 %) scored from 13 to 18 (unstable). In stable spine patients according to SINS, the mean TSS score was 9.2. In potentially unstable spine patients, the mean TSS score was 8.24. In unstable spine patients, mean TSS score was 6.28. There was a statistically significant difference of the TSS score between stable and unstable patients. After evaluating TSS score in each patient, the worse the SINS, the worse was also the TSS score.

Reliability of the evaluation of posterior ligamentous complex injury in thoracolumbar spine trauma with the use of computed tomography scan.

PURPOSE: The AOSpine thoracolumbar (TL) spine injury classification system is based mainly on computed tomography (CT). The main purpose of this study was to evaluate the reliability of CT scan in the diagnosis of posterior ligamentous complex (PLC) injury in thoracolumbar spine trauma (TLST). METHODS: We performed a cross-sectional study of 43 patients with TLST. CT scans were evaluated independently by three spine surgeons on two separate occasions, 2 months apart. The reliability of PLC injury parameters was assessed by the Kappa coefficient (κ) and the average percentage of these parameters was established. Injuries were classified according to the AOSpine classification as type A (compression), B (anterior and/or posterior tension band injuries) or C (dislocation) injury and the reliability of the classification was calculated. RESULTS: On average, PLC injury was identified in 91.4% of type B or C injuries. Tension band injury and dislocation were found in 90.5% of type B and 93.2% of type C injuries. The intraobserver reliability for the PLC injury parameters ranged from 0.518 to 1.000, except for increased interspinous distance (IID). Interobserver reliability ranged from 0.303 to 0.688. When the patients were evaluated as a whole, dislocation showed the highest κ (0.656 and 0.688). When type A or B injuries were assessed, the highest κ were found for IID (0.533 and 0.511) and tension band injury (0.486 and 0.452). The κ for AOSpine classification was 0.526 and 0.645 in both assessments. CONCLUSIONS: In this study, the use of CT scan as the only diagnostic tool could identify PLC injury in most cases and demonstrated satisfactory reliability. Dislocation could satisfactorily diagnose type C injury, while IID was the best parameter to differentiate between type A and B injuries.

Do Physically Active Patients Have Better Functional Outcome after Stroke? A Systematic Review.

BACKGROUND AND PURPOSE: Stroke is one of the major causes of mortality and, among survivors, disability. Physical activity has a protective effect maybe due to a major control of risk factors, such as hypertension, diabetes mellitus, and body weight. However, the effect of prestroke physical activity and the poststroke functional outcomes needs clarification. METHODS: We made a systematic review of the literature to elucidate this effect through electronic search in the MEDLINE/PubMed database. Prisma statement was used as a basis for this systematic review and analysis of the risk of bias was made according to the Grading of Recommendations, Assessment, Development and Evaluation. Three studies were finally analyzed in this review. RESULTS: The largest of the studies (Rist et al) revealed no association between prior physical activity and functional outcome after stroke. The second major study (Stroud et al) showed only a slight association. Only the smallest of the 3 studies (Krarup et al) showed a protective effect of physical activity. CONCLUSIONS: The evidence of the protective effect of physical activity is still conflicting. Better longitudinal studies are still needed to see the real effect of physical activity on functional outcome after stroke.

Systematic review of the effect of dynamic fixation systems compared with rigid fixation in the anterior cervical spine.

PURPOSE: Anterior cervical fixation is a procedure widely employed in medical practice, with different fixation systems in use. This study aimed to perform a systematic review of the literature comparing the use of rigid and dynamic cervical plates regarding the fusion rate and complications. METHODS: A search was conducted in PubMed, Lilacs, and Cochrane databases and selecting comparative studies on the use of rigid and dynamic cervical plates. Prospective randomized studies were selected to describe the final results regarding the clinical and radiological outcomes; comparative observational studies were also cited. Complications of using the dynamic cervical plate were also evaluated. RESULTS: Seven comparative studies were included in the review. Five of these were prospective and randomized studies that did not report significant differences in the clinical outcome. One study reported a faster fusion rate when dynamic cervical plate was used, and another study showed a higher fusion rate when a dynamic cervical plate was applied on multiple levels. Four studies investigated the complications of using a dynamic plate and reported that changes in the cervical curvature angle and material failure were the most frequent complications. CONCLUSIONS: There were no clinical differences between the two types of cervical fixation systems. A difference in the fusion rates could not be found at any follow-up time or in any of the studies. There was a loss of lordotic correction in the dynamic systems and a higher rate of complications in patients with a loss of lordotic correction.

Angular craniometry in craniocervical junction malformation.

The craniometric linear dimensions of the posterior fossa have been relatively well studied, but angular craniometry has been poorly studied and may reveal differences in the several types of craniocervical junction malformation. The objectives of this study were to evaluate craniometric angles compared with normal subjects and elucidate the main angular differences among the types of craniocervical junction malformation and the correlation between craniocervical and cervical angles. Angular craniometries were studied using primary cranial angles (basal and Boogard's) and secondary craniocervical angles (clivus canal and cervical spine lordosis). Patients with basilar invagination had significantly wider basal angles, sharper clivus canal angles, larger Boogard's angles, and greater cervical lordosis than the Chiari malformation and control groups. The Chiari malformation group does not show significant differences when compared with normal controls. Platybasia occurred only in basilar invagination and is suggested to be more prevalent in type II than in type I. Platybasic patients have a more acute clivus canal angle and show greater cervical lordosis than non-platybasics. The Chiari group does not show significant differences when compared with the control, but the basilar invagination groups had craniometric variables significantly different from normal controls. Hyperlordosis observed in the basilar inavagination group was associated with craniocervical kyphosis conditioned by acute clivus canal angles.

Assessing the evolution of publications by Brazilian spine surgeons in the last decade.

PURPOSE: To evaluate the scientific contribution of Brazilian Spine Surgeons not only in number of publications but also in their quality between January 2000 to December 2011. METHODS: A literature search of publications by Brazilian spinal surgeons on topics concerning the spine or spinal cord was performed using an online database; Pubmed.gov. The results were limited to articles published from January 2000 to December 2011. A total of 1,778 articles were identified after a Medline search. After exclusion criteria, the study comprised 206 articles. The quality of the Journals was assessed with IF and the article quality using the Oxford classification. RESULTS: An increasing number of publications by Brazilian spine surgeons was observed in recent years: 45.1 % of those papers were published during the last 4 years (2008-2011). Clinical studies and case reports were the most frequent types of article published (37.5 vs 31.1 %). An increasing number of Brazilian publications in non-Brazilian journals has been observed in recent years (linear-by-linear association: 5.449, P = 0.020). The Arquivos de Neuro-Psiquiatria was the most frequent journal in which the papers were published (N = 67, 32 %). The IF of the publications varied from 0.021 to 8.017. The analysis of quality of the articles using the Oxford classification demonstrated that most of them provided LOE 4 (N = 113, 54.9 %) or 5 (N = 45, 21.8 %). CONCLUSIONS: There have been an increasing number of publications by Brazilian spine surgeons in recent years and the quality of the articles published has improved. Also the number of publications by Brazilians in non-Brazilian journals has increased in recent years.

Association between Brachycephaly, Chiari Malformation, and Basilar Invagination.

BACKGROUND: There is evidence that Chiari malformation (CM) and basilar invagination (BI) are largely due to disproportion between the content and volume of the posterior fossa. A recent study identified an increased association between brachycephaly and BI. In several types of craniosynostosis, the posterior fossa volume is smaller than normal, and this is more pronounced in coronal synostosis. The aim of this study is to evaluate the association between CM and BI. METHODS: The cephalic index (CI) measured on magnetic resonance imaging (MRI) from a sample of patients with craniocervical malformation was compared with that of normal subjects. RESULTS: The average CI in the craniovertebral junction malformation (CVJM) group was significantly higher in BI patients than in normal subjects. The BI patients also had the highest CI among the whole sample of patients (p = 0.009). CONCLUSIONS: In this study, BI patients had the highest CI among patients with CVJM and a significantly higher CI than those in the control group. Our data confirm the association between BI and brachycephaly.

Chamberlain's Line Violation in Basilar Invagination Patients Compared with Normal Subjects: A Systematic Literature Review and Meta-Analysis.

OBJECTIVE: To compare the measured odontoid tip violation above Chamberlain's line described in the literature to diagnose basilar invagination (BI) and to establish the normal placement of the dens tip defining individuals without BI (normal subjects). METHODS: A systematic literature review was performed to identify clinical or radiological studies that expressed the amount of odontoid violation above Chamberlain's line in patients with a BI diagnosis. In addition, a meta-analysis was performed to evaluate normal subjects' values of Chamberlain's line violation (CLV). RESULTS: There were 23 studies included (13 radiological and 10 clinical). Most studies used computed tomography and/or magnetic resonance imaging. Eight different cutoff values were used to measure dislocated odontoid apexes above Chamberlain's line regardless of the radiological modality. The mean measured amount of CLV was 3.95 mm (median 5 mm; range, 0-9 mm). The meta-analysis included 8 studies (1233 patients) with a normal sample population with a mean normal CLV of -0.63 mm (below the line) (95% confidence interval [-0.8, 1.18 mm], random effects model). CONCLUSIONS: Different values were found in the assessed studies used for CLV in BI diagnosis. This variability is especially important for type B BI, as type A BI has other craniocervical diagnostic parameters. Considering the results obtained in this meta-analysis, BI should be diagnosed in the case of any dens violation >1.18 mm.

Type II Odontoid Fractures: Is the Anterior Screw a Good Solution for all Patients? A Case Series of 60 Consecutive Patients.

OBJECTIVE: Type II odontoid fracture is the most common fracture type, and its treatment remains challenging. The objective of this study was to evaluate the results of anterior screw fixation for type II odontoid fractures in patients aged over and below 60 years. METHODS: A retrospective analysis of consecutive patients diagnosed with type II odontoid fractures who were surgically treated using the anterior approach by a single surgeon was conducted. Demographic characteristics, including age, sex, type of fracture, time from trauma to surgery, length of stay (LoS), fusion rate, complications, and reoperation, were evaluated. Surgical outcomes were compared between patients over and below 60 years of age. RESULTS: Sixty consecutive patients underwent odontoid anterior fixation during the analysis period. The mean age of patients was 49.58 ± 23.22 years. Twenty-three (38.3%) patients were aged over 60 years, and the minimum follow-up period was two years. Of the patients, 93.3% developed bone fusion, which was observed in 86.9% of patients over 60 years. Complications related to hardware failure occurred in six (10%) patients. Transient dysphagia was observed in 10% of the cases. Three (5%) patients required reoperation. Patients over 60 years had a significantly increased risk of dysphagia compared with those below 60 years (P = 0.0248). There was no significant difference between the groups regarding nonfusion rate, reoperation rate, or LoS. CONCLUSIONS: Anterior fixation of the odontoid showed high fusion rates with a low rate of complications. It is a technique to be considered for treating type II odontoid fractures in selected cases.

Effect of interbody fusion compared with posterolateral fusion on lumbar degenerative spondylolisthesis: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Lumbar degenerative spondylolisthesis is a relatively common pathology, and surgical treatment is an option in selected cases. The common use of anterior column support by interbody fusion (IBF) has not been adequately studied. PURPOSE: The primary objective of this systematic review and meta-analysis was to compare the functional and surgical outcomes after posterolateral fusion (PLF) and IBF for the treatment of degenerative spondylolisthesis. STUDY DESIGN: A systematic review and meta-analysis was conducted to identify studies analyzing the effects of IBF compared to those of instrumented PLF on degenerative spondylolisthesis. PATIENT SAMPLE: A total of 1,063 patients were included in the analysis. Of them, 470 patients were treated with PLF and 593 with IBF. OUTCOME MEASURES: The outcomes analyzed were the visual analog scale and numerical rating scale scores for back pain, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36) score, 12-Item Short Form Health Survey (physical and mental components) score, blood loss amount, surgical time, hospital stay duration, fusion rate, lumbar lordosis, sacral slope, and postoperative complications. METHODS: A search was conducted using the MEDLINE, Cochrane, and Google Scholar databases for studies published between January 1985 and February 2021. Both retrospective and prospective studies that compared between IBF and PLF were included. RESULTS: A total of 2,819 articles were screened, and 38 full-text articles were selected for a detailed investigation, of which 12 articles were found to match all the inclusion criteria and were included in the meta-analysis. There was an improvement in the sacral slope (mean difference [MD] = 3 [95% confidence interval {CI} = 0.83-5.17]) and fusion rate (odds ratio [OR] = 0.47 [95% CI = 0.26-0.86]) in the IBF group. The incidence of neural injury was higher in the IBF group (OR = 0.28 [95% CI = 0.13-0.60]) than in the PLF group. There were no differences in the back pain scores, ODI, SF-36 score, blood loss amount, surgical time, hospital stay duration, lumbar lordosis, infection, and durotomy between the groups. CONCLUSIONS: IBF for the treatment of lumbar degenerative spondylolisthesis showed better results in terms of the fusion rate and sacral slope, but which did not translate into better clinical outcomes. Further randomized and prospective studies are necessary to elucidate the optimal therapeutic options.

Aggressive dissemination of central nervous system hemangioblastoma without association with von Hippel-Lindau disease: A case report and literature review.

Background: Hemangioblastomas (HBs) typically present with benign behavior and are most commonly found in the posterior fossa. Multiple central nervous system (CNS) HBs are usually associated with von Hippel-Lindau disease, and leptomeningeal dissemination of sporadic HBs is extremely rare. A review of the literature identified 30 cases of leptomeningeal dissemination of sporadic HBs previously published in the literature. Case Description: We report the case of a patient who was diagnosed with multiple CNS HBs with aggressive progression 6 years after resection of a posterior fossa HB. He underwent multiple surgeries and died 4 years after the diagnosis of the first spinal dissemination. Conclusion: Dissemination of sporadic HBs is rare and aggressive disease evolution is usually observed. Further studies are necessary to determine the optimal therapeutic options.

Review of best classification systems for diagnosing and treating thoracolumbar spine trauma.

BACKGROUND: Improved thoracolumbar spine trauma classification (TLSTC) systems can better help diagnose and treat thoracolumbar spine trauma (TLT). Here, we identified the types of injury (rationale and description), instability criteria, and treatment guidelines of TLSTC. METHODS: We used the PubMed/MEDLINE database to assess TLSTC according to the following variables: injury morphology, injury mechanism, spinal instability criteria, neurological status, and treatment guidelines. RESULTS: Twenty-one studies, 18 case series and three reviews were included in the study. Treatment guidelines were proposed in 16 studies. The following three major parameters were identified in TLSTC studies: injury morphology (19/21 studies), posterior ligamentous complex (PLC) disruption alone as the main spinal instability criterion (15 studies), and neurological damage (12 studies). Most classification systems neglected the severity of vertebral body comminution. CONCLUSION: We identified here the 3 main parameters for the evaluation of diagnosis and treatment of TLT: injury morphology, PLC disruption, and neurological damage. Based on our review, we may conclude that further clinical validation studies of TLSTC are warranted.

Effectiveness of telemedicine in response to the COVID-19 pandemic.

OBJECTIVE: The aim of this study was to evaluate the utility of the telemedicine care model implemented to treat and guide patients with COVID-19 related symptoms and indicators during the pandemic. METHODS: This is a retrospective study with data collected from the electronic records of standardized forms for assistance. As a way of evaluating the work performed, the number of consultations, types of referrals, efficiency of care, and patient satisfaction were observed. RESULTS: Between April 2 and October 15, 2020, 92 professionals attended 3,660 patients by telemedicine; out of them, 523 (14.3%) were referred to a COVID-19 attending room, 128 (3.5%) to other specialties, 123 (3.4%) to a general emergency department, and 2,886 (78.9%) were monitored via home care. Of the total number of patients, 81 (2.2%) were hospitalized, and 13 (0.35%) died. CONCLUSION: Telemedicine offered useful tools for the care, treatment, and monitoring of patients with COVID-19 during the pandemic. The service was considered by most respondents as satisfactory, resolutive, or safe.