IMPACT OF THE COVID-19 PANDEMIC ON SPINE SURGERY IN A TERTIARY HEALTH CARE INSTITUTION.

Objectives: To assess postoperative complications, including COVID-19 infection, among patients undergoing surgeries at a tertiary institution during the pandemic, and to develop a local epidemiological profile of spine surgery patients. Methods: Retrospective descriptive study of all patients who underwent spine surgery between March 2020 and 14 January 2021 in a tertiary institution in Latin America. All patients who underwent spine surgery were included, without age restrictions. The main outcomes were postoperative complications, including COVID-19 infection. Results: 74 patients were included in the study, 43 males and 31 females. The average age was 49.6 years. The mean duration of hospitalization was 11.5 days. Urgent surgeries were performed in 60.81% of cases. During hospitalization, only 5 of 74 patients were diagnosed with COVID-19, and only 1 patient had pulmonary involvement estimated to be greater than 50%. On average, 1.9 surgical debridements were required after postoperative surgical site infection. Conclusions: During the hospitalization period, only 6.7% of patients were diagnosed with COVID-19 infection. The COVID-19 infection death rate was 1 in 5 cases. The postoperative surgical site infection rate was 10.8%, similar to the level before the pandemic. Level of Evidence IV; Observational retrospective descriptive study .

Objetivos: Avaliar complicações pós-cirúrgicas, incluindo infecções por COVID-19, entre pacientes cirúrgicos numa instituição terciária de saúde durante a pandemia, e desenvolver um perfil epidemiológico local de pacientes de cirurgias da coluna. Métodos: estudo descritivo e retrospectivo de todos os pacientes que passaram por cirurgias da coluna entre março de 2020 e 14 de janeiro de 2021, numa instituição terciária na América Latina. Todos os pacientes que passaram por cirurgias na coluna foram incluídos, sem restrição de idade. Os principais resultados foram complicações pós-cirúrgicas, incluindo a infecção por COVID-19. Resultados: 74 pacientes foram incluídos no estudo, 43 do sexo masculino e 31 do feminino. A média de idade foi de 49.6 anos. A duração média da hospitalização foi de 11.5 dias. Cirurgias urgentes foram realizadas em 60.81% dos casos. Durante a hospitalização, apenas 5 dos 74 pacientes foram diagnosticados com COVID-19, e apenas 1 deles teve envolvimento pulmonar estimado em mais que 50%. Em média, 1,9 desbridamentos cirúrgicos foram necessários após infecção do sítio cirúrgico. Conclusões: Durante o período de hospitalização, apenas 6,37% dos pacientes foram diagnosticados com infeção por COVID-19. A taxa de mortes devido à infecção por COVID-19 foi de 1 em 5. Infecções do sítio cirúrgico atingiram uma taxa de 10.8%, nível similar àquele prévio à pandemia. Nível de evidência IV ; Estudo observacional retrospectivo descritivo .

ROTATION ASSESSMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS WITH ROD DEROTATION.

OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is characterized by rotational and lateral deformity of the spine. The measurement of vertebral rotation is important for prognosis and treatment. Our objective was to evaluate whether the Nash-Moe method can be used to measure axial deformity correction with surgical treatment using the rod derotation maneuver at both the apex and extremities of the deformity in patients with AIS. METHODS: Rotation was assessed using the Nash and Moe criteria, on preoperative and postoperative radiographs. We also evaluated the severity on the coronal plane using the Cobb method, ratio of correction achieved, screw density, and number of vertebrae involved in the instrumentation. RESULTS: The Cobb method correction average was 54.8%. When we disregarded vertebrae that presented preoperative Nash-Moe grade 0, the average measurable correction was 54.5% in the first non-instrumented vertebra above, 69.2% in the first instrumented vertebra, 32.2% in the apical vertebra, 36.8% in the last instrumented vertebra, and 30% in the first non-instrumented vertebra below. In our study, 32.14% of the patients presented a measurable correction in the apical vertebra. CONCLUSION: On the axial plane, correction can be satisfactorily evaluated using the Nash-Moe method. Level of Evidence VI. Case Series.

OBJETIVO: A escoliose idiopática do adolescente é caracterizada por deformidade rotacional e lateral da coluna vertebral. A medição da rotação vertebral é importante para o prognóstico e tratamento. Nosso objetivo foi avaliar se o método de Nash-Moe pode ser usado para medir a correção da deformidade axial com o tratamento cirúrgico usando a manobra de derotação em ambos os ápices e extremidades da deformidade em pacientes com EIA. MÉTODOS: A rotação foi avaliada usando os critérios de Nash e Moe em radiografias pré e pós-operatórias. Também avaliamos a severidade no plano coronal pelo método de Cobb, a razão de correção alcançada, a densidade do parafuso e o número de vértebras envolvidas na instrumentação. RESULTADOS: A correção do método de Cobb foi de 54,8%. Quando desconsideramos vértebras que apresentavam grau 0 no pré-operatório de Nash-Moe, encontramos, em média, 54,5% de correção mensurável na primeira vértebra não instrumentada acima, 69,2% na primeira vértebra instrumentada, 32,2% na vértebra apical, 36,8% na última vértebra instrumentada e 30% na primeira vértebra não instrumentada abaixo. Em nosso estudo, ٣٢,١٤٪ dos pacientes apresentaram uma correção mensurável na vértebra apical. CONCLUSÃO: No plano axial, a correção pode ser avaliada satisfatoriamente pelo método de Nash-Moe. Nível de Evidência VI. Série de casos.

SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS.

OBJECTIVE: The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver. STUDY DESIGN: Report of a case series with description of a new surgical technique. METHODS: The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used. RESULTS: In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively). CONCLUSION: The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.

OBJETIVO: O propósito do estudo foi demonstrar, por meio de uma série de casos, uma nova técnica de sacrectomia com uso de enxerto encavilhado da crista ilíaca de cadáver. DESENHO DO ESTUDO: Relato de série de casos com descrição de uma nova técnica cirúrgica. MÉTODOS: A técnica usa quatro barras para sustentação da parte posterior da coluna e um enxerto encavilhado nas asas do ilíaco, com compressão da coluna e pelve sobre ele, para suporte da parte anterior da coluna. Foram operados três casos e em todos eles, realizou-se vertebrectomia. RESULTADOS: Nos dois primeiros casos, a técnica foi utilizada em duas etapas. A primeira etapa foi realizada por via anterior e acesso peritoneal, e a segunda etapa, por via posterior. No terceiro caso, o acesso retroperitoneal por via anterior significou que a técnica pôde ser realizada em apenas uma etapa, resultando em redução do tempo cirúrgico total (1250 x 1750 x 990 minutos, respectivamente). CONCLUSÃO: A nova técnica permite a fixação com estabilidade biomecânica, que é essencial para suportar a tensão na transição lombossacral e para a reabilitação precoce. Nível de evidência IV, série de casos.

FOUR-LEVEL EN BLOC VERTEBRECTOMY: A NOVEL TECHNIQUE AND LITERATURE REVIEW.

OBJECTIVE: To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction. METHODS: A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital. RESULTS: The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient. CONCLUSION: The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

OBJETIVO: Demonstrar uma nova técnica de reconstrução por vertebrectomia em bloco multinível. MÉTODOS: Descrição de uma reconstrução pós-vertebrectomia em bloco multinível, em paciente tratado num hospital oncológico público universitário, com indicação de ressecção curativa de sarcoma de Ewing. RESULTADOS: O procedimento proposto foi viável para a ressecção em bloco de quatro vértebras e a reconstrução foi aceitável e satisfatória em termos de estabilidade mecânica, sem causar dano neurológico ao paciente. CONCLUSÃO: O uso de aloenxerto com parafuso intramedular bloqueado é uma solução adequada para a reconstrução da coluna anterior e medial após vertebrectomias multiníveis. Além disso, a associação de quatro parafusos intramedulares dá estabilidade à reconstrução. Benefícios imediatos da técnica são o tempo de hospitalização mais curto e a redução da morbidade cirúrgica, em comparação com outras técnicas, comumente utilizadas. Nível de Evidência V, Estudo clínico de nova técnica cirúrgica e revisão da literatura.

COMPLICATED LUMBAR TUBERCULOUS SPONDYLODISCITIS IN DISSEMINATED TUBERCULOSIS, TREATED USING A NON-CONVENTIONAL ANTERIOR SUPPORT SYSTEM FOR HYDROSTATIC DISTRACTION: A CASE REPORT.

OBJECTIVE: To describe a case of disseminated tuberculosis affecting the lumbar spine that was treated using a non-conventional anterior support system. BACKGROUND: Tuberculous spondylodiscitis is the most common and most severe form of extrapulmonary tuberculosis. Although antibiotic therapy is the most frequently used treatment, surgery is necessary in cases of neurological deficit, spinal instability, significant deformity, severe sepsis, paravertebral and epidural abscesses or in cases wherein clinical treatment has failed. A surgical procedure is also indicated when a biopsy is required. With the development of new methods for reconstruction and fixation of the spine, complete debridement of the tuberculous foci has become an increasingly common approach, but there is a lack consensus on the best technique. METHODS AND RESULTS: The patient suffered from disseminated tuberculosis affecting the lumbar region of the spine, with an abscess in the psoas muscle. He underwent extensive debridement via both anterior and posterior approaches, using a non-conventional anterior support system that promotes hydrostatic distraction. CONCLUSIONS: Treatment using the hydrostatic distraction system was able to reestablish both the stability and anatomy of the lumbar curve. Level of evidence IV, Case report.

OBJETIVO: Descrever um caso de tuberculose disseminada afetando a coluna lombar, tratada com um sistema de suporte anterior não convencional. CONTEXTO: Espondilodiscite tuberculosa é a forma mais comum e mais grave de tuberculose extrapulmonar. Embora o principal tratamento seja a antibioticoterapia, o tratamento cirúrgico é importante em casos de déficit neurológico, instabilidade da coluna e deformidade significativa, sepse grave, abscessos paravertebrais ou peridurais ou em casos de falha do tratamento clínico. Cirurgia também é necessária quando há necessidade de biópsia. Com o desenvolvimento de novos métodos para a reconstrução e fixação da coluna, cada vez mais se faz o debridamento completo do foco da tuberculose vertebral, mas há falta de consenso sobre a melhor técnica. MÉTODOS E RESULTADOS: O paciente sofria de tuberculose disseminada afetando a coluna, na região lombar, com abscesso do músculo psoas. Foi tratado com extenso debridamento pelas vias anterior e posterior, usando um sistema não convencional de suporte anterior que promove distração hidrostática. CONCLUSÕES: O tratamento com o distrator hidrostático foi capaz de restabelecer a estabilidade e a anatomia da curva lombar. Nível de evidência IV, Relato de caso.

Correlation between the degree of correction of neuromuscular scoliosis and patient quality of life.

OBJECTIVE:: There are few data on patient satisfaction with surgery for the correction of neuromuscular scoliosis or on the correlation between patient satisfaction and the degree of curve correction achieved by surgery. Our aim was to determine the correlations between both patient satisfaction and perception of quality of life and the degree of curve correction. METHODS:: We interviewed 18 patients and administered a questionnaire that collected social and economic data and information about functional ability, comorbidities and satisfaction. Statistical analysis was performed using chi-square tests, Pearson correlation and paired t-tests. RESULTS:: The mean correction achieved was 42.8%, i.e., 34.17 degrees. Early and late complication rates were low (11.1% each). Almost all of the patients (94.4%) were satisfied with the surgery, and expectations were met for 61.1% of them. Quality of life and aesthetics were improved in 83.4% and 94.4% of cases, respectively. No correlation was found between satisfaction and degree of correction. CONCLUSION:: Our surgical results are similar to those of other studies with respect to the degree of correction and patient satisfaction. The disparity between satisfaction and fulfillment of expectations may be due to unrealistic initial expectations or misunderstanding of the objective of surgery. Our findings corroborate the hypothesis that satisfaction is multifactorial and not restricted to a quantitative goal. The satisfaction of patients who undergo operation for neuromuscular scoliosis does not depend directly on the degree of deformity correction. The relationship between satisfaction and the success of the correction procedure is complex and multifactorial.

Effects of ganglioside G(M1) and erythropoietin on spinal cord lesions in rats: functional and histological evaluations.

OBJECTIVE: To evaluate the functional and histological effects of ganglioside G(M1) and erythropoietin after experimental spinal cord contusion injury. METHODS: Fifty male Wistar rats underwent experimental spinal cord lesioning using an NYU-Impactor device and were randomly divided into the following groups, which received treatment intraperitoneally. The G(M1) group received ganglioside G(M1) (30 mg/kg); the erythropoietin group received erythropoietin (1000 IU/kg); the combined group received both drugs; and the saline group received saline (0.9%) as a control. A fifth group was the laminectomy group, in which the animals were subjected to laminectomy alone, without spinal lesioning or treatment. The animals were evaluated according to the Basso, Beattie and Bresnahan (BBB) scale, motor evoked potential recordings and, after euthanasia, histological analysis of spinal cord tissue. RESULTS: The erythropoietin group had higher BBB scores than the G(M1) group. The combined group had the highest BBB scores, and the saline group had the lowest BBB scores. No significant difference in latency was observed between the three groups that underwent spinal cord lesioning and intervention. However, the combined group showed a significantly higher signal amplitude than the other treatment groups or the saline group (p<0.01). Histological tissue analysis showed no significant difference between the groups. Axonal index was significantly enhanced in the combined group than any other intervention (p<0.01). CONCLUSION: G(M1) and erythropoietin exert therapeutic effects on axonal regeneration and electrophysiological and motor functions in rats subjected to experimental spinal cord lesioning and administering these two substances in combination potentiates their effects.

Electromyographic study of the masseter muscle after low-level laser therapy in patients undergoing extraction of retained lower third molars / Estudio electromiográfico del músculo masetero tras terapia con láser de baja intensidad en pacientes sometidos a extracción de tercer molar mandibular retenido

The surgery for extraction of the retained lower third molar is one of the most commonly performed procedures in the field of maxillofacial surgery. During this procedure, the surgical trauma can cause damage to the function of muscles involved in mandibular movements, such as the masseter muscle. In order to accelerate post-surgical recovery, many physiotherapy resources are employed, including laser therapy. The aim was to analyze the electrical activity of the masseter muscle treated with Low-level Laser (LLL) after surgical trauma. Assessments of masseter muscle on a sample of 60 patients were performed by surface electromyography in four instances: immediate preoperative, postoperative at 7, 14 and 21 days. The patients were divided into two groups: 1- untreated group with LLL in the postoperative; 2- group treated with LLL (810 nm; 10 J/cm2) in the immediate postoperative and at 3, 6 and 9 days after surgery. On the seventh day after surgery 23.3 % of the patients in the group receiving LLL showed recovery of their muscle activity as they presented in the immediate preoperative, versus only 3.3 % of the untreated group. On the 14th day, 73.3% of treated patients showed functional rehabilitation, versus 6.7% in the untreated group, and on the 21st, 80% versus 10% in the untreated group. On the 14th postoperative day the electrical activity of the masseter muscle treated with LLL after surgical trauma was compatible with a condition of complete functional recovery. The findings of this electromyographic study indicated that LLL proved to be an efficient physiotherapeutic method for stimulating the masseter muscle functional recovery after surgery of retained lower third molars.

La cirugía para extracción del tercer molar mandibular retenido es uno de los procedimientos más realizados en el campo de la cirugía maxilofacial. Durante este procedimiento, el trauma quirúrgico puede causar daño a la función de los músculos involucrados en los movimientos mandibulares, entre ellos el músculo masetero. Con el objetivo de acelerar la recuperación postoperatoria, son utilizados muchos recursos de fisioterapia, incluyendo la terapia con láser. El objetivo de este estudio fue analizar la actividad eléctrica del músculo masetero tratado con láser de baja intensidad (LBI) después del trauma quirúrgico. Se realizaron evaluaciones del músculo masetero en una muestra de 60 pacientes, a través de electromiografía de superficie en cuatro momentos: preoperatorio inmediato, postoperatorio a los 7, 14 y 21 días. Los pacientes fueron divididos en dos grupos: 1 - grupo no tratado con LBI en el postoperatorio; 2 - grupo tratado con LBI (810 nm; 10 J/cm2) en el postoperatorio inmediato y a los 3, 6 y 9 días tras cirugía. Al séptimo día tras cirugía el 23,3 % de los pacientes del grupo tratado con LBI presentaron recuperación de su actividad muscular equivalente a lo presentado en el preoperatorio inmediato, frente a sólo el 3,3 % del grupo no tratado. En el día 14, el 73,3% de los pacientes tratados presentaron rehabilitación funcional, frente al 6,7% del grupo no tratado y en el vigésimo primer día, el 80% frente al 10% del grupo no tratado. En el dia 14 postoperatorio la actividad eléctrica del músculo masetero tratado con LBI después del trauma quirúrgico fue compatible con una condición de recuperación funcional completa. Los hallazgos de este estudio electromiográfico indicaron que el LBI es un eficiente método fisioterápico para estimular la recuperación funcional del músculo masetero tras cirugía de terceros molares mandibulares retenidos.

A computerized system for the application of Basso, Beattie and Bresnahan scale in Wistar rats.

OBJECTIVES: To develop and test a computer program to assist researchers in assigning scores in the application of the Basso, Beattie and Bresnahan (BBB) scale and to compare these scores when doing so in free, targeted and automated computer-assisted modes. METHOD: To test the program, the participants used the Impactor methodology recommended by the New York University (USA), in which 12 Wistar rats submitted to spinal cord injury were filmed on the 28(th) day after the injury. Eight researchers from the Laboratory of Medical Investigation, Faculdade de Medicina da Universidade de São Paulo, SP, Brazil took part in the study. The two heads of the laboratory, with 15 years of experience in the application of the scale, were considered the gold standard. RESULTS: The results of the scale application were not significantly different in relation to the gold standard, considering the mean of the evaluators in each method: free, targeted and automated form (with the help of the computer). CONCLUSIONS: The application of the BBB scale in the automated mode, using the computer program, did not present any difference in relation to the gold standard for all the evaluators. Level of Evidence II, Diagnostic Studies.

Late failure of posterior fixation without bone fusion for vertebral metastases.

OBJECTIVE: : To verify the frequency of late radiological com-plications in spinal fixation surgeries performed without fu-sion in oncological patients. METHODS: : This is a retrospective analysis analysing failure in cases of non-fused vertebral fixation in an oncology reference hospital between 2009 and 2014. Failure was defined as implant loosening or bre-akage, as well as new angular or translation deformities. RESULTS: : One hundred and five cases were analyzed. The most common site of primary tumor was the breast and the most common place of metastasis was the thoracic spine. The average follow-up was 22.7 months. Nine cases (8%) of failure were reported, with an average time until failure of 9.5 months. The most common failure was implant loosening. No case required further surgery. CONCLUSION: : The occurrence of failure was not different than that reported for fused cases. The time interval until failure was higher than the median of survival of the majority (88%) of cases. Level of Evidence IV, Therapeutic Study.

Epidemiological study of cauda equina syndrome.

OBJECTIVE: : The primary purpose of this study was to determine the characteristics and outcomes of the patients admitted at our clinics diagnosed with cauda equina syndrome (CES). Secondarily, this study will serve as a basis for other comparative studies aiming at a better understanding of this condition and its epidemiology. METHODS: : We conducted a retrospective study by reviewing the medical records of patients diagnosed with CES and neurogenic bladder between 2005 and 2011. The following variables were analyzed: gender, age, etiology, topographic level of the lesion, time between disease onset and diagnosis, presence of neurogenic bladder, time between diagnosis and surgery, neurological damage and neurogenic bladder persistence. RESULTS: : Considering that CES is a rare condition, we were not able to establish statistic correlation between the analyzed variables and the outcomes of the disease. However, this study brought to light the inadequacy of our public health system in treating that kind of patient. CONCLUSION: : The study shows that despite the well-defined basis for managing CES, we noted a greater number of patients with sequels caused by this condition, than is seen in the literature. The delayed diagnosis and, consequently, delayed treatment, were the main causes for the results observed. Level of Evidence IV, Case Series .

Tomographic correlation of the Magerl technique for C1-C2 arthrodesis in rheumatoid arthritis.

OBJECTIVE: To use the tomographic analysis of C1 and C2 vertebrae to assess the possibility of using Magerl's technique in patients with rheumatoid arthritis. Other objectives were to obtain anatomical data for the choice of the surgical technique in general, to establish safety parameters and obtain epidemiological data of the population in question. METHODS: We retrospectively reviewed the CT scans of 20 patients with rheumatoid arthritis of the Outpatient Spine Group, IOT-HCFMUSP. Data were analyzed statistically to obtain the mean values and the variance of each measurement: the length of the C2 pedicle to the C1 lateral mass, the thickness of the pedicle and the angle of attack of the screw in the isthmus of C2 to the horizontal. RESULTS: THE MEAN VALUES WERE, RESPECTIVELY: right 23.08 mm and left 23.16 mm, right 6.46 mm and left 6.50 mm, right 44.50(o) and left 44.95(o). DISCUSSION: The leading screw's manufacturers have implants compatible with the anatomical measurements found in this work. Considering the wide diffusion and mastery of Magerl's technique in our country and around the world, this is a safe surgical option that provides mechanical stability. CONCLUSION: Magerl's technique, according to tomographic analysis, can be used in patients with rheumatoid arthritis. Levels of Evidence IV,Case Series.