Three-level thoracic disc herniation: transthoracic decompression without fixation.

Thoracic disc herniation is a rare pathology compared to the rest of the herniated discs. Due to their difficult access to the area of compromise and proximity to the spinal cord they represent a real challenge for the spine surgeon. The objective is to report an atypical case with three symptomatic dorsal disc herniations which required surgical treatment. Surgery was performed in two times with a lapse of 12 months between interventions. It was done a minimally invasive transthoracic decompression and intersomatic arthrodesis without instrumentation. The patient presented good neurological recovery without any serious sequelae.

La hernia de disco dorsal es una afección poco frecuente en comparación con el resto de las hernias discales. Por su difícil acceso a la zona de compromiso y cercanía de la médula espinal representan un verdadero desafío para el cirujano de columna. El objetivo del trabajo es presentar un caso atípico con tres hernias de disco dorsales sintomáticas en forma sincrónica que requirió tratamiento quirúrgico. La cirugía se hizo en dos tiempos con un lapso de 12 meses entre las intervenciones. Se realizó descompresión transtorácica mínimamente invasiva y artrodesis intersomática sin instrumentación en cada nivel. El paciente presentó buena recuperación neurológica sin ninguna secuela grave.

Ultrasonic Bone Scalpel versus Conventional Technique for Thoracolumbar Spinal Decompression: A Prospective Randomized Controlled Trial / Bisturi ósseo ultrassônico versus técnica convencional para descompressão espinhal torácica: Um teste controlado randomizado prospectivo

Abstract Objective The purpose of the present study is to compare intraoperative blood loss, operating time, laminectomy time, hospital length of stay, and complications in thoracolumbar spinal decompression using ultrasonic bone scalpels (UBSs) with conventional procedures. Methods Forty-two patients who underwent decompressive laminectomy and pedicular screw fusion with a surgical level of 1-5 levels between February 1, 2020, and June 30, 2022, in a single institution were evaluated for eligibility, and 11 were excluded due to a history of spinal surgery (n= 3), spinal tumor (n= 3), and spinal infection (n= 5). A total of 31 patients were randomly divided into the UBS group (n =15) and the conventional group (n =16). Intraoperative blood loss, operating time, laminectomy time, hospital length of stay, and complications were recorded. Results Intraoperative blood loss and laminectomy time were significantly lower in the UBS group (656.0 ± 167.6 ml, 54.5 ± 27.4 minutes, respectively) than in the conventional group (936.9 ± 413.2 ml, 73.4 ± 28.1 minutes, respectively). Overall operation time, hospital length of stay, and complications were all similar between the groups. Conclusion The UBS is a useful instrument for procedures performed near the dura mater or other neural tissue without excessive heat or mechanical injury. This device is recommended for various spinal surgeries in addition to high-speed burrs and Kerrison rongeurs.

Resumo Objetivo O objetivo do presente estudo é comparar perda de sangue intraoperatória, tempo de operação, tempo de laminectomia, tempo de internação hospitalar e complicações na descompressão espinhal torácica utilizando bisturis ósseos ultrassônicos (BOUs) em relação aos procedimentos convencionais. Métodos Quarenta e dois pacientes submetidos a laminectomia descompressiva e fusão pedicular do parafuso com um nível cirúrgico de 1 a 5, entre 1° de fevereiro de 2020 e 30 de junho de 2022 em uma única instituição, foram avaliados para elegibilidade e 11 foram excluídos devido ao histórico de cirurgia espinhal (n= 3), tumor espinhal (n= 3) e infecção espinhal (n= 5). Perda de sangue intraoperatória, tempo de operação, tempo de laminectomia, tempo de internação e complicações foram registradas. Resultados A perda de sangue intraoperatória e o tempo de laminectomia foram significativamente menores no grupo BOU (656,0 ± 167,6 ml, 54,5 ± 27,4 min, respectivamente) do que no grupo convencional (936,9 ± 413,2 ml, 73,4 ± 28,1 min, respectivamente). O tempo de funcionamento total, o tempo de internação e as complicações foram todos semelhantes entre os grupos. Conclusão O bisturi ósseo ultrassônico é um instrumento útil para procedimentos realizados próximos à dura-máter ou outro tecido neural sem calor excessivo ou lesão mecânica. Este dispositivo é recomendado para várias cirurgias de coluna vertebral, juntamente com rebarbas de alta velocidade e pinça Kerrison.

Tridimensional models and radiographic study of dorsal laminectomy and thoracolumbar hemilaminectomy in dogs.

PURPOSE: To create three-dimensional anatomical models of the thoracic and lumbar portions of the canine spine that reproduce the vertebral surgical approaches of dorsal laminectomy and hemilaminectomy, and to perform the respective radiographic evaluations of each approach. METHODS: In a digital archive of the canine spine, digitally replicate the dorsal laminectomy and hemilaminectomy in the thoracic and lumbar portions and, then, make tridimensional prints of the vertebral models and obtain radiographs in three dorsoventral, ventrodorsal and laterolateral projections. RESULTS: The anatomical models of the surgical spinal canal accesses of the thoracic and lumbar portions showed great fidelity to the natural bones. The created accesses have the proper shape, location and size, and their radiographic images showed similar radiodensities. CONCLUSIONS: The replicas of the dorsal laminectomy and hemilaminectomy developed in the anatomical models in the thoracic and lumbar portions are able to represent the technical recommendations of the specialized literature, as well as their respective radiographic images, which have certain radiological properties that allow to make a deep radiological study. Therefore, the models are useful for neurosurgical training.

Pain After Anterior Vertebral Body Tethering: Incidence, Risk Factors, and Timing.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To examine the incidence and risk factors for postoperative pain following anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Up to 78% of patients with AIS report preoperative pain; it is the greatest patient concern surrounding surgery. Pain significantly decreases following posterior spinal fusion, but pain following AVBT is poorly understood. MATERIALS AND METHODS: We retrospectively reviewed 279 patients with a two-year follow-up after AVBT for AIS. We collected demographic, radiographic, and clinical data pertinent to postoperative pain at each time interval of preoperative and postoperative visits (6 wk, 6 mo, 1 y, and annually thereafter). RESULTS: Within our cohort, 68.1% of patients reported preoperative pain. Older age ( P =0.014) and greater proximal thoracic ( P =0.013) and main thoracic ( P =0.002) coronal curve magnitudes were associated with preoperative pain. Pain at any time point > 6 weeks postoperatively was reported in 41.6% of patients; it was associated with the female sex ( P =0.032), need for revision surgery ( P =0.019), and greater lateral displacement of the apical lumbar vertebrae ( P =0.028). The association between preoperative and postoperative pain trended toward significance ( P =0.07). At 6 months postoperatively, 91.8% had pain resolution; the same number remained pain-free at the time of last follow-up. The presence of a postoperative complication was associated with new-onset postoperative pain that resolved ( P =0.009). Only 8.2% had persistent pain, although no risk factors were found to be associated with persistent pain. CONCLUSION: In our cohort of 279 patients with a minimum 2-year follow-up after AVBT, 68.1% reported preoperative pain. Nearly 42% reported postoperative pain at any time point, but only 8.2% had persistent pain. Postoperative pain after AVBT was associated with female sex, revision surgery, and Lenke lumbar modifier. AVBT is associated with a significant reduction in pain, and few patients report long-term postoperative pain.

What Happens After a Vertebral Body Tether Break? Incidence, Location, and Progression With Five-year Follow-up.

STUDY DESIGN: Retrospective review. OBJECTIVE: To study risk factors for anterior vertebral body tether (VBT) breakage. SUMMARY OF BACKGROUND DATA: VBT is used to treat adolescent idiopathic scoliosis in skeletally immature patients. However, tethers break in up to 48% of cases. MATERIALS AND METHODS: We reviewed 63 patients who underwent thoracic and/or lumbar VBT with a minimum five-year follow-up. We radiographically characterized suspected tether breaks as a change in interscrew angle >5°. Demographic, radiographic, and clinical risk factors for presumed VBT breaks were evaluated. RESULTS: In confirmed VBT breaks, the average interscrew angle change was 8.1°, and segmental coronal curve change was 13.6°, with a high correlation ( r =0.82). Our presumed VBT break cohort constituted 50 thoracic tethers, four lumbar tethers, and nine combined thoracic/lumbar tethers; the average age was 12.1±1.2 years and the mean follow-up was 73.1±11.7 months. Of 59 patients with thoracic VBTs, 12 patients (20.3%) had a total of 18 breaks. Eleven thoracic breaks (61.1%) occurred between two and five years postoperatively, and 15 (83.3%) occurred below the curve apex ( P <0.05). The timing of thoracic VBT breakage moderately correlated with more distal breaks ( r =0.35). Of 13 patients who underwent lumbar VBT, eight patients (61.5%) had a total of 12 presumed breaks. Six lumbar breaks (50%) occurred between one and two years postoperatively, and seven (58.3%) occurred at or distal to the apex. Age, sex, body mass index, Risser score, and curve flexibility were not associated with VBT breaks, but the association between percent curve correction and thoracic VBT breakage trended toward significance ( P =0.054). Lumbar VBTs were more likely to break than thoracic VBTs ( P =0.016). Seven of the patients with presumed VBT breaks (35%) underwent revision surgery. CONCLUSIONS: Lumbar VBTs broke with greater frequency than thoracic VBTs, and VBT breaks typically occurred at levels distal to the curve apex. Only 15% of all patients required revision. LEVEL OF EVIDENCE: 3.

Acquired butterfly vertebra as a sequela of eosinophilic granuloma.

Butterfly vertebras are an abnormal embryological formation of the spinal bodies that occur because of a lack of fusion of the chondrification centers of the vertebral bodies. Langerhans cell histiocytosis is an entity that frequently involves vertebral bodies resulting in flat vertebras, and recovery of the vertebral body height is a very unusual finding. We present a case report of a pediatric patient with a thoracic acquired butterfly vertebra which occurred secondary to a Langerhans cell histiocytosis involvement. It is extremely rare to find vertebra plana that regains its complete height but is even more infrequent to evidence of a butterfly vertebra deformity that is not congenital.

Preoperative MRI Reliably Predicts Pedicle Dimensions on Intraoperative CT Images in Structural Main Thoracic Curves in Patients With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: The aim of this study was to compare the length and diameter of thoracic pedicles in patients with adolescent idiopathic scoliosis (AIS) as measured on preoperative magnetic resonance imaging (pMRI) to intraoperative computed tomography (iCT) scan. SUMMARY OF BACKGROUND DATA: Optimally sized pedicle screw placement during instrumented posterior spinal fusion for AIS can maximize correction and minimize screw pullout. While iCT-guided navigation can quickly estimate screw position and size, this technology is not universally available. Many surgeons utilize pMRI, when obtained, to estimate screw sizes. Data comparing these measurements on pMRI and iCT is limited. We hypothesized that in patients with surgical magnitude AIS, pedicle length, and diameter measured on pMRI would have at least moderate reliability compared to those made on iCT images. MATERIALS AND METHODS: The pMRI and iCT for 60 patients with structural thoracic curves who underwent posterior spinal fusion for AIS at a single center between 2009 and 2017 were analyzed. Bilateral T5-T12 vertebral levels were evaluated for pedicle chord length and pedicle isthmic diameter on both pMRI and iCT. Between-study reliability and interrater reliability was evaluated for each level of the thoracic spine. RESULTS: There is good reliability for pedicle length [intraclass correlation coefficient (ICC)=0.8, 95% confidence interval (CI): 0.78-0.83] and diameter (ICC=0.86, 95% CI: 0.84-0.88) between pMRI and iCT. When assessed by level, T6 has the lowest reliability for length (ICC=0.52, 95% CI: 0.33-0.67) and diameter (ICC=0.55, 95% CI: 0.35-0.69). Interrater reliability ranged from moderate-to-good reliability for all pedicle measurements for both length and diameter on pMRI and iCT. CONCLUSION: Pedicle measurements made on pMRI may be used with reasonable reliability to predict pedicle dimensions visualized on iCT, allowing surgeons to preoperatively plan pedicle screw sizes based off magnetic resonance imaging.

Mid and lower thoracic kyphosis changes during adulthood: the influence of age, sex and thoracic coronal curvature.

INTRODUCTION: There is conflicting data on how thoracic kyphosis changes throughout adulthood. We evaluated mid and lower thoracic kyphosis (MTK) in various age groups and the influence of age, sex and coronal curve (CC) on MTK. MATERIAL AND METHODS: We studied 1323 patients 15-80 years-old (54.4% females) previously evaluated with chest radiographs. We established three groups: patients 15-40 (group 1); 41-60 (group 2) and 61-80 years old (group 3). MTK (T5-T12) and CC were measured using Cobb's method. We established differences in MTK between groups using ANOVA with Bonferroni correction. We performed a correlation analysis of MTK with age and CC, and a linear regression analysis to determine if age, sex and CC independently predicted MTK. RESULTS: MTK increased with older age: mean MTK group 1 = 23.4°; group 2 = 27.9° and group 3 = 34.4°, p < 0.01. The increase in MTK was observed in both genders. Scoliosis was more common in females (15.4%) than in males (6.7%), p < 0.01. MTK was correlated with age (r = 0.4; p < 0.01) and slightly correlated with CC (r = 0.07, p < 0.01). MTK was larger in females than in males (29.1° vs. 27.6°, p < 0.01). Age (ß-coefficient = 0.26) and CC (ß-coefficient = 0.14), but not sex, independently influenced MTK in the regression analysis. CONCLUSION: MTK increases with advancing age during adulthood in both genders; CC, but not sex, was an independent predictor of MTK.

The effect of direct vertebral rotation on the spine parameters (coronal and sagittal) in adolescent idiopathic scoliosis.

BACKGROUND: Idiopathic scoliosis is accompanied by postural alterations, instability of gait, and functional disabilities. The objective was to verify radiographic parameters (coronal and sagittal) of adolescents with idiopathic scoliosis (AIS) pre- and post-surgery with direct vertebral rotation (DVR), associated with type 1 osteotomies in all segments (except the most proximal) and type 2 in the periapical vertebrae of the curves. METHODS: A prospective study design was employed in which 41 AIS were evaluated and compared pre- and post-surgery. Scoliosis was confirmed by a spine X-ray exam (Cobb angle). Eight radiographic parameters were measured: Cobb angles (thoracic proximal and distal), segmental kyphosis, total kyphosis, lumbar lordosis, pelvic incidence, sacral slope, and pelvic tilt. RESULTS: The Cobb angle averaged 51.3∘± 14.9∘. Post-surgery, there were significant reductions for the following spine measurement parameters: Cobb angle thoracic proximal (p= 0.003); Cobb angle thoracic distal (p= 0.001); Cobb angle lumbar (p= 0.001); kyphosis (T5-T12, p= 0.012); and kyphosis (T1-T12, p= 0.002). These reductions showed the effectiveness of surgical correction to reduce Cobb angles and improve thoracic kyphosis. The values obtained for lumbar lordosis, pelvic incidence, sacral slope, and pelvic tilt were not significantly different pre- and post-surgery. CONCLUSION: The surgical technique of DVR in AIS proved to be effective in the coronal and sagittal parameters directed at Cobb angles and thoracic kyphosis in order to favor the rehabilitation process.

Machine Learning Predicts the 3D Outcomes of Adolescent Idiopathic Scoliosis Surgery Using Patient-Surgeon Specific Parameters.

STUDY DESIGN: Retrospective descriptive, multicenter study. OBJECTIVE: The aim of this study was to predict the three-dimensional (3D) radiographic outcomes of the spinal surgery in a cohort of adolescent idiopathic scoliosis (AIS) as a function preoperative spinal parameters and surgeon modifiable factors. SUMMARY OF BACKGROUND DATA: Current guidelines for posterior spinal fusion surgery (PSF) in AIS patients are based on two-dimensional classification of the spinal curves. Despite the high success rate, the prediction of the 3D spinal alignment at the follow-ups remains inconclusive. A data-driven surgical decision-making method that determines the combination of the surgical procedures and preoperative patient specific parameters that leads to a specific 3D global spinal alignment outcomes at the follow-ups can lessen the burden of surgical planning and improve patient satisfaction by setting expectations prior to surgery. METHODS: A dataset of 371 AIS patients who underwent a PSF with two-year follow-up were included. Demographics, 2D radiographic spinal and pelvic measurements, clinical measurements of the trunk shape, and the surgical procedures were collected prospectively. A previously developed classification of the preoperative global 3D spinal alignment was used as an additional predictor. The 3D spinal alignment (vertebral positions and rotations) at two-year follow-up was used as the predicted outcome. An ensemble learner was used to predict the 3D spinal alignment at two-year follow-up as a function of the preoperative parameters with and without considering the surgeon modifiable factors. RESULTS: The preoperative and surgical factors predicted three clusters of 3D surgical outcomes with an accuracy of 75%. The prediction accuracy decreased to 64% when only preoperative factors, without the surgical factors, were used in the model. Predictor importance analysis determined that preoperative distal junctional kyphosis, pelvic sagittal parameters, end-instrumented vertebra (EIV) angulation and translation, and the preoperative 3D clusters are the most important patient-specific predictors of the outcomes. Three surgical factors, upper and lower instrumented vertebrae, and the operating surgeon, were important surgical predictors. The role of surgeon in achieving a certain outcome clusters for specific ranges of preoperative T10-L2 kyphosis, EIV angulation and translation, thoracic and lumbar flexibilities, and patient's height was significant. CONCLUSION: Both preoperative patient-specific and surgeon modifiable parameters predicted the 3D global spinal alignment at two-year post PSF. Surgeon was determined as a predictor of the outcomes despite including 20 factors in the analysis that described the surgical moves. Methods to quantify the differences between the implemented surgeon modifiable factors are essential to improve outcome prediction in AIS spinal surgery.Level of Evidence: 3.

Concurrent Validity of Digital Image-based Postural Assessment as a Method for Measuring Thoracic Kyphosis: A Cross-Sectional Study of Healthy Adults.

OBJECTIVE: To analyze the concurrent validity of the Digital Image-based Postural Assessment (DIPA) method for identifying the magnitude and classification of thoracic kyphosis in adults. METHODOLOGY: On the same day and in the same place, thoracic kyphosis was assessed in 68 adults using 2 methods: the DIPA software protocol and radiography. The DIPA software provided angular values of thoracic kyphosis based on trigonometric relations, while with the radiograph, the curvature was calculated using the Cobb method. The following tests were applied in the statistical analysis: Pearson's correlation, Bland-Altman's graphic representation, root mean square error, and receiver operating characteristic (ROC) curve; α = 0.05. The reference angular values for the standard thoracic posture used in DIPA were determined with the ROC curve based on the Cobb angles. RESULTS: The correlation between the angles obtained for thoracic kyphosis using the DIPA and Cobb methods was found to be high (r = 0.813, P < .001), and the accuracy was ±4°. According to Bland-Altman's representation, the magnitudes provided by the DIPA software were in agreement with those of the Cobb method. In reference values for determining the standard posture of the thoracic spine, the ROC curve indicated good accuracy in diagnosing a decrease in thoracic kyphosis (with a value of 33.9°) and excellent accuracy in diagnosing thoracic hyperkyphosis (with a value 39.9°) when using DIPA. CONCLUSION: The DIPA postural assessment method is valid in the sagittal plane for identifying the magnitude of thoracic kyphosis in adults. Furthermore, it is accurate in diagnosing alterations in thoracic kyphosis.

Intraoperative Prone Radiographs During Scheuermann Kyphosis Correction Closely Estimate Standing Thoracic and Lumbar Parameters at 2 Years.

BACKGROUND: In patients with Scheuermann kyphosis (SK) undergoing posterior spinal fusion with instrumentation (PSFI), intraoperative lateral radiographs assess deformity correction in the prone position. The relationship between thoracic and (partially un-instrumented) lumbar parameters on prone intraoperative versus standing postoperative radiographs is unknown. METHODS: Forty-five consecutive patients with SK who underwent PSFI between 2007 and 2014 were reviewed. Thoracic kyphosis (TK), lumbar lordosis (LL), instrumented level kyphosis [upper instrumented vertebrae (UIV)-lower instrumented vertebrae (LIV)], and traditional sagittal parameters were recorded from preoperative standing, intraoperative prone, first outpatient standing, and >2-year standing radiographs and time periods were compared. Exclusion criteria included reduction modification after intraoperative radiographs and postoperative construct revision prohibiting comparison to initial intraoperative radiographs. RESULTS: Twenty-five patients averaging 16 (12 to 20) years old during surgery with 3.1 (2 to 7) years follow-up met inclusion criteria. Average surgical variables included: 13±1 fusion levels, UIV at T2, LIV at L3, 3.8±1.6 osteotomies per patient, and 43±9% correction of TK. Preoperative TK and LL measured 82 and 76 degrees, respectively. TK on intraoperative (47 degrees), 6-week (49 degrees), and >2-year (50 degrees) radiographs changed significantly only between intraoperative and >2-year radiographs (P=0.03) by just 3 degrees. LL increased 5 degrees from intraoperative prone to 6-week standing radiographs (51 to 56 degrees, P=0.01) without further significant change at >2 years (59 degrees, P=0.09). Instrumented levels (UIV-LIV) had increased kyphosis at 6 weeks (32 to 35 degrees, P=0.01) without further change at >2 years (36 degrees, P=0.06). CONCLUSIONS: TK on intraoperative prone radiographs during PSFI for SK should match the standing TK ∼6 weeks later. Intraoperative prone LL only slightly increases on early standing radiographs. Assuming a routine postoperative course, intraoperative radiographs slightly underestimate TK (by 3 degrees) and LL (by 8 degrees) on >2-year standing radiographs. These parameters (TK, LL, UIV-LIV) are visualized during surgery and should be used in future studies to predict long-term outcomes. LEVEL OF EVIDENCE: Level IV-retrospective study.

Idiopathic Ventral Spinal Cord Herniation: Video Report and Systematic Review.

BACKGROUND: Idiopathic ventral spinal cord herniation (ISCH) is a rare disease; however, it is an important differential diagnosis. Its treatment presents some controversies. CASE DESCRIPTION: We report on a 55-year-old woman who had been presenting with relevant back pain and leg weakness for the past 3 years and urinary incontinence for the past 3 months. Clinical examination disclosed paresis on the right inferior limb and right foot, as well as a T6-level painful hypoesthesia. Magnetic resonance imaging disclosed a T4/T5 ISCH. The patient underwent surgical decompression. During the procedure, we opened the arachnoid and cut the dentate ligaments of the spine, which considerably improved the mobility and safety of the procedure. In the early follow-up, our patient presented a partial improvement regarding the paresis grades and hypoesthesia pain relief on the left side. A video showing the surgical procedure and case evolution is presented. We also assembled literature reviews to compare our case with others. ISCH is becoming a more recognized cause of progressive thoracic myelopathy. However, this condition is still frequently misdiagnosed. Magnetic resonance imaging is the key for diagnosis. The objective of surgical treatment is to prevent myelopathy progression. The technique presented in this report is an appropriate surgical option, once it is a safer way to identify and treat the defect. The neurologic condition usually improves greatly after surgical treatment, especially when the patient presents positive predictive factors. CONCLUSIONS: ISCH is being more recognized. The technique presented is an appropriate surgical option.

A magnetic resonance imaging study of local anesthetic spread in patients receiving an erector spinae plane block.

PURPOSE: Despite the popularity of the erector spinae plane (ESP) block, both the mechanism of the block and the extent of injectate spread is unclear. This study used magnetic resonance imaging (MRI) to evaluate the spread of local anesthetic injectate following ESP blocks in six patients with pain. METHODS: Six patients received a left-sided ultrasound-guided ESP block at the T10 level. The injectate contained 29.7 mL of 0.25% bupivacaine and 0.3 mL of gadolinium in the first patient, with an additional 5 mL (50 mg) of triamcinolone in the subsequent five patients. Sensory block to pinprick and cold as well as pain score (with 0 indicating no pain and 10 being maximum pain) were assessed 20 and 30 min respectively following the ESP block. MRI was performed one hour after the block. RESULT: The injectate spread into the intercostal space and neural foramina in all six patients, but the extent of cephalocaudal spread was variable, with a median [interquartile range] spread of 9 [5-11] and 3 [2-6] levels for the intercostal space and neural foramina, respectively. The injectate also spread extensively within the erector spinae muscles. Spread to the epidural space was seen in two patients. Sensory block was achieved in both ventral and dorsal dermatomes in all patients, though the extent was variable. CONCLUSIONS: Our study showed that the ESP block injectate consistently spread to the erector spinae muscles, neural foramina, and intercostal space. It was associated with sensory changes and pain relief in the dorsal and ventral thoracic and abdominal walls. Nevertheless, the extent of spread to the neural foramina and intercostal space, and the sensory block itself, was highly variable.

RéSUMé: OBJECTIF: Malgré la popularité du bloc plan des érecteurs du rachis (PER), le mécanisme du bloc et l'ampleur de la diffusion du produit injecté ne sont pas clairement connus. Cette étude a utilisé l'imagerie par résonance magnétique (IRM) pour évaluer la diffusion de l'anesthésique local injecté après des blocs du PER chez six patients présentant des douleurs. MéTHODES: Six patients ont reçu un bloc du PER guidé par échographie du côté gauche au niveau T10. Le produit injecté contenait 29,7 mL de bupivacaïne 0,25 % et 0,3 mL de gadolinium pour le premier patient avec un supplément de 5 mL (50 mg) de triamcinolone pour les cinq patients suivants. Le bloc sensitif au toucher/piquer et au froid, ainsi que le score de douleur (où 0 indique une absence de douleur et 10, une douleur maximum) ont été évalués respectivement 20 et 30 minutes après le bloc du PER. Une IRM a été réalisée une heure après le bloc. RéSULTAT: Le produit injecté a diffusé dans l'espace intercostal et les foramens intervertébraux chez les six patients, mais l'étendue de la diffusion céphalocaudale a été variable avec une diffusion médiane [plage interquartile] de 9 [5 à 11] niveaux pour les espaces intercostaux et 3 [2 à 6] niveaux pour les foramens intervertébraux. Le produit injecté a également largement diffusé dans les muscles érecteurs du rachis. Une diffusion vers l'espace épidural a été observée chez deux patients. Un bloc sensitif des dermatomes ventraux et dorsaux a été obtenu chez tous les patients, bien que son étendue ait été variable. CONCLUSIONS: Notre étude a montré que le produit injecté dans un bloc du PER diffusait constamment dans les muscles érecteurs du rachis, les foramens intervertébraux et les espaces intercostaux. Il a été associé à des modifications sensorielles et à un soulagement de la douleur dans les parois thoraciques et abdominales, ventrales et dorsales. Néanmoins, l'étendue de la diffusion vers les foramens intervertébraux et les espaces intercostaux, ainsi que le bloc sensitif proprement dit ont été très variables.

MRI-detected spinal disc degenerative changes in athletes participating in the Rio de Janeiro 2016 Summer Olympics games.

OBJECTIVE: To describe the frequency and the distribution of degenerative disc disease (DDD) detected in athletes who underwent spine MRI in the 2016 Summer Olympic Games in Rio de Janeiro. METHODS: Data on spine MRI examinations from the 2016 Summer Olympics were retrospectively analyzed. We assessed the frequency of DDD of the cervical (Cs), thoracic (Ts), and lumbar (Ls) spine using Pfirrmann's classification. Grade II and III were considered as mild, grade IV as moderate, and grade V as severe disc degeneration. Data were analyzed according to the location of the degenerative disc, type of sport, age-groups, and gender of the athletes. RESULTS: One hundred out of 11,274 athletes underwent 108 spine MRI's (21 C, 6 T, and 81 L) (53% Females (F), 47% Males (M)). The frequency of DDD was 40% (42% F, 58% M) over the entire spine (28% mild, 9% moderate and 3% severe). There were 58% (12%F, 88%M) of the cervical spine discs that showed some degree of degeneration (44% mild, 13.5% moderate and 1% severe). Athletics, Boxing, and Swimming were the sports most affected by DDD in the Cs. There were 12.5% of the thoracic discs that showed some degree of degeneration, all were mild DDD and were exclusively seen in female athletes. There were 39% (53% F, 47% M) of the lumbar discs with DDD (26% mild, 9% moderate, and 4% severe). CONCLUSION: Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of DDD of cervical and lumbar spines. Recognition of these conditions is important to develop training techniques that may minimize the development of degenerative pathology of the spine.

Thoracic idiopathic spinal cord herniation in a young patient: a diagnostic and therapeutic challenge.

Idiopathic Spinal Cord Herniation (ISCH) is considered to be a rare cause of Thoracic Myelopathy. It is secondary to the gliding of the Spinal Cord through an anterior dural defect, without a completely defined cause. We present a case of ISCH which, even though was in its usual location, developed in a woman at a younger age than expected. The patient was 20 years old when diagnosed with Brown-Séquard Syndrome. MRI showed herniation at T4-T5 level, which was corrected using a posterior approach to expose the dural defect, reduce the herniation and place a heterologous graft. Postoperatively, neurological function improved, and adequate reduction was seen on imaging. Given the reports of recurrence and deterioration that have been seen after 18 months, follow-up was prolonged for a total of 2 years. We consider postoperative MRI performance important to establish the degree of reduction and alignment of the Spinal Cord.

[Klippel-Feil autosomal dominant syndrome: A malformation of vertebral segmentation]. / Síndrome de Klippel-Feil autosómico dominante: Una malformación de segmentación vertebral.

INTRODUCTION: Klippel-Feil syndrome is a highly heterogeneous complex skeletal disorder characterized by the con genital fusion of two or more cervical vertebrae. The classic clinical triad consists of a short neck, low hairline, and neck movements limitation. The associated mutations are located in the loci of the GDF3 gene (chromosome 12p13.31), GDF6 (chromosome 8q22.1), and MEOX1 (chromosome 17q21.31). OBJECTIVE: To describe the clinical-radiological findings and pedigree of a patient with Klippel-Feil syndrome. CLINICAL CASE: A 5-year-old patient with short neck, low posterior hairline, and limitation of lateral movements. The cervical flexion and extension radiographs showed fusion blocks between C1-2-3, C4-5, and C6-7. The chest CT scan showed multiple hemivertebrae in the upper third of the thoracic vertebrae corresponding to ribs I-IV. The karyotype was normal, 46, XX. Reduced penetrance was present in five of the family members. The fusion of C2-3 was present in four members and one individual had low fusion in C5-6. Three of the five affected individuals had a fusion between the capitate and the hamate bone. CONCLUSION: The malformation of congenital vertebral segmentation is a case of interest since it is an uncommon diagnosis in the pediatric age and whose clinical suspicion can be generated from the clinical examination, radiological study com plemented with the pedigree interpretation in Mendelian inheritance disorders, allowing to provide opportunely genetic counseling to the family.