Spinopelvic Parameters in the Clinical and Functional Outcomes of Patients Submitted to Lumbar Interbody Fusion Surgery ­ A Prospective Study / Parâmetros espinopélvicos nos resultados clínicos e funcionais de pacientes submetidos a fusão intersomática lombar: um estudo prospectivo

Objectives The relevance of spinopelvic parameters in the patients' clinical and functional outcomes has been widely studied in long spinal fusion. Yet, the importance of the spinopelvic parameters in short-segment fusion surgeries needs further investigation. We analyzed the spinopelvic parameters and surgical outcomes of patients undergoing short-segment lumbar interbody fusion. Materials and Methods An observational, prospective study was conducted between January and June 2021. We selected 25 patients with lumbar stenosis, with or without concomitant spondylolisthesis, undergoing transforaminal lumbar interbody fusion. Variables related to the patient, diagnosis, and surgery were collected. The clinical and functional outcomes were assessed using the Visual Analogue Scale for low-back and leg pain and the Oswestry Disability Index (ODI). The surgical outcomes and spinopelvic parameters were analyzed pre- and postoperatively. Results There was a significant clinical and functional improvement after surgery (p < 0.001), with a mean ODI decrease of 63.6%. The variables of obesity, concomitant spondylolisthesis, absence of osteotomy, and two-level fusion were all associated with lower levels of improvement after surgery (p < 0.05). Pelvic incidence minus lumbar lordosis (PI-LL) was the only parameter that significantly changed regarding the pre and postoperative periods (p < 0.05). Before surgery, PI-LL < 10° correlates with less low-back pain after surgery (r » 0.435; p < 0.05). Postoperatively, no correlation was found between surgical outcomes and all the spinopelvic parameters analyzed. Conclusions The clinical and functional outcomes significantly improved with the surgical intervention but did not correlate with the change in spinopelvic parameters. Patients with preoperative PI-LL < 10° seem to benefit the most from surgery, showing greater improvement in back pain.

Objetivos A influência dos parâmetros espinopélvicos nos resultados clínicos e funcionais dos pacientes tem sido amplamente estudada nas cirurgias de fusão espinhal que envolvem longos segmentos. Contudo, a literatura é escassa acerca da fusão de segmentos curtos. Analisamos assim os parâmetros espinopélvicos e os resultados cirúrgicos de pacientes submetidos a fusão intersomática lombar de segmentos curtos. Materiais e Métodos Realizou-se um estudo prospectivo observacional entre janeiro e junho de 2021. Selecionaram-se 25 pacientes com estenose lombar, com ou sem espondilolistese, submetidos a fusão intersomática lombar transforaminal. Colheram-se dados relacionados com o paciente, o diagnóstico e a cirurgia. Os resultados clínicos e funcionais foram avaliados por meio da Escala Visual Analógica para dor lombar e dos membros inferiores e pela Escala de Incapacidade de Oswestry (Oswestry Disability Index, ODI, em inglês). Os resultados cirúrgicos e os parâmetros espinopélvicos foram analisadas no pré e no pós-operatório. Resultados Verificou-se uma melhoria clínica e funcional significativa após a cirurgia (p < 0,001), com redução média do ODI de 63,6%. As variáveis obesidade, espondilolistese concomitante, ausência de osteotomia e fusão de dois níveis associaram-se a menor melhoria no pós-operatório (p < 0,05). O único parâmetro que mudou significativamente antes e após a cirurgia (p < 0,05) foi a incidência pélvica menos a lordose lombar (IP-LL). No pré-operatório, uma IP-LL < 10° correlacionou-se com menos dor lombar após a cirurgia (r » 0,435; p < 0,05). No pós-operatório, não houve correlação entre os resultados clínicos e funcionais e os parâmetros espinopélvicos. Conclusão Os resultados clínicos e funcionais melhoraram significativamente após a cirurgia, mas não se correlacionam com a mudança dos parâmetros espinopélvicos. Pacientes com IP-LL< 10° no pré-operatório apresentam maior melhoria da dor lombar no pós-operatório.

Assessment of Functional Outcome Predictors in Patients Undergoing Lumbar Interbody Fusion Surgery: A Single-Centre Analysis.

Introduction Lumbar interbody fusion is a surgical modality performed in selected patients with low back and radicular pain not responding to medical therapy. We aim to evaluate the main predictors of functional outcome, assessed through Oswestry Disability Index (ODI), in patients submitted to a lumbar interbody fusion. Methods A sample of 33 patients undergoing lumbar interbody fusion at a neurosurgery department between 2017 and 2020 was selected. In order to assess functional status, ODI was applied before and after surgery. Data related to patients' medical history, current disease, and surgery performed were collected from the clinical process. Results In our cohort, functional improvement (pre-surgery ODI - post-surgery ODI) averaged 34.4 ± 23 points, suggesting robust surgical efficacy. We find patients with severe disability or worse to display relevant amelioration of their functional scores (p<0.0001), suggesting that these can benefit from lumbar interbody fusion surgery. The female gender (p=0.007) predicts a better outcome, which was surprising as no sex differences in lumbar fusion outcomes have been reported. Conversely, early symptom recurrence (p=0.015) and need for revision surgery (p=0.032) were found to be negative predictors of post-surgical functional outcome. Rapid return to the activities of daily living (p=0.001) and to work (p=0.002) was associated with post-surgical functional improvement. The underlying diagnosis that led to surgical referral and surgical modality did not affect the functional outcome in our patient cohort. Importantly, patients with previous lumbar surgeries had similar improvements to those who had never been operated on. Conclusions Severely disabled patients submitted to lumbar interbody fusion showed significant functional improvement, regardless of the referral diagnosis or the existence of previous lumbar surgeries. Additionally, sustained functional improvement resulted in a return to an active life.

Vestibular Schwannoma Leading to Contacting Aneurysm Rupture: An Unusual Presentation.

Subarachnoid hemorrhage (SAH) is a rare manifestation of brain tumors, being even rarer in vestibular schwannomas. We report the second case of a posterior circulation aneurysm close to the tumor capsule, responsible for SAH as an initial manifestation of a vestibular schwannoma. A 67-year-old female was admitted to the Emergency Department with sudden onset of nausea and headache. A diagnosis of a SAH and a tumor of the right cerebellopontine angle was made. An angiography showed an aneurysm in the dependency of the right anterior inferior cerebellar artery (AICA), juxtaposed to the tumor capsule. The patient underwent surgery, the tumor was removed, and the aneurysm was treated. This case highlights that SAH in patients with vestibular schwannoma may originate from a contact aneurysm. Although exceedingly rare, surgeons should consider this scenario in vestibular schwannoma presenting with SAH, and angiography is important for its diagnosis.

Reappraising the need for a control CT in mild head injury patients on anticoagulation.

BACKGROUND: Head injury is a frequent reason for admission to the emergency department. In parallel, there is a growing use of anticoagulants in an increasingly aging population, which renders this particular group of trauma patients more frequent. In several countries, including Portugal, a 24-h surveillance period followed by repetition of head computed tomography (CT) is the standard procedure for these patients. However, these recommendations have not been based on studies of prevalence of intracranial hemorrhages in control head CTs, namely in this group of anticoagulated patients. This study intends to evaluate the prevalence of de novo intracranial hemorrhages in control head CTs in anticoagulated patients. METHOD: An observational study was carried out, which included patients admitted to Hospital de Braga between June 2017 and January 2018, victims of head injury and on anticoagulation therapy, whose admission head CT excluded intracranial hemorrhage. RESULTS: We collected a total of 201 patients, with a mean age of 81.6 years, and 57.5% of them were prescribed warfarin; 181 of these patients repeated the head CT 24 h later. Of these 181 patients, 3 (1.66%) exhibited intracranial hemorrhage in control CT, without surgical indication. All patients were followed up 1 month after the trauma, and there was no readmission requiring hospitalization, surgery or death. CONCLUSIONS: In conclusion, de novo intracranial hemorrhage in control head CT of anticoagulated patients is rare. We propose that these patients may be discharged if the admission CT does not reveal intracranial hemorrhage, providing that they are accompanied by a caregiver and informed about red flags.

Complex sacral fracture.

We reported a case of a patient with suspected cauda equina syndrome secondary to sacral fracture, after sustaining a fall. The difficulty in early diagnosis of complex sacral fractures and the lack of clearly defined guidelines for treatment are highlighted. Thorough clinical examination is mandatory, in order to make an adequate initial assessment and follow symptoms progression and response to treatment. The threshold for performing CT imaging (or MRI, if advised), when suspecting sacral fracture and neurological compromise, should be low. A multidisciplinary approach, with contributions from orthopaedic and/or neurosurgical surgery and physiatry, should be the gold standard of treatment. In this particular case, conservative management and close follow-up led to a significant improvement of problems and a good final outcome, showing that surgical decompression is not the only valid option and that further prospective studies are needed, regarding patient selection and timing of intervention.