Comparison Between Surgical and Conservative Treatment for AOSpine Type A3 and A4 Thoracolumbar Fractures without Neurological Deficit: Prospective Observational Cohort Study.

Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit. Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up. Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p > 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p > 0.05), quality of life (EQ-5D), and return to work (DWS). Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.

Comparison Between Surgical and Conservative Treatment for AOSpine Type A3 and A4 Thoracolumbar Fractures without Neurological Deficit: Prospective Observational Cohort Study / Comparação entre tratamento cirúrgico e conservador para fraturas toracolombares AOSpine tipo A3 e A4 sem déficit neurológico: Estudo de coorte prospectivo observacional

Abstract Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit. Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up. Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p> 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p> 0.05), quality of life (EQ-5D), and return to work (DWS). Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.

Resumo Objetivo Comparar os resultados clínicos entre os tratamentos conservador (CS) e cirúrgico (CXS) das fraturas A3 e A4 sem déficit neurológico. Métodos Estudo prospectivo observacional de paciente com fraturas toracolombares tipo A3 e A4. Esses pacientes foram separados entre os grupos cirúrgico e conservador e avaliados sequencialmente através da escala numérica de dor (NRS), do questionário de incapacidade de Roland-Morris (RMDQ), do EuroQol-5D (EQ-5D) e da escala de trabalho de Denis (DWS) até 2,5 anos de acompanhamento. Resultados Ambos os grupos apresentaram melhora significante, sem diferença estatística nos questionários de dor (NRS: CXS 2,4 ± 2,6; CS 3,5 ± 2,6; p> 0,05), funcionalidade (RMDQ: CS 7 ± 6,4; CXS 5,5 ± 5,2; p> 0,05), qualidade de vida (EQ-5D) e retorno ao trabalho (DWS). Conclusão Ambos os tratamentos são opções viáveis e com resultados clínicos equivalentes. Há uma tendência a melhores resultados no tratamento cirúrgico das fraturas A4.

Risk Factors for Postoperative Complications After Surgical Treatment of Type B and C Injuries of the Thoracolumbar Spine.

BACKGROUND: Unstable thoracolumbar spinal injuries benefit from surgical fixation. However, perioperative complications significantly affect outcomes in surgicallytreated spine patients. We evaluated associations between risk factors and postoperative complications in patients surgically treated for thoracolumbar spine fractures. METHODS: We conducted a retrospective multicenter study collating data from 21 spine centers across 9 countries on the treatment of AOSpine types B and C injuries of the thoracolumbar spine treated via a posterior approach. Comparative analysis was performed between patients with postoperative complications and those without. Univariate and multivariable analyses were performed. RESULTS: Among 535 patients, at least 1 complication occurred in 43%. The most common surgical complication was surgical-site infection (6.9%), while the most common medical complication was urinary tract infection (13.8%). Among 136 patients with American Spinal Injury Association (ASIA) Impairment Scalelevel A disability, 77.9% experienced at least 1 complication. The rate of complications also rose sharply among patients waiting >3 days for surgery (P<0.001), peaking at 68.4% among patients waiting ≥30 days. On multivariable analysis, significant predictors of complications were surgery at a governmental hospital (odds ratio = 3.38, 95% confidence interval = 1.73-6.60), having ≥1 comorbid illness (2.44, 1.61-3.70), surgery delayed due to health instability (2.56, 1.50-4.37), and ASIA Impairment Scalelevel A (3.36, 1.78-6.35), while absence of impairment (0.39, 0.22-0.71), ASIAlevel E (0.39, 0.22-0.67) and, unexpectedly, delay caused by operating room unavailability (0.60, 0.36-0.99) were protective. CONCLUSIONS: Types B and C thoracolumbar spine injuries are associated with a high risk of postoperative complications, especially common at governmental hospitals, and among patients with comorbidity, health instability, longer delays to surgery, and worse preoperative neurologic status.

Success and failure after surgery of degenerative disease of the lumbar spine: an operational definition based on satisfaction, pain, and disability from a prospective cohort.

BACKGROUND: To describe success and failure (S&F) after lumbar spine surgery in terms equally understandable across the entire health ecosystem. METHODS: Back and leg pain and disability were prospectively recorded before and up to 12 months after the procedure. Satisfaction was recorded using a Likert scale. Initially, patients were classified as satisfied or unsatisfied. Optimal satisfaction/unsatisfaction cutoff values for disability and pain were estimated with ROC curves. Satisfied and unsatisfied groups underwent a second subdivision into four subcategories: success (satisfied AND pain and disability concordant with cutoff values), incomplete success (satisfied AND pain and disability nonconformant with cutoff values), incomplete failure (unsatisfied AND pain and disability nonconformant with cutoff values), and failure (unsatisfied AND pain and disability concordant with cutoff values). RESULTS: A total of 486 consecutive patients were recruited from 2019-2021. The mean values of preoperative PROMs were ODI 42.2 (+ 16.4), NPRS back 6.6 (+ 2.6) and NPRS leg 6.2 points (+ 2.9). Of the total, 80.7% were classified as satisfied, and 19.3% were classified as unsatisfactory. The optimal disability and pain cutoff values for satisfaction/unsatisfaction (NPRS = 6, AND ODI = 27) defined a subdivision: 59.6% were classified as success, 20.4% as incomplete success, 7.1% as incomplete failure and 12.4% as failure. The descriptions of each group were translated to the following: success-all patients were satisfied and presented no or only mild to tolerable pain and no or borderline disability; incomplete success - all patients were satisfied despite levels of pain and/or disability worse than ideal for success; incomplete failure - all patients were not satisfied despite levels of pain and/or disability better than expected for failure; failure - all patients were unsatisfied and presented moderate to severe pain and disability. CONCLUSION: It is possible to report S&F after surgery for DDL with precise and meaningful operational definitions focused on the experience of the patient.

Management of Unilateral Cervical Facet Joint Dislocation in Neurologically Intact Patients: Results of an Ao Spine latin American Survey.

BACKGROUND: The treatment of unilateral CFD in patients without neurologic deficits remains controversial, especially in the choice of the best surgical approach. Our objective is to determine the way spine surgeons from Latin America manage this condition. METHODS: A survey regarding management and surgical strategies was conducted by the AO Spine Latin American Trauma Study Group considering the treatment of unilateral CFD. RESULTS: All AO Spine Latin American Trauma Study Group members were sent a link to the survey, among whom 285 replied, with 197 respondents answering all the questions. Nonsurgical management was considered by 25% of the surgeons. The majority stated that magnetic resonance imaging is necessary (65%) to treat this type of patient. A posterior approach was preferred by 44%, an anterior approach by 29%, and a combined approach by 25%, while 2.2% did not answer. Traction was not used by the majority of respondents (62%). In the setting of an anterior disk herniation, the majority of surgeons preferred to employ an anterior (45%) or combined (44%) approach versus an isolated posterior approach (only 0.5%). Comparing early versus late cervical trauma, fewer surgeons adopted an isolated anterior approach with the latter (29% vs. 15%). CONCLUSIONS: Wide variations exist in the management of unilateral CFD by Latin American surgeons, with early injuries generally treated using either an anterior or posterior approach and treated early but after an MRI, while a combined approach is used more commonly with late injuries. Either an anterior or combined approach is used when disk herniation is present.

Cerebellar hemorrhage as a complication of spine surgery.

BACKGROUND: The association between remote cerebellar hematoma (RCH) and spinal surgery is poorly understood and rarely reported. We present seven cases of RCH after spinal surgery. METHODS: Seven patients were diagnosed with RCH utilizing computed tomography and/or magnetic resonance, between 2012 and 2016. Their clinical presentations, imaging data, treatment modalities, and outcome were analyzed. There were five females and two males with an average age of 55.8 ± 8.4 years. The age of onset ranged from 43 to 67 years and the time to clinical presentation ranged from 3 h to 5 days. Patients presented with: diplopia/strabismus (one patient), dysphagia/urinary incontinence (one patient), respiratory arrest (one patient), meningismus (one patient), and dysarthria (two patients), along with other symptoms/signs. RESULTS: Three patients were successfully managed without surgery, two required external ventricular drainage, and two were treated with posterior fossa decompression plus ventriculostomy. Four patients recovered completely, two showed mild residual deficits at discharge, while one expired 7 days postoperatively. CONCLUSION: RCH is an uncommon and underdiagnosed complication of spine surgery. It should be suspected when intracranial symptoms occur after spinal procedures.

Double-blind randomized clinical trial of vancomycin in spinal arthrodesis: no effects on surgical site infection.

OBJECTIVE: Surgical site infection (SSI) results in high morbidity and mortality in patients undergoing spinal fusion. Using intravenous antibiotics in anesthesia induction reduces the rate of postoperative infection, but it is not common practice to use them topically, despite recent reports that this procedure helps reduce infection. The objective of this study was to determine whether the topical use of vancomycin reduces the rate of postoperative SSI in patients undergoing thoracolumbar fusion. METHODS: A randomized, double-blind clinical trial in a single hospital was performed comparing vancomycin and placebo in thoracolumbar fusion patients. RESULTS: A total of 96 patients were randomized to placebo or vancomycin treatment. The mean patient age was 43 ± 14.88 years, 74% were male, and the most common etiology was fall from height (46.9%). The overall rate of postoperative SSI was 8.3%, and no difference was found between the groups: postoperative infection rates in the vancomycin and placebo groups were 8.2% and 8.5% (relative risk [RR] of SSI not using vancomycin 1.04, 95% confidence interval [CI] 0.28-3.93, p = 0.951), respectively. Patients with diabetes mellitus had higher SSI rates (RR 8.98, 95% CI 1.81-44.61, p = 0.007). CONCLUSIONS: This is the first double-blind randomized clinical trial to evaluate the effects of topical vancomycin on postoperative infection rates in thoracolumbar fusion patients, and the results did not differ significantly from placebo.Clinical trial registration no.: RBR-57wppt (ReBEC; http://www.ensaiosclinicos.gov.br/).

Spondylodiscitis investigation and therapeutic protocol: neurosurgery service results / Protocolo investigativo e terapêutico de espondilodiscite: resultados de um serviço de neurocirurgia / Investigación de espondilodiscitis y protocolo terapéutico: resultados del servicio de neurocirugía

ABSTRACT Objective: Spondylodiscitis is still a frequent pathology among neurosurgical services, and its correct treatment involves infectious, neurological and orthopedic goals. The authors describe the protocol and report the diagnostic and therapeutic results after its implementation. Methods: A prospective prognostic study (Level I) including patients with primary spondylodiscitis treated in the Neurosurgical Service of Cristo Redentor Hospital from January 2014 to March 2018. Demographic, spine, infectious and treatment-related variables were analyzed. The numerical variables are presented as mean and standard deviation or median and interquartile range (according to their parametricity), and are compared by the student's t-Test or Mann-Whitney U Test, respectively. Results: Thirty seven patients were included. The sexes were evenly distributed, with predominantly Caucasians, and a mean age of 56.89 ±15.33. Hypertension and type 2 diabetes were the most frequent comorbidities. Vertebral lumbar level was the most involved segment. Pathogens were identified in 34 cases (91%), with Staphylococcus aureus being the most prevalent, followed by Koch Bacilli. Inflammatory markers are higher in pyogenic infections at hospital admission, but lower at hospital discharge when compared to tuberculous discitis (p<0.01). Mean hospital stay was higher in the pyogenic group. Conclusion: The protocol described has a high diagnostic level of the pathogen, with cure of infection and satisfactory neurologic outcome in all cases. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.

RESUMO Objetivo: Espondilodiscite é uma patologia frequente nas enfermarias neurocirúrgicas, cujo tratamento adequado envolve questões infecciosas, neurológicas e ortopédicas. Os autores descrevem um protocolo reportando resultados diagnósticos e terapêuticos após sua implementação. Método: Estudo prognóstico prospectivo (Nível I) incluindo pacientes com espondilodiscite primária tratados de janeiro 2014 a março de 2018. Variáveis relacionadas a dados demográficos, vertebrais, infecciosos e terapêuticos foram analisados. Variáveis numéricas serão apresentadas como média e desvio padrão ou mediana e intervalo interquartil (conforme sua parametricidade) e analisadas com Teste T-Student ou Teste Mann-Whittney, respectivamente. Resultados: 37 pacientes foram incluídos, cuja média de idade foi 56.89 ±15.33. Hipertensão arterial e Diabetes foram as comorbidades mais prevalentes. O segmento lombar foi o mais acometido. Houve identificação do patógeno em 34 casos (91%), sendo o Staphylococcus aureus o mais frequente, seguido pelo Bacilo de Koch. Os marcadores inflamatórios foram maiores no grupo de discite piogênica no momento da admissão hospitalar, mas com valores inferiores aos da discite tuberculosa na alta hospitalar (p<0.01). A média de internação hospitalar foi maior no grupo piogênico. Conclusão: O protocolo descrito tem elevada taxa de identificação do patógeno com critérios de cura infecciosa e desfecho neurológico satisfatório em todos os casos descritos. Nível de Evidência I, Estudos diagnósticos - Investigação de um exame para diagnóstico.

RESUMEN Objetivo: La espondilodiscitis sigue siendo una patología frecuente en los servicios de neurocirugía y su tratamiento correcto incluye objetivos infecciosos, neurológicos y ortopédicos. Los autores describen un protocolo e informan los resultados diagnósticos y terapéuticos después de su implementación. Métodos: Estudio pronóstico prospectivo (Nivel I) que incluyó pacientes con espondilodiscitis primaria tratados en el Servicio de Neurocirugía del Hospital Cristo Redentor desde enero de 2014 hasta marzo de 2018. Se analizaron variables demográficas, vertebrales, infecciosas y relacionadas con el tratamiento. Las variables numéricas se presentan como promedio y la desviación estándar o mediana y rango intercuartil (según su parametricidad) y se comparan mediante la prueba t de Student o la prueba U de Mann-Whitney, respectivamente. Resultados: Se incluyeron 37 pacientes. Los sexos se distribuyeron uniformemente, con predominancia de caucásicos y una edad promedio de 56,89 ± 15,33. La hipertensión y la diabetes tipo 2 fueron las comorbilidades más frecuentes. El nivel lumbar fue el segmento más afectado. Se identificaron patógenos en 34 casos (91%), siendo el Staphylococcus aureus el más frecuente, seguido por el bacilo de Koch. Los marcadores inflamatorios fueron más en las infecciones piógenas en el hospital, pero más bajos en el alta hospitalaria en comparación con la discitis tuberculosa (p < 0,01). La estancia hospitalaria promedio fue mayor en el grupo piógeno. Conclusiones: El protocolo descrito tiene un alto nivel de diagnósticos del patógeno, con curación de la infección y resultados neurológicos satisfactorios en todos los casos. Nivel de Evidencia I, Estudios de diagnósticos - Investigación de un examen para diagnóstico.

Subaxial spine arthrodesis in patients with spine fractures and facet joint dislocations: Is magnetic resonance imaging required to determine the optimal surgical approach?

BACKGROUND: The medical literature suggests that facet dislocations (FDs) must be managed surgically, even in the absence of spinal cord injury. In fact, there is no standard guideline for managing FD cases and whether magnetic resonance imaging (MRI) should be utilized for optimizing treatment planning. METHODS: Fifteen cases of FD were evaluated twice by nine spine surgeons. The first assessment included computed tomography (CT) images only. Secondarily, original CT studies were supplemented with MRI. In each case, the participating surgeon had to acknowledge whether and what surgical treatment they would offer. Data for the two responses from all nine surgeons were then compared. RESULTS: Based on CT images alone, there was no consensus regarding treatment choices in 13 cases, and a trend toward consensus in just two instances (κ = 0.01). When MRI scans were added to CT studies, among the 15 cases evaluated, 10 cases demonstrated a trend toward consensus, and in 1 case consensus was achieved. The Kappa interpersonal agreement based on MRI was 0.13. The analysis of the answers by each contributor in each case demonstrated that in 58.51% of cases the surgical treatment options were changed when analyzed by CT + MRI, in comparison to the options indicated based on CT alone. CONCLUSION: It appears that obtaining an MRI in addition to a CT before spine surgery for FD is essential mandatory, as it changed the treatment option in nearly 60% of cases.

Reliability of Tokuhashi Score to Predict Prognosis: Comparison of 117 Patients.

BACKGROUND: Spinal metastatic disease compromises the quality of life and prognosis of the patients. Prognosis is an important factor for the decision-making process and needs to be precise in order to adjust the intensity of therapy. The Tokuhashi score is a universal instrument to determine the prognosis. The objective was to analyze the effectiveness of the Tokuhashi score in determining the prognosis of the patients with spine metastasis by comparing the expected survival time from the Tokuhashi score with the survival time observed among surgical patients. METHODS: This retrospective study was performed from October 2008 to October 2015. The inclusion criteria were symptomatic patients with spinal metastasis who underwent spinal cord decompression and had a minimum of 1-year follow-up. The exclusion criteria were patients without histologic confirmation and were lost to follow-up. The Tokuhashi score was applied, and once the expected survival was defined, it was compared with the survival time observed in the follow-up. RESULTS: The sample studied was 117 patients. The commonly female (58%) and breast spinal metastasis was often observed (25.6%). The patients were followed for a minimum period of 12 months. The actual survival was beyond that estimated by the Tokuhashi score (P < 0.05). CONCLUSION: The Tokuhashi score was not reliable to predict the prognosis. Patients with lower scores that surgical treatment was not recommended by the Tokuhashi score had better quality of life and longer survival after surgery. Tokuhashi score is not a precise tool to establish the best therapy and survival in patients with spinal metastasis.

Epidemiology and Management of Spinal Trauma in Children and Adolescents <18 Years Old.

OBJECTIVE: This retrospective study reports the epidemiology, clinical aspects, and management of spinal trauma in children and adolescents. METHODS: Multicenter study of 215 cases of spinal trauma in individuals <18 years of age. All patients were submitted to preoperative and postoperative radiologic and clinical evaluation. The fractures were classified according to the AOSpine fracture classification. Neurological evaluation was performed using the Frankel scale at admission to hospital and at the last follow-up. RESULTS: Mean age was 14.7 (± 2.5) years and most of the patients were male (72.6%). Falls were responsible for 52.6% of the spinal trauma. Compression fracture was the most common type of fracture, observed in 48.4% of the cases. Most spinal fractures were located at the thoracic level (58.7%). Associated injuries were observed in 37.2% of the cases. The complication rates were 15.8%. Normal neurological examination was observed in 160 cases (74.4%) at the final follow-up. Neurological impairment was mostly observed due to shallow water diving, dislocation fractures types, and fractures located between the lower cervical spine and the thoracic spine. Surgical treatment was performed in 73.8% of the cases. Better neurological outcome was observed in fractures due to falls, fractures located in the upper cervical (C1-C2) and lower lumbar spine injuries (L3-L5). CONCLUSIONS: Surgical treatment is often necessary in children and adolescents after spinal trauma. Higher incidence of spinal cord injury was observed after shallow water diving, fractures located in the lower cervical spine and thoracic spine, and type B and C fractures.

Thoracolumbar spinal arthrodesis - epidemiology and costs / Artrodese de coluna toracolombar - epidemiologia e custos / Artrodesis de la columna toracolumbar - epidemiología y costos

ABSTRACT Objective: To describe the epidemiology of patients with thoracolumbar spine fracture submitted to surgery at Hospital Cristo Redentor and the related costs. Methods: Prospective epidemiological study between July 2014 and August 2015 of patients with thoracolumbar spine fracture with indication of surgery. The variables analyzed were sex, age, cost of hospitalization, fractured levels, levels of arthrodesis, surgical site infection, UTI or BCP, spinal cord injury, etiology, length of stay, procedure time, and visual analog scale (VAS) . Results: Thirty-two patients were evaluated in the study period, with a mean age of 38.68 years. Male-female ratio was 4:1 and the most frequent causes were fall from height (46.87%) and traffic accidents (46.87%). The thoracolumbar transition was the most affected (40.62%), with L1 vertebra involved in 23.8% of the time. Neurological deficit was present in 40.62% of patients. Hospital stay had a median of 14 days and patients with neurological deficit were hospitalized for a longer period (p<0.001), with an increase in hospital costs (p= 0.015). The average cost of hospitalization was U$2,874.80. The presence of BCP increased the cost of hospitalization, and patients with spinal cord injury had more BCP (p= 0.014) . Conclusion: Public policies with an emphasis on reducing traffic accidents and falls can help reduce the incidence of these injuries and studies focusing on hospital costs and rehabilitation need to be conducted in Brazil to determinate the burden of spinal trauma and spinal cord injury.

RESUMO Objetivo: Descrever a epidemiologia dos pacientes com fratura de coluna toracolombar submetidos à cirurgia no Hospital Cristo Redentor e os custos relacionados. Métodos: Estudo epidemiológico prospectivo entre julho de 2014 e agosto de 2015 de pacientes com fratura da coluna toracolombar com indicação de cirurgia. Foram analisadas as variáveis sexo, idade, custo da internação hospitalar, níveis fraturados, níveis de artrodese, infecção de sítio cirúrgico, ITU ou BCP, lesão medular, etiologia, dias de internação, tempo de procedimento e escala visual analógica (EVA) . Resultados: Foram avaliados 32 pacientes no período estudado, com média de idade de 38,68 anos. A relação entre homens e mulheres foi 4:1 e as causas mais frequentes foram queda de altura (46,87%) e acidentes de trânsito (46,87%). A transição toracolombar foi a mais acometida (40,62%) com a vértebra de L1 envolvida em 23,8% das vezes. Apresentaram déficit neurológico 40,62% dos pacientes. O tempo de permanência hospitalar teve mediana de 14 dias e os pacientes com déficit neurológico permaneceram internados por período mais prolongado (p <0,001), com aumento dos custos hospitalares (p= 0,015). O custo médio da internação foi de U$ 2.874,80. A presença de BCP aumentou o custo da internação e os pacientes com lesão medular tiveram mais BCP (p= 0,014). Conclusão: Políticas públicas com ênfase na redução de acidentes de trânsito e quedas podem ajudar a reduzir a incidência dessas lesões e estudos com foco nos gastos hospitalares e em reabilitação precisam ser realizados no Brasil para determinar o fardo socioeconômico do traumatismo vertebral e traumatismo medular.

RESUMEN Objetivo : Describir la epidemiología de los pacientes con fractura de columna toracolumbar sometidos a cirugía en el Hospital Cristo Redentor y los costos relacionados. Métodos : Estudio epidemiológico prospectivo entre julio de 2014 y agosto de 2015 de pacientes con fracturas de la columna toracolumbar con indicación de cirugía. Se analizaron las variables sexo, edad, costo de hospitalización, niveles fracturados, niveles de artrodesis, infección del sitio quirúrgico, ITU o BCP, lesión de la médula espinal, etiología, duración de la estancia hospitalaria, tiempo del procedimiento y la escala visual analógica (EVA). Resultados: Fueron evaluados 32 pacientes durante el período de estudio, con un promedio de edad de 38,68 años. La relación entre hombres y mujeres fue de 4:1 y las causas más frecuentes fueron las caídas de altura (46,87%) y los accidentes de tránsito (46,87%). La transición toracolumbar fue la más afectada (40,62%) con la vértebra de L1 involucrada en 23,8% de los casos. Presentaron déficit neurológico 40,62% de los pacientes. La estancia hospitalaria tuvo mediana de 14 días y los pacientes con déficit neurológico permanecieron hospitalizados por un período más largo (p <0,001), con un aumento de los gastos de hospital (p= 0,015). El costo promedios de hospitalización fue de U$ 2.874,80. La presencia de BCP aumentó el costo de la hospitalización y los pacientes con lesión de la médula espinal tuvieron más BCP (p= 0,014) . Conclusión : Políticas públicas, con énfasis en la reducción de los accidentes de tránsito y las caídas pueden ayudar a reducir la incidencia de estas lesiones y los estudios centrados en los costos hospitalarios y de rehabilitación deben ser llevados a cabo en Brasil para determinar la carga socioeconómica del trauma espinal y la lesión de médula espinal.

Management of Type II Odontoid Fractures: Experience from Latin American Spine Centers.

OBJECTIVE: To analyze characteristics of type II odontoid fracture (TII-OF), including clinical and radiographic factors, that influence surgical planning in 8 Latin American centers. METHODS: Retrospective chart review was performed of 88 patients with TII-OF between 2004 and 2015 from 8 Latin American centers. Parameters studied included 1) demographic data and causes of TII-OF, 2) clinical and neurologic presentation, 3) characteristics of fracture (degree of odontoid displacement, displacement of odontoid relative to C2 body, anatomy of fracture line, distance between fragments, presence of comminution, contact area between odontoid and C2 body), 4) type of treatment, and 5) clinical and radiographic outcome. Bone fusion was assessed using computed tomography. RESULTS: Mean patient age was 45.33 years ± 23.54; 78.4% of patients were male. Surgery was the primary treatment in 65 patients (73.8%), with an anterior approach in 64.6%. Surgery was usually preferred in patients with posterior or horizontal oblique fracture lines, local pain, and a smaller bone contact surface between the odontoid and the body of C2. A posterior approach was chosen when distance between the fractured bone fragments was >2 mm or after failed conservative or anterior odontoid screw treatment in a symptomatic patient. CONCLUSION: The treatment of choice for TII-OF in 8 Latin American trauma centers was surgery through an anterior approach using screw fixation. Posterior segmental C1-C2 fixation was indicated when distance between bone fragments was >2 mm and in symptomatic patients with nonunion.

Ligamentum flavum hematoma: a case report and literature review / Hematoma de ligamento amarelo: relato de caso e revisão da literatura / Hematoma del ligamento amarillo: caso clínico y revisión de la literatura

The aim is to present a rare case of ligamentum flavum hematoma in the lumbar region, discuss its physiopathology and treatment and review the literature. A woman aged 68 presented with neurogenic claudication due to degenerative lumbar spondylolisthesis that evolved into a sudden worsening with cauda equina syndrome. The magnetic resonance imagining (MRI) showed signs of degeneration of the lumbar spine, with a narrow spinal canal from L2 to S1, anterolisthesis L4 L5 and an expansive lesion hyperintense on T1-weighted and hypointense on T2-weighted images considered compatible with hematoma in the topography of the yellow ligament in L1-L2. The patient underwent laminectomy and lumbar fixation. Her evolution was good in the postoperative period and at 18 months of follow-up hse walked alone, despite the pain that is controlled with simple medications. Even though rare, it seems that ligamentum flavum hematoma has a relationship with the degeneration and rupture of small vessels associated with micro trauma to the spine. Its physiopathology is not well defined and treatment is similar to other spine compression processes.

O objetivo é apresentar um caso raro de hematoma do ligamento amarelo na região lombar, discutir sua fisiopatologia e tratamento e revisar a literatura. Uma mulher de 68 anos apresentou-se com claudicação neurogênica devido à doença degenerativa lombar e espondilolistese que evoluiu para uma piora súbita com a síndrome da cauda equina. A imagem por ressonância magnética (IRM) mostrou sinais de degeneração da coluna lombar, com um canal vertebral estreito de L2 a S1, ântero-listese de L4 L5 e, posteriormente no nível da L1-L2, um processo expansivo arredondado e hiperintenso em T1 e com bordas hipointensas em T2 ponderada, compatível com hematoma na topografia do ligamento amarelo. A paciente foi submetida a laminectomia e fixação lombar. Sua evolução foi boa no período pós-operatório e, aos 18 meses de follow-up andou sozinha, apesar da dor que é controlada com medicamentos simples. Mesmo sendo raro, parece que o hematoma do ligamento amarelo tem uma relação com a degeneração e ruptura de pequenos vasos associadas a microtraumas na coluna vertebral. Sua fisiopatologia ainda não é bem definida e o tratamento é semelhante ao de outros processos de compressão da coluna vertebral.

El objetivo es presentar un caso raro de un hematoma ligamento flavum en la región lumbar, discutir su fisiopatología y el tratamiento y revisión de la literatura. Una mujer de 68 años presentó claudicación neurogénica debido a la espondilolistesis lumbar degenerativa y que se convirtió en un repentino empeoramiento con el síndrome de cauda equina. Una imagen de resonancia magnética (RM) mostró signos de degeneración de la columna lumbar, con canal espinal estrecho de L2 a S1, anterolistesis L4 L5 y en la L1-L2, un proceso expansivo redondeado e hiperintenso en T1 y hipointenso en los bordes en T2, compatible con hematoma en la topografía del ligamento amarillo. La paciente fue sometida a laminectomía y fijación lumbar. Su evolución fue buena en el postoperatorio y, a los 18 meses de seguimiento caminaba sola, a pesar del dolor que se controla con medicamentos simples. Aunque raro, parece que el hematoma del ligamento amarillo tiene relación con la degeneración y la ruptura de pequeños vasos asociadas a micro-traumas en la columna vertebral. Su fisiopatología no está bien definida y el tratamiento es similar a otros procesos de compresión de la columna vertebral.

Chondromyxoid fibroma of C1: first case report / Fibroma condromixóide de C1: primeiro relato de caso / Fibroma condromixoide de C1: primer caso

BACKGROUND: Chondromyxoid fibroma (CMF) is a rare, benign primary bone tumor. The cervical spine is an uncommon site for this tumor, with only 10 reported cases to date and none involving the first cervical vertebra (C1). CASE REPORT: Female patient, 25-year-old monozygotic female twin, presented with cervical pain. Radiographic imaging demonstrated a contrast-enhanced, right-sided lytic lesion of the insufflated type in C1, with a punched-out appearance and extending to the anterior arch. A postero-lateral and a posterior approach were performed in two steps to resect the tumor followed by occipitocervical fixation. Pathology confirmed the diagnosis of CMF. At one year, the patient remains disease free with excellent spinal stability. CONCLUSION: Spinal surgeons may need to treat rare spinal tumors. Despite the proximity to neural and vascular structures, the goal of surgery is always a radical resection due to high recurrence rates.

REVISÃO: O fibroma condromixóide (FCM) é um tumor ósseo primário, benigno e raro. A coluna cervical é um local incomum desse tumor, com apenas 10 casos relatados, sendo que nenhum envolveu a primeira vértebra cervical (C1). RELATO DO CASO: Paciente do sexo feminino, 25 anos, gêmea monozigótica, apresentando dor cervical. A imagem radiográfica demonstrou lesão lítica contrastada, predominantemente na massa lateral de C1 com extensão para o arco posterior e anterior. A ressecção do tumor foi feita em dois tempos, inicialmente uma abordagem postero-lateral, seguida pela via posterior. Nesta última, foi relizada uma fixação occiptocervical. O exame anátomo-patológico foi compatível com FCM. Passado um ano dos procedimentos, a paciente permanecia sem doença e com estabilidade craniocervical. CONCLUSÃO: Especialistas de coluna devem ter o conhecimento de que estes tumores raros podem acometer a coluna vertebral e, apesar da sua proximidade com tecido neural e estruturas vasculares, o objetivo da cirurgia é a sua ressecção radical devido ao alto índice de recidiva.

REVISIÓN: El fibroma condromixoide (FCM) es un tumor óseo primario, benigno y raro. La columna cervical es un lugar raro de este tumor, con solamente 10 casos relatados, siendo que ninguno involucra a la primera vértebra cervical (C1). RELATO DEL CASO: Paciente del sexo femenino, 25 años, gemela monozigótica, presentando dolor cervical. La imagen radiográfica demostró una lesión contrastada, predominantemente en la masa lateral de C1 con extensión hacia el arco posterior y anterior. La resección del tumor se realizó en dos tiempos, inicialmente una aproximación posterolateral, seguida por la vía posterior. En esta última, se realizó una fijación occipitocervical. El análisis anatomopatológico fue compatible con FCM. Pasado un año de los procedimientos, la paciente permanecía sin enfermedad y con estabilidad cranio-cervical. CONCLUSIÓN: Especialistas de columna deben tener el conocimiento de que estos tumores raros pueden acometer a la columna vertebral y, a pesar de su proximidad con el tejido neural y las estructuras vasculares, el objetivo de la cirugía es su resección radical debido al alto índice de recidiva.

Microvascular decompression of the trigeminal nerve: technical note / Descompressão microvascular do nervo trigêmeo: nota técnica

The technique described by Jannetta uses Teflon ?turfs? (polytetrafluoroethylene). With the technological advancement of materials it is increasingly harder to find Teflon in the market. The author describes a technique which uses a portion of a vascular prosthesis made of polyester (FlowNit Bioseal®) manufactured by JOTEC® Gmbh reference 35BI1206. The use of this vascular prosthesis seems to be an effective alternative for intracranial neurovascular decompression. One of its advantages is having a circumferential format, which provides greater stability and safety to possible displacement.

A técnica descrita por Jannetta utiliza ?tufos? de Teflon (politetrafluoroetileno). Com o avanço tecnológico dos materiais, está cada vez mais difícil a aquisição de Teflon no mercado. O autor descreve uma técnica utilizando uma porção de prótese vascular de poliéster (FlowNit Bioseal®), fabricado por JOTEC® Gmbh referência 35BI1206. O uso da prótese vascular parece ser uma alternativa efetiva para descompressão neurovascular intracraniana. Possui a vantagem de apresentar o formato circunferencial, que permite maior estabilidade e segurança em possíveis deslocamentos.

Implantação do sistema de procedimentos de alta complexidade em neurocirurgia: resultados / Implementation of high complexity service in a city hospital of metropolitan region of Porto Alegre city, Brazil

Objetivo: Demonstrar a maneira como foi implementado o Serviço de Alta Complexidade em Neurocirurgia num município da região metropolitana de Porto Alegre e seus resultados benéficos à população, aos neurocirurgiões e à Instituição Hospitalar. Material e método: São demonstrados os argumentos que o grupo de neurocirurgiões adotou para convencer a direção do Hospital Municipal de Novo Hamburgo(HMNH) a investir na especialidade antes mesmo de ter noção real das vantagens e dos lucros que adviriam. Resultados: Foi constatado que havia uma evasão mensal de aproximadamente 30 pacientes dos municípios que compunham a região para outro centro de referência (“Hospital Referência”). Essa evasão propiciaria um rendimento em torno de R$ 57 mil. Foi demonstrado que o “Hospital Referência” havia saltado de um faturamento de pouco mais de R$ 100 mil para aproximadamente R$ 500 mil após a implantação do Sipac-Neuro, e que a média de valores das autorizações de internações hospitalares(AIH) desse hospital era de R$ 1.056,12 contra R$ 382,84 do HMNH. A seguir, descrevem-se os passos que foram necessários para o credenciamento junto ao Ministério da Saúde, a implantação do serviço e os futuros investimentos que se pretende realizar em função dos novos aportes financeiros proporcionados pela Alta Complexidade. Os resultados financeiros iniciais após o credenciamento foram significativos. Conclusão: A organização e demonstração real, com exemplos de outras instituições,são instrumentos úteis e facilitadores para o convencimento das direções de hospitais que ainda são céticos quanto às vantagens proporcionadas pelo Sipac-Neuro.Administração hospitalar.

Objective: To present how a High Complexity Neurosurgical Service (accredited by the Ministry of Health denominated Sipac – Neuro) was implemented in a public hospital of the metropolitan region of the city of Porto Alegre, Brazil. Material and method: The arguments used by the group of neurosurgeons that convinced the direction of the Hospital Municipal de Novo Hamburgo (HMNH) to invest on neurosurgery, before knowing the advantages and profit that would be generated is presented. Result: It was verified that there was an monthly evasion rate of approximately 30 patients from the regions covered by HMNH to other reference center (“Reference” hospital) during the year of 2001. This evasion would have yielded around R$ 57,000. It was demonstrated that the “Reference” hospital leaped from an income of around R$100,000 to around R$ 500,000 after the implementation of the Sipac-Neuro and that the average cost of Authorization for Hospitalization (AIH) at that hospital was R$ 1,056.12 compared to R$ 382.84at HMNH. The method of accreditation with the Ministry of Health is described here in, as well as the implementation of the Service and the future investments that are to be made as a result of the new financial resources as a result of this accreditation for high complexity. Conclusion: It is concluded that the organization and actual demonstration by means of the examples of other institutions is a useful and helpful tool to convince hospital administrations who remain skeptical as to the advantages obtained with a Sipac-Neuro.