Surgical management of Chiari II malformation: a systematic review of literature.

PURPOSE: Chiari II malformation (CM-II) is a congenital malformation of the posterior fossa associated with myelomeningocele. Of the symptomatic patients, 10-33% require surgical treatment. To this date, there is not a consensus about the best surgical technique, and whether to do duroplasty. METHODS: A literature search of the PubMed database and crossed references was performed, per PRISMA guidelines. Data regarding demographic features, extent of cervicomedullary deformity, clinical presentation, surgical techniques, and clinical outcomes were extracted. Pearson's chi-squared test was applied. The p-values under 0.05 were considered statistically significant. RESULTS: Twenty studies (N = 330) were analyzed. C3 and C4 levels represented 56.4% of the lowest tonsil displacement. The most reported symptom was dysphagia/swallowing dysfunction (53.8%). Suboccipital craniectomy (SOC) and cervical spine expansion (CSE) with duroplasty were the most reported technique. Dural augmentation was performed in 57.4% of the patients. After surgery, 59.6% observed an improvement in symptoms and quality of life, 12.5% were unchanged, and 27.8% had a worsened clinical status. The mortality rate was 2.5% during the first month after surgery, and 17.4% at the last follow-up evaluation. Patients who underwent CSE presented a better clinical outcome (p = 0.002). The SOC procedure could not be correlated with symptom improvement (p = 0.06). CONCLUSION: CM-II is associated with high morbidity and mortality. An early onset symptomatic CM-II demands intervention, which provided an improvement of outcome in most patients included in this review. The best surgical technique and the exact effect of the surgical management of CM-II on mortality are not yet clear.

Multilevel spinal epidural empyema: series of clinical cases and bibliographic / Empiema epidural espinhal multinível: série de casos clínicos e revisão bibliográfica / Empiema epidural espinal multinivel: serie de casos clínicos y revisión bibliográfica

ABSTRACT: Multilevel spinal epidural empyema (SEE) is a rare and serious infection of the spine with a high rate of morbidity and mortality. Although abscesses or empyema of the spine sector are well studied, this pathology is surprising due to its rarity and diagnostic and therapeutic challenge. It stands out for being more common in adulthood and in males and is associated with predisposing pathologies. The bacteriological agent responsible in most cases is Staphylococcus aureus. Early treatment is essential and is based on two pillars: antibiotic therapy and decompressive surgery. We present two clinical cases with multilevel involvement that evolved favorably both infectiously and neurologically without causing spine instability and we carried out a bibliographic review of the subject. Level of Evidence IV; Case Report.

RESUMO: O empiema epidural espinhal multinível (EEE) e uma infecção rara e grave da coluna vertebral, com alta taxa de morbidade e mortalidade. Embora os abscessos ou empiemas de um setor da coluna vertebral sejam bem estudados, esta patologia surpreende pela sua raridade e desafio diagnóstico e terapêutico. Destaca-se por ser mais comum na idade adulta, no sexo masculino, e estar associada a patologias predisponentes. O agente bacteriológico responsável na maioria dos casos e o Staphylococcus aureus. O tratamento precoce e essencial e baseia-se em dois pilares: antibioticoterapia e cirurgia descompressiva. Apresentamos dois casos clínicos com envolvimento multinível que evoluíram favoravelmente tanto infecciosa quanto neurologicamente sem causar instabilidade da coluna vertebral e realizamos uma revisão bibliográfica do assunto. Nível de Evidencia IV; Estudo de Caso-controle.

RESUMEN: El empiema epidural espinal (EEE) multinivel es una infección rara y grave de la columna vertebral con alta tasa de morbimortalidad. Si bien los abscesos o empiemas de un sector de la columna están bien estudiados, esta patología sorprende por su rareza, reto diagnóstico y terapeutico. Se destaca por ser más frecuente en la edad adulta, en el sexo masculino y se ve asociada a patologías predisponentes. El agente bacteriológico responsable en la mayoría de los casos es el Staphylococcus aureus. El tratamiento precoz es fundamental y está basado en dos pilares: antibioticoterapia y quirúrgico descompresivo Presentamos dos casos clínicos con afectación multinivel que evolucionaron favorablemente tanto en lo infeccioso como en lo neurológico sin provocar una inestabilidad del raquis y realizamos revisión bibliográfica del tema. Nivel de Evidencia IV; Estudio de Caso-control.

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.

Citrobacter koseri: A rare cause of an epidural spinal abscess.

Background: Citrobacter koseri, a Gram-negative organism, rarely causes an epidural spinal abscess. Case Description: A 50-year-old male presented with mild paraparesis attributed to an magnetic resonance (MR)-documented spinal epidural abscess (SEA) at the T10-level. Following surgical debridement, cultures grew C. koseri, a rare Gram-negative organism. The abscess was subsequently managed with a prolonged course of antibiotics resulting in complete symptom and MR-documented radiological resolution. Conclusion: A 50-year-old male presented with a T10 SEA attributed to a rare Gram-negative organism, C. koseri. The abscess was appropriately managed with surgical decompression/debridement, followed by prolonged antibiotic therapy.

Spinal cord occupation ratio (SCOR) and its application in the diagnosis of cervical spinal cord compression in Mucopolysaccharidoses

Abstract Introduction Mucopolysaccharidoses (MPS) can lead to cervical spinal cord compression (SCC). Diagnostic scores for SCC in MPS use the obliteration of the passage of cerebrospinal fluid in the anterior and posterior spinal cord in the sagittal section of magnetic resonance imaging (MRI). The spinal cord occupation ratio (SCOR) published, by Nouri et al (2018), establishes the spinal cord filling index for the spinal cord, identifying disproportionate spinal cord occupation in the canal. When evaluating congenital canal stenosis, the risk of spinal cord injury has been considered increased when the SCOR is ≥70% in the median sagittal plane or ≥ 80% in the axial plane. Although these values ​​have not been validated for MPS populations, they could be useful. Objective To verify the SCOR in MPS patients with diagnosis of cervical SCC comparing the SCOR with other markers proposed in the existing MPS SCC scores, such as the extent of gliosis, clinical impact and the SCC assessment as represented by the obliteration of CSF flow. Methods We reviewed imaging tests of the cervical spine from MPS patients with previously confirmed SCC, using the SCOR measure in the median sagittal plane, evaluation of the presence and extent of spinal gliosis on MRI, evaluation of the clinical impact using a clinical score and evaluation of the images for the obliteration of cerebral spinal fluid (CSF) flow. Results Thirty-one MRI of 24 different patients were included. The average SCOR was 87.1%. This was lower (81.6%) in patients without gliosis, when compared to those with focal (90.5%) and extensive (97%) gliosis. The only patient with gliosis associated with a lacunar lesion, resulting from an acute compressive injury, had a 68% SCOR, due to the atrophic spinal cord injury. As expected, SCOR was higher in patients with total or partial CSF obliteration, but one among the 3 patients without CSF flow obliteration, with a 76% SCOR, had already developed focal gliosis and mild clinical abnormalities. Patients with more extensive gliosis had higher clinical scores. Four patients had more than one imaging scan evaluated. SCOR upward trend showed an annual average increase of 3.8%. Discussion & Conclusions The use of SCOR allows the diagnosis of cervical spinal canal stenosis in an objective way. It is possible that the cut-off values used by Nouri et al in patients with congenital stenosis could be useful to diagnose cervical stenosis in MPS patients, preceding the finding of CSF flow obstruction, presence of gliosis or clinical abnormalities. Furthermore, the use of SCOR may assist in the longitudinal evaluation of disease progression. Better follow-up and timely diagnosis allows for scheduling of surgery at the best clinical moment, minimizing complications.

Fibrosis epidural postquirúrgica: presentación de un caso con enfoque médico legal / Postsurgical epidural fibrosis: presentation of a case with a medical-legal approach

Resumen La fibrosis epidural es un hallazgo clínico y radiológico el cual se encuentra relacionado directamente en su génesis con los procedimientos quirúrgicos realizados en la columna vertebral. Esta patología es la causa más frecuente del síndrome de cirugía fallida de columna, manifestada clínicamente como un dolor equiparable en severidad al presentado previo a la intervención quirúrgica realizada. La fibrosis epidural es parte del proceso de cicatrización usual de los tejidos circundantes de la columna vertebral, en otras palabras, es esperable que esta suceda, sin embargo, solo una mínima cantidad de las personas intervenidas desarrollan clínicamente la sintomatología. La importancia del análisis de esta patología radica en que estas valoraciones son ingresadas al Departamento de Medicina Legal por asunto de reagravación de alguna secuela ocasionada por algún evento traumático. Es imprescindible conocer a profundidad los diferentes aspectos etiológicos, fisiopatológicos, clínicos, radiológicos y terapéuticos que involucran esta patología vertebral, así como, el respectivo análisis médico legal en este tipo de casos, tomando en consideración todos los elementos de juicio que permitan relacionar este hallazgo con algún hecho denunciado. En el presente artículo se realizará un análisis médico legal de un caso de reagravación por fibrosis epidural valorado en el Departamento de Medicina Legal de Costa Rica, donde el peritado interpone una denuncia contra el ente asegurador al ser rechazada la posibilidad de reapertura del riesgo laboral presentado.

Abstract The epidural fibrosis is a clinical and radiological finding that is related with the surgical procedures performed on the spine. This pathology is the most frequent cause of failed back syndrome or post laminectomy syndrome, that is clinically manifested by an acute pain comparable in severity with the surgical intervention. Epidural fibrosis is part of the usual healing process of the surrounding tissues of the spine, in other words, it's to be expected as a result of this procedures, nevertheless, only a small number of people who have been intervened, actually develop the symptoms clinically. The importance of this pathology lies in the fact that these assessments are attended in the Legal Medicine Department due to the aggravation issues of any sequel caused by a traumatic event. It is essential to know such things as the etiology, pathophysiology, clinical manifestations, radiological findings, and the therapeutic aspects that involve this vertebral disease, as well as, the respective forensic analysis, in order to use all the elements of judgment that allows to relate what is documented with the denounced findings.

Reporte de caso: Quiste neuroentérico intradural/extramedular en paciente joven / Case report: Intradural/extramedullary neurenteric cyst in a young patient

Introducción: Los quistes neuroentéricos son lesiones congénitas, benignas, solitarias e infrecuentes del eje espinal, compuestas de tejido endodérmico heterotópico, productos del cierre incompleto del tubo neural. Se presentan, principalmente, en hombres durante la primera y segunda década de vida. Se localizan mayoritariamente en el espacio intradural/extramedular, ventralmente a la médula espinal, a nivel cervical bajo o torácico superior. La sintomatología neurológica depende de la localización del quiste. El diagnóstico presuntivo se realiza con una resonancia magnética, y el definitivo con un estudio histopatológico, llevado a cabo posterior a la exéresis completa o parcial de la muestra, con abordaje posterior, en la mayoría de los casos. Caso: Se describe el caso de una paciente de 35 años, quien tiene antecedente de haber presentado a los 14 años un quiste neuroentérico intradural/extramedular, a nivel cervial bajo. Había debutado con cervicalgia irradiada a miembros superiores e inferiores, radiculopatía, pérdida de la fuerza muscular, e hiperreflexia. Se realizó en ese momento una resonancia magnética, evidenciando una lesión ocupante de espacio en C5 y C6, la cual fue intervenida quirúrgicamente a través de una laminectomía en C5-C6 con abordaje posterior. Se realizó exéresis completa de la misma. El estudio anatomopatológico reportó quiste neuroentérico intradural/extramedular, sin atipias celulares. La evolución posoperatoria de la paciente resultó satisfactoria. Conclusión: Se describe este caso clínico, resaltando su importancia, al tratarse de lesiones sumamente infrecuentes en la literatura médica, con sintomatología poco específica, pudiendo confundirse con otras patologías, y recidivar, incluso después de haberse extraído completamente

Introduction: Neuroenteric cysts are congenital, benign, solitary, and infrequent lesions of the spinal axis, composed of heterotopic endodermic tissue, resulting from an incomplete closure of the neural tube. They mainly occur in men, during the first or second decade of life. Most of these cysts are located in the intradural/extramedullary compartment, ventrally to the spinal cord, especially at the lower cervical or upper thoracic spine. The neurological symptomatology varies depending on the location of the cyst. The presumptive diagnosis is made with magnetic resonance imaging, and the definitive diagnosis is made with a histopathological assessment, which is done after a complete or partial resection of the mass, generally with a posterior approach. Case presentation: We describe the case of a 35-year-old female patient, with the medical history of presenting an intradural/extramedullary neuroenteric cyst, located at the lower cervical level, at the age of 14. She presented cervical pain irradiated to upper and lower limbs, radicular pain, loss of muscular strength, and hyperreflexia. A magnetic resonance imaging was indicated, showing a space-occupying lesion at the C5 and C6 levels, which was surgically intervened through a posterior cervical (C5-C6) laminectomy. A complete resection of this mass was performed. The histopathological assessment reported an intradural/extramedullary neuroenteric cyst, with no cellular atypia. The patient's postoperative progress and development were satisfactory. Conclusion: The objective is to describe this case, highlighting its importance, since these lesions are extremely infrequent in the medical literature, with a non-specific symptomatology, which is why they can be confused with other pathologies, and recur, even after their complete resection.

Cognitive functional therapy (CFT) compared with core training exercise (CTE) in patients with failed back surgery syndrome (FBSS): A study protocol for a randomized controlled trial.

OBJECTIVE: This study aims to investigate the efficacy of cognitive functional therapy (CFT) compared to core training exercise (CTE) on pain and specific disability of patients with failed back surgery syndrome (FBSS). DESIGN: This will be a randomized controlled clinical trial of two groups with blinded evaluators. SETTING: The study will be conducted at the Federal University of Santa Catarina (UFSC) and a private clinic in Florianópolis, SC, Brazil. PARTICIPANTS: A total of 80 participants, of both sexes, with FBSS. INTERVENTION: Subjects will be randomized into two groups: one group receiving CFT or CTE. Individuals will be assisted once a week, for a maximum period of 12 weeks, with four being the minimum number of visits and 12 being the maximum number of visits. MEASUREMENTS: The primary outcomes will be pain and specific disability. CONCLUSIONS: This is the first study investigating whether CFT is efficacious for patients with FBSS and chronic low back pain. The study's sample size was calculated to detect the effect of clinically relevant treatment with a low risk of bias. This clinical trial was designed to be able to reproduce an approach as a physiotherapist trained in CFT would do. That is, in a pragmatic way, increasing the significance of this study. CTE comprises a strategy widely used by physiotherapists to treat low back pain. Given that the scientific evidence of its efficacy for pain management is limited, the findings of this study will assist physiotherapists in their clinical decision-making.

Meningocele sacro anterior gigante y síndrome de Currarino incompleto en paciente adulta: reporte de un caso

Anterior sacral meningocele is a protrusion of the dural sac through a bone defect in the sacrum anterior wall. It can occur in isolation or be associated with other malformations, such as the Currarino syndrome, which is part of the classic triad together with hemisacrum and anorectal malformation, although it has great variability. This is the case of an adult woman with chronic constipation, recurrent urinary infection and marked abdominal distension, diagnosed with giant anterior sacral meningocele and incomplete Currarino syndrome. The patient underwent a sacral laminectomy and thecal sac ligation at the level of the bone defect. This article describes this rare type of occult spinal dysraphism as well as the surgical technique used.

Extradural synovial cyst of the cervical spine in a Saint Bernard

Background: Extradural synovial cysts (ESC) originate from an extrusion of the synovium in unstable or degeneratedjoints. In the spine, this condition can cause neurological signs such as hyperesthesia, proprioceptive ataxia and paresis.Since extradural presentations of synovial cysts are unusual in dogs, the aim of this manuscript is to report a case ofextradural synovial cyst of the cervical spine, as well as the clinical findings, diagnosis, surgical treatment and clinicalevolution after therapy.Case: A 3-year-old spayed Saint Bernard weighing 60 kg was presented to a Veterinary Medical Teaching Hospital with ahistory of acute paraparesis that evolved to non-ambulatory tetraparesis five days after the appearance of the first clinicalsigns. Neurological examination revealed non-ambulatory tetraparesis, normal muscle tone and segmental spinal reflexesin the thoracic and pelvic limbs, as well as cervical pain associated with limited neck movement. According to the neurological examination, the likely lesion location was the C1-C5 spinal cord segment. The differential diagnosis list includedintervertebral disc disease, caudal cervical spondylomyelopathy, neoplasm, infectious or noninfectious inflammatorydisease, and cystic diseases. Complete blood (cell) count and serum biochemistry tests were within reference limits. Thecerebrospinal fluid analysis revealed 35 mg/dL of protein (< 30 mg/dL) and 27 cells (up to 5 cells/mm3) with a predominance of lymphocytes. In plain radiography, bone proliferations of the C4 (caudal) C5 (cranial) articular processes wereobserved and, in myelography, extradural spinal cord compression was evident between C4-C5 on the right side. The animal underwent dorsal laminectomy for spinal cord decompression. An extradural synovial cyst and proliferated articularprocesses were removed. At 1,281 days after surgery, the dog was clinically normal and presented no neurological deficits...(AU)

Extradural synovial cyst of the cervical spine in a Saint Bernard

Background: Extradural synovial cysts (ESC) originate from an extrusion of the synovium in unstable or degeneratedjoints. In the spine, this condition can cause neurological signs such as hyperesthesia, proprioceptive ataxia and paresis.Since extradural presentations of synovial cysts are unusual in dogs, the aim of this manuscript is to report a case ofextradural synovial cyst of the cervical spine, as well as the clinical findings, diagnosis, surgical treatment and clinicalevolution after therapy.Case: A 3-year-old spayed Saint Bernard weighing 60 kg was presented to a Veterinary Medical Teaching Hospital with ahistory of acute paraparesis that evolved to non-ambulatory tetraparesis five days after the appearance of the first clinicalsigns. Neurological examination revealed non-ambulatory tetraparesis, normal muscle tone and segmental spinal reflexesin the thoracic and pelvic limbs, as well as cervical pain associated with limited neck movement. According to the neurological examination, the likely lesion location was the C1-C5 spinal cord segment. The differential diagnosis list includedintervertebral disc disease, caudal cervical spondylomyelopathy, neoplasm, infectious or noninfectious inflammatorydisease, and cystic diseases. Complete blood (cell) count and serum biochemistry tests were within reference limits. Thecerebrospinal fluid analysis revealed 35 mg/dL of protein (< 30 mg/dL) and 27 cells (up to 5 cells/mm3) with a predominance of lymphocytes. In plain radiography, bone proliferations of the C4 (caudal) C5 (cranial) articular processes wereobserved and, in myelography, extradural spinal cord compression was evident between C4-C5 on the right side. The animal underwent dorsal laminectomy for spinal cord decompression. An extradural synovial cyst and proliferated articularprocesses were removed. At 1,281 days after surgery, the dog was clinically normal and presented no neurological deficits...

TRANSFORAMINAL INTERSOMATIC LUMBAR ARTHRODESIS: COMPARISON BETWEEN AUTOGRAFT AND CAGE IN PEEK.

OBJECTIVE: To compare the postoperative outcomes of transforaminal intersomatic lumbar arthrodesis with structured iliac bone autograft and PEEK device. METHODS: The total of 93 medical records of patients undergoing transforaminal intersomatic fusion between January 2012 and July 2017 with at least 1 year of postoperative follow-up, with complete medical record, containing clinical file and radiological exams, were reviewed. RESULTS: From the medical records evaluated, 48 patients underwent the procedure with structured iliac autograft (group 1) and 45 with PEEK device (group 2). There was an improvement in functional capacity in both groups (p < 0.001), however there was no difference when comparing them (p = 0.591). CONCLUSION: The postoperative clinical and radiological results of lumbar arthrodesis with TLIF technique, using a structured iliac bone autograft compared to a PEEK device, were similar. Level of Evidence II, Retrospective study.

OBJETIVO: Comparar os desfechos pós-operatórios da artrodese lombar intersomática transforaminal com autoenxerto ósseo ilíaco estruturado e dispositivo em poliéter-éter-cetonico-polímero (PEEK). MÉTODOS: Foram revistos 93 prontuários de pacientes submetidos à fusão intersomática transforaminal entre janeiro de 2012 e julho de 2017 com pelo menos um ano de acompanhamento pós-operatório, com prontuário completo, contendo ficha clínica e exames radiológicos. RESULTADOS: Dos prontuários avaliados, 48 pacientes foram submetidos ao procedimento com autoenxerto ilíaco estruturado (Grupo 1) e 45 com dispositivo em PEEK (Grupo 2). Houve melhora da capacidade funcional em ambos os grupos (p < 0,001), no entanto não houve diferença ao compará-los (p = 0,591). CONCLUSÃO: Os resultados clínicos e radiológicos pós-operatórios da artrodese lombar na técnica Fusão Intersomática Lombar Transforaminal (TLIF) utilizando autoenxerto ósseo ilíaco estruturado, em comparação com o uso de dispositivo em PEEK, foram semelhantes. Nível de Evidência II, Estudo retrospectivo.

Estenosis lumbar degenerativa: conceptos básicos, evaluación clínica y manejo / Degenerative lumbar spinal stenosis: basic concepts, clinical evaluation, treatment

La estenorraquis lumbar es la disminución del volumen del canal raquídeo en la columna. Es la causa más frecuente de dolor lumbociático y lumbocrural en población mayor de 60 años. Existen múltiples causas. La más común es la degenerativa que consiste en una disminución del canal secundario a varios factores como protrusión del disco intervertebral, hipertrofia y abombamiento del ligamento amarillo, engrosamiento de la capsula articular y por osteofitos. Los síntomas principales son el dolor lumbar irradiado a extremidades inferiores tipo lumbociática o lumbocruralgia y la claudicación neural intermitente. Generalmente no hay déficit motor ni sensitivo. La resonancia magnética es el estudio de elección para el diagnóstico, pero debe complementarse con radiografías y con frecuencia con tac para una mejor valoración de la patología. El tratamiento inicial siempre es conservador, que incluye uso de antiinflamatorios, analgésicos, relajantes musculares, kinesioterapia e infiltraciones de columna (epidurales o radiculares). La mayoría de los pacientes responden satisfactoriamente a este manejo. El tratamiento quirúrgico está indicado a los pacientes que presentan un dolor intenso, que afecta su calidad de vida y que no mejora con el tratamiento conservador. Consiste en la descompresión quirúrgica de las raíces lumbares a través de laminectomía. En ocasiones se recomienda complementar la descompresión con artrodesis específicamente cuando la estenorraquis se asocia a otras condiciones como espondilolistesis degenerativa, escoliosis, desbalance sagital o coronal, inestabilidad segmentaria y en enfermedad del segmento adyacente.

Spinal lumbar stenosis is a narrowing of the spinal canal in the lumbar spine. Is the most frequent cause of sciatic pain or cruralgia in the elderly population over 60 years old. Exist many etiologies. The most common is degenerative caused by many factors including bulging disc, hypertrophy of flavum ligament as well as facet capsule thickening and by osteophytes formation. The main symptoms of spinal stenosis are radicular pain and neurogenic claudication. Lumbar flexion usually improves the symptom and deambulation often worsens the pain. Most of the time neurologic examination is normal. The gold standard study is mri but is necessary to complement with x rays and ct to obtain a better evaluation. Initial treatment is always conservative and consists in nsaid's, muscle relaxants, physical therapy and steroid spinal injections. Most of the patients respond well to this treatment. Surgical treatment is indicated when the patient has a severe pain, quality of life is miserable and conservative treatment fails. Decompression is the gold standard surgical treatment. The addition of an arthrodesis or spinal fusion is recommended in degenerative spondylolisthesis, scoliosis, sagital or coronal imbalance, deformity correction, recurrent spinal stenosis and in cases of adjacent level disease problem.

Transforaminal intersomatic lumbar arthrodesis: comparison between autograft and cage in peek / Artrodese lombar intersomática transforaminal: comparado autoenxerto e cage-peek

ABSTRACT Objective: To compare the postoperative outcomes of transforaminal intersomatic lumbar arthrodesis with structured iliac bone autograft and PEEK device. Methods: The total of 93 medical records of patients undergoing transforaminal intersomatic fusion between January 2012 and July 2017 with at least 1 year of postoperative follow-up, with complete medical record, containing clinical file and radiological exams, were reviewed. Results: From the medical records evaluated, 48 patients underwent the procedure with structured iliac autograft (group 1) and 45 with PEEK device (group 2). There was an improvement in functional capacity in both groups (p < 0.001), however there was no difference when comparing them (p = 0.591). Conclusion: The postoperative clinical and radiological results of lumbar arthrodesis with TLIF technique, using a structured iliac bone autograft compared to a PEEK device, were similar. Level of Evidence II, Retrospective study.

RESUMO Objetivo: Comparar os desfechos pós-operatórios da artrodese lombar intersomática transforaminal com autoenxerto ósseo ilíaco estruturado e dispositivo em poliéter-éter-cetonico-polímero (PEEK). Métodos: Foram revistos 93 prontuários de pacientes submetidos à fusão intersomática transforaminal entre janeiro de 2012 e julho de 2017 com pelo menos um ano de acompanhamento pós-operatório, com prontuário completo, contendo ficha clínica e exames radiológicos. Resultados: Dos prontuários avaliados, 48 pacientes foram submetidos ao procedimento com autoenxerto ilíaco estruturado (Grupo 1) e 45 com dispositivo em PEEK (Grupo 2). Houve melhora da capacidade funcional em ambos os grupos (p < 0,001), no entanto não houve diferença ao compará-los (p = 0,591). Conclusão: Os resultados clínicos e radiológicos pós-operatórios da artrodese lombar na técnica Fusão Intersomática Lombar Transforaminal (TLIF) utilizando autoenxerto ósseo ilíaco estruturado, em comparação com o uso de dispositivo em PEEK, foram semelhantes. Nível de Evidência II, Estudo retrospectivo.

Tumor maligno de columna vertebral / Malignant tumor of the spine

RESUMEN Introducción: Los tumores de columna vertebral son neoplasias poco comunes que pueden ser de origen primario o secundario. Las de origen primario son las que se presentan con menor recurrencia clínica, y se caracterizan generalmente por manifestaciones de dolor a nivel local y en menor proporción, por afectación neurológica. Objetivo: Describir el proceso de diagnóstico de un paciente con tumor de columna lumbar, el tratamiento recibido y su evolución. Caso clínico: Paciente de 77 años de edad con cuadro clínico consistente en dolor lumbar, paresias y parestesias. Se realizaron ayudas diagnósticas como radiografía y tomografía, en las que se evidenció una extensa lesión tumoral de la columna lumbar, valorada por cirugía de columna. Se realizó laminectomía descompresiva a nivel de L4 bilateral, artrodesis de T12 a L5 y se tomó biopsia abierta del tumor de la columna. Después de la cirugía la paciente presentó mejoría de la sintomatología. El informe anatomopatológico del tumor evidenció un tumor maligno indiferenciado. Conclusiones: El diagnóstico de tumor en columna lumbar se basa en evidencia clínica, imágenes diagnósticas, biopsia e inmunohistoquímica; una vez realizado el diagnóstico, el tratamiento debe incluir una combinación de quimioterapia, radioterapia y cirugía. La tomografía axial computarizada se utiliza como ayuda quirúrgica. Durante el procedimiento quirúrgico es pertinente realizar la resección de la lesión y obtener una confirmación histológica para definir el tratamiento antineoplásico y la malignidad de dicho tumor. El tratamiento oportuno reduce el riesgo de daño neurológico y mantiene la estabilidad mecánica espinal(AU)

ABSTRACT Introduction: Spinal tumors are rare neoplasms that can be of primary or secondary origin. Those of primary origin are those that present with less clinical recurrence, and are generally characterized by manifestations of local pain and to a lesser extent, by neurological involvement. Objective: To describe the diagnostic process of a patient with lumbar spine tumor, the treatment received and the evolution. Clinical report: We report a case of a 77-year-old patient, with a clinical situation of low back pain, paresis and paresthesias. Diagnostic aids such as radiography and tomography were performed, which showed an extensive tumor lesion of the lumbar spine, it was assessed for spinal surgery. Decompressive laminectomy was performed at the bilateral L4 level, arthrodesis from T12 to L5, and an open biopsy of the spinal tumor was taken. The patient had improvement in symptoms after surgery. The pathological report of the tumor showed an undifferentiated malignant tumor. Conclusions: The diagnosis of lumbar spine tumor is based on clinical evidence, diagnostic images, biopsy and immunohistochemistry. Once the diagnosis is made, treatment should include a combination of chemotherapy, radiation therapy, and surgery. Computerized axial tomography is used as a surgical aid. During the surgical procedure, it is pertinent to resect the lesion and to obtain histological confirmation to define the antineoplastic treatment and the malignancy of said tumor. Prompt treatment reduces the risk of neurological damage and maintains spinal mechanical stability.

EFFECT OF PLATELET-RICH PLASMA, FAT PAD AND DURAL MATRIX IN PREVENTING EPIDURAL FIBROSIS.

OBJECTIVE: Epidural fibrosis is one of the main reasons for requiring repeated surgical intervention. Our objective was to compare the effect of Platelet Rich Plasma (PRP) on the development of epidural fibrosis with collagen dural matrix and free autogenous fat graft. METHODS: Male rats were separated into 3 groups. Laminectomy was implemented on the rats and epidural fat pad was placed in the first group (n = 7); equal size of collagen dural matrix was applied in the second group (n = 7); a single dose of PRP was applied in the third group (n = 7). RESULTS: Epidural fibrosis was more common in the group that collagen dural matrix was applied when compared the ones that PRP was applied. PRP group presented better values in preventing epidural fibrosis when compared to the fat pad group, however this difference was not statistically significant. CONCLUSION: PRP is a material that can be easily obtained from the very blood of patients and at an extremely low cost; the main clinical relevance of our study is that the PRP might be an efficient material for better clinical results after laminectomy surgery due to its tissue healing and epidural fibroris preventing potentials. Level of Evidence V, Animal research.

OBJETIVO: A fibrose epidural é uma das principais razões que motiva intervenções cirúrgicas repetidas. O objetivo deste estudo foi comparar o efeito do plasma rico em plaquetas (PRP) no desenvolvimento de fibrose epidural com matriz de colágeno e enxerto de gordura autógena. MÉTODOS: Ratos machos foram separados em 3 grupos. A laminectomia foi aplicada nos ratos e gordura epidural foi colocada no primeiro grupo (n = 7); matriz de colágeno de tamanho igual foi aplicada no segundo grupo (n = 7); uma dose única de PRP foi aplicada no terceiro grupo (n = 7). RESULTADOS: A fibrose epidural foi mais comum no grupo em que a matriz de colágeno foi aplicada, quando comparada aos animais do grupo PRP. O grupo PRP apresentou os melhores valores na prevenção da fibrose epidural quando comparado ao grupo enxerto de gordura, porém a diferença não foi estatisticamente significante. CONCLUSÃO: PRP é um material de fácil obtenção do sangue dos pacientes e a baixo custo; a principal relevância clínica de nosso estudo é que o PRP pode ser um material eficiente para obter melhores resultados clínicos após a laminectomia devido à sua cicatrização tecidual e potencial de prevenção de fibrose epidural. Nível de evidência V, Pesquisa com animais.

Effect of platelet-rich plasma, fat pad and dural matrix in preventing epidural fibrosis / Efeito do plasma rico em plaquetas, enxerto de gordura e matriz de colágeno na prevenção da fibrose epidural

ABSTRACT Objective: Epidural fibrosis is one of the main reasons for requiring repeated surgical intervention. Our objective was to compare the effect of Platelet Rich Plasma (PRP) on the development of epidural fibrosis with collagen dural matrix and free autogenous fat graft. Methods: Male rats were separated into 3 groups. Laminectomy was implemented on the rats and epidural fat pad was placed in the first group (n = 7); equal size of collagen dural matrix was applied in the second group (n = 7); a single dose of PRP was applied in the third group (n = 7). Results: Epidural fibrosis was more common in the group that collagen dural matrix was applied when compared the ones that PRP was applied. PRP group presented better values in preventing epidural fibrosis when compared to the fat pad group, however this difference was not statistically significant. Conclusion: PRP is a material that can be easily obtained from the very blood of patients and at an extremely low cost; the main clinical relevance of our study is that the PRP might be an efficient material for better clinical results after laminectomy surgery due to its tissue healing and epidural fibroris preventing potentials. Level of Evidence V, Animal research.

RESUMO Objetivo: A fibrose epidural é uma das principais razões que motiva intervenções cirúrgicas repetidas. O objetivo deste estudo foi comparar o efeito do plasma rico em plaquetas (PRP) no desenvolvimento de fibrose epidural com matriz de colágeno e enxerto de gordura autógena. Métodos: Ratos machos foram separados em 3 grupos. A laminectomia foi aplicada nos ratos e gordura epidural foi colocada no primeiro grupo (n = 7); matriz de colágeno de tamanho igual foi aplicada no segundo grupo (n = 7); uma dose única de PRP foi aplicada no terceiro grupo (n = 7). Resultados: A fibrose epidural foi mais comum no grupo em que a matriz de colágeno foi aplicada, quando comparada aos animais do grupo PRP. O grupo PRP apresentou os melhores valores na prevenção da fibrose epidural quando comparado ao grupo enxerto de gordura, porém a diferença não foi estatisticamente significante. Conclusão: PRP é um material de fácil obtenção do sangue dos pacientes e a baixo custo; a principal relevância clínica de nosso estudo é que o PRP pode ser um material eficiente para obter melhores resultados clínicos após a laminectomia devido à sua cicatrização tecidual e potencial de prevenção de fibrose epidural. Nível de evidência V, Pesquisa com animais.

Chitosan-Hydroxyapatite Scaffold for Tissue Engineering in Experimental Lumbar Laminectomy and Posterolateral Spinal Fusion in Wistar Rats.

STUDY DESIGN: Experimental study with an animal model. PURPOSE: To evaluate the role of a chitosan and hydroxyapatite composite for spinal fusion in a lumbar experimental model based on regenerative tissue engineering principles. OVERVIEW OF LITERATURE: Chitosan and hydroxyapatite represent an alternative biodegradable implant material for tissue engineering and regeneration. The combination of chitosan and hydroxyapatite in a 20:80 ratio could potentiate their individual properties as an implantable composite for experimental laminectomy. METHODS: Phase I: design and synthesis of a porous composite scaffold composed of chitosan-hydroxyapatite using a freeze drying technique. Phase II: experimental microsurgical lumbar laminectomy at L5. A total of 35 Wistar rats were categorized into three experimental groups: control (laminectomy alone), experimental (laminectomy with implant), and reference (intact spine) (n=5 per group). Postoperative structural and functional evaluations were performed using computed tomography scans. In addition, radiologic, clinical, histological, and immunohistochemical microstructures were evaluated. RESULTS: At the laminectomy site, the composite implant induced bone regeneration, which was observed in the axial reconstruction of the rat lumbar spine in all cases. Biomechanical changes in the lumbar spine were observed by radiology in both groups after the surgery. The posterolateral space was covered by a bone structure in the treated spine, a condition not seen in the control group. The range of motion was 7.662°±0.81° in the scaffold group versus 20.72°±3.47° in the control group. Histological findings revealed qualitatively more bone tissue formation in the implant group. CONCLUSIONS: A composite of chitosan-hydroxyapatite at a 20:80 ratio induced bone formation after experimental laminectomy in rats and led to spinal fusion, which was assessed by radiology and biomechanical tests. No functional complications in posture or walking were observed at 90 days post-surgery, despite biomechanical changes in the spine.

Preliminary results of vertebral canal decompression by spinous process splitting / Resultados preliminares da descompressão do canal vertebral por separação do processo espinhoso / Resultados preliminares de la descompresión del canal vertebral por separación del proceso espinoso

ABSTRACT Objective Considering that the technique of spinous process splitting has been advocated as a less invasive treatment of lumbar stenosis, the objective of this study was to evaluate the preliminary results of this technique in the surgical treatment of lumbar canal stenosis. Methods Twenty patients with lumbar spinal canal stenosis who underwent surgical treatment for lumbar canal decompression with the spinous process splitting technique were assessed in the preoperative period and on postoperative days 1, 7 and 30 for VAS for lower back and lower limbs pain and radiographic evaluation of the operated segment. Results The mean visual analogue scale score for lumbar pain in the preoperative assessment was 4.2 ± 3.37 and 0.85 ± 0.88, 1.05 ± 1.19 and 1.15 ± 1.04 after 1, 7 and 30 postoperative days, respectively. The mean VAS score for lower limb pain was 8 ± 1.72 preoperatively, and 0.7 ± 1.13, 0.85 ± 1.04, and 1.05 ± 1 after 1, 7, and 30 postoperative days, respectively. There were no radiographic signs of instability of the vertebral segment operated in the radiographic evaluation. Conclusions Decompression of the lumbar canal through the spinous process splitting technique in patients with lumbar canal stenosis had good immediate and short-term results in relation to low back and lower limbs pain. Level of evidence IV; Therapeutic Study.

RESUMO Objetivo A técnica da separação do processo espinhoso tem sido preconizada como técnica menos invasiva para o tratamento da estenose lombar. Objetivo é avaliar os resultados preliminares dessa técnica no tratamento cirúrgico da estenose do canal lombar. Métodos Vinte pacientes portadores de estenose do canal vertebral lombar e submetidos ao tratamento cirúrgico para descompressão do canal lombar, por meio da técnica da separação do processo espinhoso, foram avaliados no período pré-operatório, um, sete e trinta dias de pós-operatório, por meio da escala visual de avaliação da dor lombar e dor nos membros inferiores e avaliação radiográfica do segmento operado. Resultados O escore médio da escala visual analógica da dor lombar na avaliação pré-operatória foi 4,2 ± 3,37 e, respectivamente, 0,85 ± 0,88; 1,05 ± 1,19 e 1,15 ± 1,04 após um, sete e trinta dias de pós-operatório. O escore médio da escala visual analógica da dor nos membros inferiores foi 8 ± 1,72 no pré-operatório e, respectivamente, 0,7 ± 1,13; 0,85 ± 1,04 e 1,05 ± ١ após um, sete e trinta dias de pós-operatório. Não foram observados sinais radiográficos de instabilidade do segmento vertebral operado na avaliação radiográfica. Conclusão A descompressão do canal lombar por meio da técnica da separação do processo espinhoso nos pacientes com estenose do canal lombar apresentou bons resultados imediatos e a curto prazo, em relação à dor lombar e dor nos membros inferiores . Nível de evidência IV; Estudo Terapêutico.

RESUMEN Objetivo Teniendo en cuenta que la técnica de separación del proceso espinoso ha sido recomendada para el tratamiento menos invasivo de la estenosis lumbar, el objetivo de este estudio fue evaluar los resultados preliminares de esta técnica en el tratamiento quirúrgico de la estenosis del canal lumbar. Métodos Veinte pacientes con estenosis del canal espinal lumbar que se sometieron a tratamiento quirúrgico para descompresión del canal lumbar con la técnica de separación del proceso espinoso se evaluaron en el período preoperatorio y en los días 1, 7 y 30 postoperatorios mediante EVA para del dolor lumbar y de los miembros inferiores y evaluación radiográfica del segmento operado. Resultados La puntuación promedio de la escala visual analógica del dolor lumbar en la evaluación preoperatoria fue de 4,2 ± 3,37 y 0,85 ± 0,88; 1,05 ± 1,19 y 1,15 ± 1,04 después de 1, 7 y 30 días postoperatorios. La puntuación promedio de la EVA para el dolor de las extremidades inferiores fue 8 ± 1,72 en el preoperatorio y de 0,7 ± 1,13; 0,85 ± 1,04 y 1,05 ± 1 después de 1, 7 y 30 días postoperatorios, respectivamente. No se observaron signos radiográficos de inestabilidad del segmento vertebral operado en la evaluación radiográfica. Conclusiones La descompresión del canal lumbar por medio de la técnica de separación del proceso espinoso en pacientes con estenosis del canal lumbar tuvo buenos resultados inmediatos y a corto plazo con relación al dolor lumbar y las extremidades inferiores. Nivel de evidencia IV; Estudio Terapéutico.

Upper thoracic dumbbell-shaped tumor resected in one stage posterior approach: case report.

Upper thoracic tumors may develop spinal cord compression. By surgery at the time of diagnosis, a neurological deficit can be avoided. However, this particular localization requires a double approach to decompress the spinal cord and thoracic structures. The posterior extracavitary approach results in resection of the spinal canal, the foraminal component, and the extraspinal fragment, but is not routinely used by most neurosurgeons. A 56-year-old woman with a two-month history of axial thoracic pain and cough. The patient has a normal neurological examination. Thoracic computed tomography (CT) scan with contrast agent was performed, evincing a dumbbell-shaped tumor on the left T3-T4. Magnetic resonance imaging (MRI) confirms the diagnosis, showing a 4 cm diameter tumor that compresses the spinal cord without myelopathy. The surgery was performed posteriorly, with costotransversectomy, allowing complete resection under intraoperative neurophysiological monitoring. The patient developed no thoracic or neurological complications. One-stage posterior approach is possible and effective during the treatment of the upper thoracic dumbbell-shaped tumors, avoiding a change in surgical position, thoracic morbidity, and dependence on assisting surgeons.