Minimally Invasive Treatment for Lumbar Disc Herniation: A Matched Comparison Between Tubular Microdiscectomy and Percutaneous Endoscopic Lumbar Discectomy.

Background and objectives Discectomy for lumbar disc herniation is the most common spinal surgical procedure. Technological advances have led to the emergence of minimally invasive surgical approaches such as tubular microdiscectomy (TMD) and percutaneous endoscopic lumbar discectomy (PELD). The purpose of this study was to compare the clinical outcomes of PELD to those of TMD at one-year follow-up. Materials and methods This observational registry-based (Spine Tango) cohort study included patients with symptomatic lumbar disc herniation submitted to PELD or TMD. The inclusion criteria were patients who underwent minimally invasive lumbar discectomy (PELD or TMD), patients who attended a follow-up after a minimum of 12 months post surgery, and valid pre- and postoperative questionaries. The primary endpoint was defined as the difference between pre- and postoperative Core Outcome Measures Index (COMI) for the back. The matching was based on a 1:1 nearest neighbor matching without replacement. Results A total of 109 patients were included in this study. Propensity score matching (PSM) was performed achieving 86 patients in the matched sample. Regarding COMI improvement, we found no significant difference between the PELD and TMD groups (paired t-test: estimate, -0.23; standard error, 0.6; p=0.7), and we also did not find any significant difference between groups concerning Oswestry Disability Index (ODI) and EuroQol 5 Dimension (EQ-5D). Medication usage and return to work were similar among the matched groups. Conclusions PELD is a technique that minimizes tissue damage achieving good clinical outcomes similar to TMD. This was observed one year after surgery from patient-reported outcome measures (PROMs) that measured pain improvement, disability, and quality of life.

Cross-cultural adaptation, validation and establishment of the minimal clinically important change score of the European Portuguese core outcome measures index in patients with lumbar degenerative spine disease.

PURPOSE: The core outcome measures index (COMI) for the back is a questionnaire that evaluates five domains and has been translated into several languages and validated for different populations. We aimed to translate, cross-culturally adapt and validate it in European Portuguese for use in patients with degenerative lumbar disease. Additionally, we aimed to establish the minimal clinically important change score (MCIC). METHODS: The translation and cultural adaptation were done according to published guidelines. Patients awaiting surgery at a neurosurgical center completed the COMI, Oswestry Disability Index (ODI), EQ-5D questionnaires and a pain visual analog scale (VAS). To evaluate COMI's reproducibility, patients completed the questionnaire twice within two weeks, preoperatively, in addition to answering a transition question. The MCIC was determined by analysis of postoperative changes in total COMI score, using the anchor method, with a question ascertaining surgical outcome as perceived by the patient. RESULTS: The first set of questionnaires was answered by 108 patients and the second, by 98 patients. COMI's construct validity was confirmed by demonstrating the hypothesized correlation between each domain's score (Spearman Rho > 0.4) and the corresponding questionnaire score (ODI, EQ-5D and VAS) and through adequate correlation (Spearman > 0.6) between COMI's total score and ODI and EQ-5D total scores. Intraclass correlation coefficients between each domain and COMI's total score were > 0.8. The MCIC was calculated as 2.1. CONCLUSION: The cross-culturally adapted COMI questionnaire is a valid clinical assessment tool for European Portuguese-speaking patients with degenerative lumbar disease, with an MCIC of 2.1 points.

Relationship between fatty infiltration of paraspinal muscles and clinical outcome after lumbar discectomy.

Introduction: Cross sectional area (CSA) and fat infiltration (FI) are important parameters to assess paravertebral muscle atrophy. However, the relationship of muscular fat infiltration in patients with symptomatic lumbar disc herniation undergoing surgery remains unclear. Research question: Does lumbar paravertebral muscle atrophy have prognostic value regarding the clinical outcome for patients with symptomatic lumbar disc herniation undergoing surgery? Methods: Patients over 18 years of age with lumbar disc herniation and radicular pain who underwent single-level discectomy were included. Multifidus, erector spinae and psoas cross-sectional area (CSA) and fatty infiltration (FI) were measured by ImageJ software at the levels of L3-L4, L4-L5 and L5-S1 from T2-weighted Magnetic Resonance axial images. Clinical status was assessed preoperatively and one-year after surgery with patient reported outcome measurements (PROMS), that included Numeric Rating Score for back and leg pain, Core Outcome Measurement Index (COMI), Oswestry Disability Index and EuroQoL-5D. Univariate and multiple linear regressions were performed. Results: Erector spinae FI was the only muscle-related factor that correlated to postoperative PROMS. Postoperative COMI was higher in patients with FI>30% (median: 4.4, IQR: 3.2) and lower when FI<15% (median: 1.2, IQR: 1.6) (Kruskal-Wallis, p â€‹< â€‹0.001). Male gender was associated with better outcome as well as erector spinae FI<15%, while FI >30% was related to worse postoperative status. Conclusions: In the current study, increased fat infiltration of erector spinae muscles correlated to less favorable clinical outcomes following lumbar discectomies.

Treatment of old cervical bilateral facet dislocation: Case report and literature review / Tratamiento de las secuelas de una luxación facetaria bilateral cervical: caso clínico y revisión bibliográfica

Late diagnosis of cervical bilateral facet dislocation is rare and contributes to concerns in the management of these patients. We present a case of a 44-year-old woman presented 8 months after a trauma with persistent neck pain, without neurological deficits. A bilateral C5-C6 facet dislocation was identified. The patient was treated with a combined C5-C6 approach: posterior facet joints release, anterior discectomy and fusion, bilateral posterior fixation. Surgery was performed under intraoperative neurophysiological monitoring. The postoperative period was uneventful, and the patient presented functional improvement. Late surgical treatment of bilateral cervical facet dislocation is safe and feasible. Combined procedures are needed for proper reduction and stabilization of the spine. Intraoperative neurophysiological monitoring adds value to this technique contributing to good outcomes

El diagnóstico tardío de la luxación facetaria bilateral cervical es infrecuente y contribuye a crear problemas en el tratamiento de estos pacientes. Presentamos el caso de una mujer de 44 años que, 8 meses después de un traumatismo, presentaba dolor continuo en el cuello, en ausencia de deficiencias neurológicas. Se identificó una luxación facetaria bilateral en C5-C6. La paciente recibió tratamiento quirúrgico combinado en C5-C6: liberación posterior de las articulaciones facetarias, discectomía anterior y artrodesis, fijación posterior bilateral. La intervención quirúrgica se realizó con monitorización neurofisiológica intraoperatoria. La paciente presentó una evolución postoperatoria sin complicaciones y mejoría funcional. El tratamiento quirúrgico tardío de la luxación facetaria cervical bilateral es seguro y viable. Es necesario utilizar procedimientos combinados para lograr una reducción y estabilización correctas de la columna vertebral. La monitorización neurofisiológica intraoperatoria aporta valor añadido a esta técnica y contribuye a lograr buenos resultados

Treatment of chronic HCV infection with DAAs in Rio de Janeiro/Brazil: SVR rates and baseline resistance analyses in NS5A and NS5B genes.

The selection of viral strains with resistance-associated substitutions at hepatitis C virus (HCV) NS5A and NS5B genes is considered one of the limiting factors for achieving sustained virologic response (SVR) to combination of direct-acting antivirals daclatasvir (DCV) and sofosbuvir (SOF). Since 2015, this interferon-free regimen has been available in Brazilian clinical routine for treating mono- and HCV/HIV-coinfected patients chronically infected with genotypes 1 and 3. Our aim was to assess SVR rate for Brazilian patients chronically infected with genotypes 1 and 3 after DCV/SOF therapy and the frequency of baseline RASs in HCV NS5A and NS5B genes. Serum samples were collected from 107 monoinfected patients and 25 HCV/HIV co-infected patients before antiviral therapy with DCV/SOF. Genetic diversity of NS5A and NS5B genes was assessed by direct nucleotide sequencing. Overall, SVR rate was 95.4% (126/132), and treatment failure occurred in five monoinfected and one HCV/HIV co-infected patient. NS5A RASs frequency was higher for HCV/HIV patients (28%) than monoinfected patients (16.8%). No difference was evidenced between mono- and HCV/HIV-coinfected groups (15% vs. 16%) regarding NS5B gene. Genotype (GT) 1b strains had significantly more baseline substitutions in NS5A (31.6%) than GT 1a and 3a. At least one primary NS5A RAS described in literature at loci 28, 30, 31 or 93 was identified in HCV GTs 1 strains for both groups. As for NS5B, RASs at positions 159 and 316 was observed only in GT 1b strains. This study highlighted that SVR rate in clinical routine in Brazil was similar to randomized clinical trials (89-98%). Our research provided genetic data about the circulation of resistant variants in Brazil. Despite its presence, most of identified baseline mutations did not negatively impact treatment outcome. Genetic diversity of circulating strains suggested that most of the Brazilian HCV chronic carriers are susceptible to new therapeutic regimens including recently approved DAAs.

How Does Minimally Invasive Transforaminal Lumbar Interbody Fusion Influence Lumbar Radiologic Parameters?

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has become a popular method of interbody fusion. Clinical outcomes after single-level MIS-TLIF have been reported, but few studies have focused on the radiologic changes in the segmental parameters of the operated and adjacent segments and in lumbar lordosis. METHODS: From March 2009 to September 2016, 117 patients who underwent a single-level MIS-TLIF surgery for lumbar degenerative disease were enrolled in this retrospective study. The anterior disc height (ADH), posterior disc height (PDH), and segmental angle (SA) of the operated and adjacent levels and lumbar lordosis (LL) were evaluated on radiographs obtained pre- and postoperatively at 6- to 12-month follow-up visits. Cage-related parameters including fusion and subsidence rates were analyzed on postoperative computed tomography scans. Clinical assessment used validated outcome scores such as the Oswestry Disability Index questionnaire and the Odom criteria. RESULTS: ADH and PDH of the operated segment increased significantly after surgery, but no significant changes were seen in the SA of that level. Statistically significant decreases were observed in the PDH of both adjacent segments and increases in the adjacent superior SA. LL showed a slight but statistically significant improvement after surgery that was mostly correlated with a postoperative increase in the adjacent superior SA (r = 0.58; P < 0.001). No significant correlations were found between clinical and radiologic results. CONCLUSIONS: Single-level MIS-TLIF increased disc height but not the SA at the operated level. LL improvement after surgery was mainly associated with the increase of the cranial segmental angle.