COVID-19 Impact Among Spine Surgeons in Latin America.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim of this study was to evaluate the impact of the COVID-19 outbreak in spine surgeons in Latin America. METHODS: A questionnaire was sent to Latin American spine surgeons from April 4 to 6, 2020. Surgeon characteristics were recorded. The impact of COVID-19 on economic well-being, work, and mental health were also determined. All variables were compared and analyzed. RESULTS: Two hundred four surgeons answered the complete survey; most of them were male (96.6%), the average age was 47.7 years; 58.8% (n = 120) were orthopedic surgeons and 41.2% (n = 84) were neurosurgeons. The majority of the respondents were from Argentina (59.8%, n = 122), followed by Brazil (17.2%, n = 35), Chile (6.4%, n = 13), and Mexico (5.9%, n = 12). Most of the surgeons reported performing emergency procedures only during the pandemic (76.5%, n = 156). Half used telemedicine or online consultation modalities (54.4%, n = 111). The average concern about the financial situation due to the pandemic was 7.53 in a scale of 1 to 10 (10 being the worst scenario). Twenty-two percent (n = 45) of the surgeons had a score over 10 in the Patient Health Questionnaire (PHQ-9; scores higher than 10 needs referral to confirm depression diagnosis). Young age and neurosurgery as a specialty were associated with higher PHQ-9 scores. CONCLUSIONS: COVID-19 has an impact in the daily working practice and financial situation of spine surgeons in Latin America. The long-term psychological impact should be taken into consideration to avoid a heavier burden for health care providers.

Técnica de "slalom" quirúrgico en estenosis de canal lumbar multinivel. Serie de casos tratados de manera simultánea con descompresión endoscópica y tubular con asistencia microscópica bilateral / Slalom Technique as a treatment in multilevel lumbar spinal stenosis. Series of cases treated simultaneously with endoscopic and tubular decompression with microscopic assistance

Introducción: La laminectomía unilateral para descompresión bilateral por abordaje único ha tomado relevancia en pacientes con estenosis multinivel. Cuando se realiza en más de un nivel por un abordaje único, de manera alterna y de forma cruzada, al abordaje anterior es conocida como técnica de "slalom". Elobjetivode este artículo es presentar una serie de casos tratados con la técnica de "slalom" con asistencia endoscópica y microscópica bilateral, simultánea, en pacientes con estenosis de canal lumbar multinivel.materiales y métodos: Análisis retrospectivo de pacientes tratados de forma simultánea, entre enero de 2017 y enero de 2018, todos operados por el mismo equipo quirúrgico con separadores tubulares, y asistencia endoscópica y micros-cópica simultánea.Resultados: Se incluyó a 4 hombres, con una edad promedio de 73.5 años y patología lumbar multinivel. Se descomprimieron 10 segmentos (2,5 media de niveles por paciente), con un tiempo quirúrgico promedio de 107 minutos. No hubo complicaciones asociadas y los pacientes recibieron el alta hospitalaria el día de la cirugía.Conclusiones:La técnica de "slalom" mínimamente invasiva resulta ser un procedimiento muy eficaz para resolver síntomas de estenosis multinivel asociada a una técnica combinada bilateral con dos equipos quirúrgicos para el tratamiento de este tipo de pacientes. Nivel de Evidencia: IV

Introduction: Unilateral laminectomy for bilateral decompression (ULBD) by single approach has become relevant in patients with multilevel stenosis, when it is performed at more than one level with single approach, alternately and crosswise to the previous approach is known as a slalom technique.The objective of the following work is to present a series of cases treated with the slalom technique with bilateral endoscopic and microscopic assistance, simultaneous in patients with multilevel lumbar canal stenosis. Materials and Methods: Retrospective analysis of patients treated simultaneously between the months of January 2017 to January 2018, all operated by the same surgical team with tubular separators and simultaneous endoscopic and microscopic assistance. Results: Four patients, all male, with an average age of 73.5 years with multilevel lumbar pathology, were included. In total 10 segments were decompressed (2.5 average level for patients), with an average surgery of 107 minutes. No associated complications, with hospital discharge within the day of surgery. Conclusions: The minimally invasive Slalom technique turns out to be a very effective procedure to resolve symptoms of multilevel stenosis associated with a bilateral combined technique with two surgical teams, resulting in a viable option for the treatment of this type of patient. Level of Evidence: IV

Descompresión lumbar en pacientes con enfermedad de Parkinson: serie de casos tratados con cirugía mínimamente invasiva / Lumbar decompression in patients with Parkinson's disease: series of cases treated with minimally invasive surgery

Introducción: La enfermedad de Parkinson afecta principalmente a personas >65 años. El cuadro degenerativo lumbar en el contexto de un canal estrecho sumado a la alteración neuromuscular y la mala calidad ósea, favorece al desequilibrio sagital y coronal. Los pacientes que necesitan cirugía tienen altas tasas de revisión y reoperación con técnicas instrumentadas y no ins-trumentadas. El objetivo de este estudio fue evaluar la técnica quirúrgica de descompresión mínimamente invasiva en pacientes con enfermedad de Parkinson y dolor radicular o claudicación neurogénica en los miembros inferiores. materiales y métodos: Se evaluó a pacientes con diagnóstico de canal lumbar estrecho y enfermedad de Parkinson tratados quirúrgicamente. El procedimiento se indicó por síntomas de canal estrecho o estenosis foraminal de causa degenerativa. Todos fueron tratados con una cirugía descompresiva a través de una hemilaminectomía mínimamente invasiva mediante retracción tubular y asistencia con microscopia. Resultados: De enero de 2015 a diciembre de 2017, se trató a 6 pacientes con enfermedad de Parkinson y canal lumbar estrecho. Se descomprimieron 12 niveles en total, todos estuvieron internados <24 h. No se necesitaron transfusiones, no hubo complicaciones asociadas, el tiempo promedio de cirugía fue de 120 minutos. El seguimiento mínimo fue de 12 meses, los síntomas no reaparecieron. Conclusiones: La elevada tasa de complicaciones en pacientes operados con enfermedad de Parkinson y la disminución de las complicaciones en este estudio sugieren que la cirugía mínimamente invasiva de columna lumbar debería ser una alternativa quirúrgica en estos pacientes. Nivel de Evidencia: IV

Introduction: Parkinson's disease mainly affects patients aged 65 and older. The degenerative condition at the lumbar spine in the context of a narrow canal added to the neuromuscular disorder and poor bone quality favors sagittal and coronal imbalance. Patients who need surgery have high rates of revision and reoperation with instrumented and non-instrumented techniques. The objective of this study was to evaluate the minimally invasive surgical decompression technique in patients with Parkinson's disease and radicular pain or neurogenic claudication in the lower limbs. Materials and Methods: Surgically treated patients with a diagnosis of lumbar spinal stenosis and Parkinson's disease were evaluated. The indication for the procedure was due to symptoms of the lumbar or foraminal stenosis of degenerative cause. All the patients were treated with decompressive surgery through a minimally invasive hemilaminectomy using tubular retraction and assistance with microscopy. Results: From January 2015 to December 2017, 6 patients with Parkinson's disease and lumbar spinal stenosis were treated. A total of 12 segments were decompressed, all patients were hospitalized for less than 24 hours. They did not require a transfusion nor suffered associated complications, with an average surgery time of 120 minutes. All with a minimum follow-up of 12 months and no relapse of the symptoms. Conclusion: The high rate of surgical complications in patients with Parkinson's disease, in contrast to the low rate of complications in the present study, suggests that minimally invasive surgery of the lumbar spine should be a surgical alternative in these patients. Level of Evidence: IV

Impacto psicosocial de la pandemia por COVID-19 en cirujanos de columna argentinos / Psychosocial impact of the COVID-19 pandemic on Argentine spinal surgeons

Objetivo: Evaluar el impacto psicosocial de la pandemia por COVID-19 en los cirujanos de columna de Argentina. Material y métodos: Se envió un cuestionario diseñado específicamente a los cirujanos de columna de Argentina entre el 4-6 de abril del 2020. Las preguntas incluyeron variables demográficas, económicas, laborales y la escala de depresión PHQ-9. Las variables fueron comparadas y analizadas y las diferencias estadísticamente significativas remarcadas. Resultados: Respondieron en forma completa la encuesta 122 cirujanos de columna de Argentina, la mayoría hombres (97%), la edad promedio fue de 44 años; la mitad (n: 61) eran traumatólogos y la otra mitad neurocirujanos. La mayoría respondieron estar solo haciendo cirugías de emergencia (84%, n: 102). La preocupación promedio respecto a la situación financiera fue de 7.8 en una escala de 1 al 10. El 20% (n: 24) tenía un score superior a 10 en la escala de PHQ-9. Los cirujanos más jóvenes y los neurocirujanos tenían estadísticamente scores de PHQ-9 más altos. Conclusión: Se evaluó el impacto durante la pandemia por COVID-19 en la situación laboral y financiera de los cirujanos de columna encuestados. El impacto psicológico en el largo plazo debe ser considerado, para evitar secuelas en este grupo de profesionales de la salud.

Objective: The aim of this study is to evaluate the psycho-social impact of the COVID-19 outbreak in spine surgeons in Argentina. Methods: A questionnaire was sent to Argentina spine surgeons from April 4-6th, 2020. Questions regarding demographics, economic, working status and the PHQ-9 score were included. All variables were compared, analyzed and statistically significant differences were recorded. Results: 122 surgeons from Argentina answered the complete survey, most of them were male (97 %), the average age was 44 years; half (n: 61) of them were orthopedic surgeons and half neurosurgeons. Most of the surgeons reported performing emergency procedures only during the pandemic (84 %, n: 102). The average concern about the financial situation due to the pandemic was 7.8 in a scale of 1 to 10. Twenty percent (n: 24) of the surgeons had a score over 10 in the PHQ-9. Young age and neurosurgery as a specialty were statistically related with higher PHQ-9 scores. Conclusions: COVID-19 impact ́s in working practice and financial situation of Argentina ́s spine surgeons that answered this survey was evaluated. The long-term psychological impact should be taken into consideration to avoid a heavier burden for health care providers.

Hemorragia subaracnoidea posterior a descompresión Lumbar mínimamente invasiva. Presentación de un caso y revisión de la literatura / Subarachnoid hemorrhage after minimally invasive lumbar decompression. Case report and literature review

Introducción: Las lesiones durales son complicaciones frecuentes en la cirugía de columna. La fuga de liquidocefalorraquideo (LCR) puede originar hemorragia en todos los compartimientos del cerebro. La mayoría ocurre en venas ubicadas en región cerebelosa.Material y método: Se presenta un caso de hemorragia subaracnoidea posterior a una descompresión lumbar mínimamente invasiva asociada a desgarro dural. Resultados: Evoluciona en el postoperatorio con síntomas neurológicos de cefaleas y trastornos del sensorio por lo que se decide evaluarlo con estudios por imágenes vasculares cerebrales identificándose sangrado subaracnoideo.Discusión: El sitio más frecuente de hemorragia intracraneal posterior a una cirugía de columna es el cerebelo. El mecanismo de acción de este tipo de sangrados es desconocido y controversial, hay algunos reportes que sugieren que se trataría de un sangrado venoso. El síntoma más característico de este síndrome es la cefalea. Aunque se desconoce la etiología exacta, se postula que la pérdida de volumen de LCR causa una caída en la presión intracraneal, lo que lleva a un agrandamiento de los senos venosos durales que predisponen al paciente a un hematoma subdural espontáneoConclusión: La fuga de LCR, las alteraciones asociadas al edema cerebral en la hipotensión cerebral podría ser llave del mecanismo que desencadena una hemorragia subaracnoidea.

compartments of the brain. Most occur in veins located in the cerebellar region.Material and method: A case of subarachnoid hemorrhage after a minimally invasive lumbar decompression associated with dural tear is presented.Results: It evolves in the postoperative period with neurological symptoms of headaches and sensory disorders, so it is decided to evaluate it with studies by cerebral vascular images identifying subarachnoid bleeding.Discussion: The most frequent site of intracranial hemorrhage after spinal surgery is the cerebellum. The mechanism of action of this type of bleeding is unknown and controversial, there are some reports that suggest that it would be a venous bleeding. The most characteristic symptom of this syndrome is headache. Although the exact etiology is unknown, it is postulated that the loss of CSF volume causes a drop in intracranial pressure, which leads to an enlargement of the dural venous sinuses that predispose the patient to a spontaneous subdural hematomaConclusion: CSF leakage, alterations associated with cerebral edema in cerebral hypotension could be key to the mechanism that triggers a subarachnoid hemorrhage.

Tasa de infección en 212 pacientes consecutivos tratados mediante descompresión tubular mininvasiva de la columna lumbar / Infection rate in 212 consecutive patients treated by minimally invasive lumbar tubular decompression

Introducción: Las infecciones del sitio quirúrgico pueden requerir tratamientos prolongados con antibióticos, una estancia hospitalaria más prolongada y operaciones repetidas. Las incisiones pequeñas y la posibilidad de evitar la disección subperióstica en la cirugía mininvasiva pueden reducir, al mínimo, el riesgo de infecciones posoperatorias. Sin embargo, los estudios publicados sobre infecciones después de procedimientos mininvasivos son escasos. El objetivo de este estudio fue evaluar retrospectivamente una serie de pacientes operados, de manera consecutiva, con una técnica mininvasiva y la incidencia de infección posoperatoria. Materiales y Métodos: Se incluyó a los pacientes sometidos a cirugía lumbar posterior con retractores tubulares y microscopio, en nuestro Servicio, entre enero de 2015 y enero de 2018. Los procedimientos realizados fueron discectomías tubulares, descompresiones para la estenosis de canal y resecciones de quistes sinoviales. La incidencia de infección del sitio quirúrgico se calculó y comparó con el rango de tasas de infección del sitio quirúrgico publicado. Resultados: Se realizaron cirugías no instrumentadas (discectomías, descompresiones) en 212 pacientes. La media de la edad era de 62.4 años y la relación hombre:mujer, de 1,27:1. Solo un paciente sufrió una infección del sitio quirúrgico, diagnosticada el día 9 poscirugía, que fue tratada mediante lavado y limpieza de la herida. Conclusión: La tasa de infección fue del 0,47%. La cirugía mininvasiva puede disminuir notablemente la tasa de infección del sitio quirúrgico y puede ser una herramienta eficaz para reducir, al mínimo, los costos hospitalarios. Nivel de Evidencia: IV

Introduction: Surgical site infections (SSI) can lead to prolonged antibiotic treatments, increased hospital stays, and repeated operations. Small incisions and the possibility of avoiding subperiosteal dissection in minimally invasive surgery can minimize the risk of postoperative infections. However, there is a shortage of literature on infections after mini-invasive procedures. Objective: To evaluate retrospectively a series of patients consecutively operated on with minimally invasive technique and the incidence of postoperative infection. Materials and Methods: All patients undergoing posterior lumbar surgery with tubular retractors and microscope in our department from January 2015 to January 2018 were included. The procedures performed included tubular discectomies, lumbar stenosis decompressions, and synovial cyst resections. The incidence of postoperative SSIs was calculated and compared with the literature range for SSI rates. Results: A total of 212 patients underwent non-instrumented surgeries (discectomies, decompressions). The mean age was 62.4 years with a male:female ratio of 1.27:1. Only one patient had SSI, which was diagnosed on day 9 and treated by reoperation, surgical toilet of the wound, and antibiotic therapy. Conclusion: The infection rate was 0.47%. Minimally invasive surgery can significantly reduce the SSI rate and can be an effective tool in minimizing hospital costs. Level of Evidence: IV

Access to Technology and Education for the Development of Minimally Invasive Spine Surgery Techniques in Latin America.

OBJECTIVE: To evaluate access to the technologies and education needed to perform minimally invasive spine surgery (MISS) in Latin America. METHODS: We designed a questionnaire to evaluate surgeons' practice characteristics, access to different technologies, and training opportunities for MISS techniques. The survey was sent to members and registered users of AO Spine Latin from January 6-20, 2020. The major variables studied were nationality, specialty (orthopedics or neurosurgery), level of hospital (primary, secondary, tertiary), number of surgeries performed per year by the spine surgeon, types of spinal pathologies commonly managed, and number of MISS performed per year. Other variables involved specific access to different technologies: intraoperative fluoroscopy, percutaneous screws, cages, tubular retractors, microscopy, intraoperative computed tomography, neuronavigation imaging, and bone morphogenetic protein. Finally, participants were asked about main obstacles to performing MISS and their access to education on MISS techniques in their region. RESULTS: The questionnaires were answered by 306 members of AO Spine Latin America across 20 different countries. Most answers were obtained from orthopedic surgeons (57.8%) and those with over 10 years of experience (42.4%). Most of the surgeons worked in private practice (46.4%) and performed >50 surgeries per year (44.1%), but only 13.7% performed >50 MISS per year, mainly to manage degenerative pathologies (87.5%). Most surgeons always had access to fluoroscopy (79%). Only 26% always had access to percutaneous screws, 24% to tubular retractors, 34.3% to cages (anterior lumbar interbody fusion, lateral lumbar interbody fusion, or transforaminal lumbar interbody fusion), and 43% to microscopy. Regarding technologies, 71% reported never having access to navigation, 83% computed tomography, and 69.3% bone morphogenetic protein. The main limitations expressed for widely used MISS technologies were the high implant costs (69.3%) and high navigation costs (49.3%). Most surgeons claimed access to online education activities (71%), but only 44.9% reported access to face-to-face events and 28.8% to hands-on activities, their limited access largely because the courses were expensive (62.7%) or few courses were available on MISS in their region (51.3%). CONCLUSIONS: Most surgeons in Latin America have limited resources to perform MISS, even in private practice. The main constraints are implant costs, access to technologies, and limited face-to-face educational opportunities.

Neurosurgery versus orthopedic surgery: Who has better access to minimally invasive spinal technology?

BACKGROUND: Our aim was to evaluate differences in neurosurgeons versus orthopedists access to technologies needed to perform minimally invasive spine surgeries (MISS) in Latin America. METHODS: We sent a survey to members of AO Spine Latin America (January 2020), and assessed the following variables; nationality, level of hospital (primary, secondary, and tertiary), number of spinal operations performed per year, spinal pathologies addressed, the number of minimally invasive spine operations performed/year, and differences in access to MISS spinal technology between neurosurgeons and orthopedists. RESULTS: Responses were returned from 306 (25.6) members of AO Spine Latin America representing 20 different countries; 57.8% of respondents were orthopedic surgeons and 42.4% had over 10 years of experience. Although both specialties reported a lack of access to most of the technologies, the main difference between the two was greater utilization/access of neurosurgeons to operating microscope (e.g., 84% of the neurosurgeons vs. 39% of orthopedic spine surgeons). CONCLUSION: Although both specialties have limited access to MISS spinal technologies, orthopedic spine surgeons reported significantly lower access to operating microscopes versus neurosurgeons (P < 0.01).

Inestabilidad de la columna cervical subaxial por falla de la banda de tensión posterior: artrodesis contécnica de Magerl. informe preliminar de los resultados a corto plazo / Instabilidade da coluna cervical subaxial por falha da banda de tensão posterior: artrodese com técnica de Magerl. resultados preliminares a curto prazo / Subaxial cervical spine instability due to failure of posterior tension band: arthrodesis with Magerl technique. preliminary results in the short term

OBJETIVO: Analizar, retrospectivamente los resultados a corto plazo de las lesiones traumáticas inestables de la región subaxial, tratadas mediante fijación cervical por vía posterior con técnica de Magerl, utilizando sistema de barras y tornillos poliaxiales en las masas laterales. MÉTODOS: Se efectuó una revisión de pacientes con lesión traumática inestable cervical subaxial y afectación de la banda de tensión posterior (tipo B.1 de la AO), que hubieran sido operados con fijación posterior con barras y tornillos poliaxiales en las masas laterales, siguiendo la técnica de Magerl, utilizando criterios de selección anatómicos, diagnóstico-imagenológicos y éticos. Se valoraron, en el seguimiento, los resultados radiológicos, funcionales y neurológicos. RESULTADOS: Se incluyeron 9 pacientes (8 varones, 1 mujer), con edad promedio de 25 años (rango 21 - 34) y seguimiento promedio de 20 meses (rango 12 - 24). Tanto los resultados radiológicos, como los funcionales y los neurológicos, fueron excelentes en todos los casos, sin desviación en cifosis ni desplazamiento anteroposterior, y sin síntomas importantes en el seguimiento. Los dos casos tratados, con fijación de tres vértebras, presentaron cierta rigidez cervical esporádica. En ningún caso se extrajeron los implantes. CONCLUSIONES: Los beneficios obtenidos sugieren que es una técnica útil, segura, eficaz y versátil para las lesiones traumáticas inestables de la columna cervical baja, tipo B.1, inclusive aquellas multisegmentarias, especialmente en pacientes jóvenes.

OBJETIVO: Analisar retrospectivamente os resultados a curto prazo de lesões traumáticas instáveis na região cervical subaxial tratadas com fixação posterior pela técnica de Magerl, usando-se um sistema de parafusos poliaxiais e hastes nas massas laterais. MÉTODOS: Foi realizada a análise de pacientes com lesão traumática cervical subaxial instável e envolvimento da banda de tensão posterior (AO tipo B.1), que haviam sido submetidos a cirurgia com fixação posterior com parafusos poliaxiais e hastes nas massas laterais, de acordo com a técnica de Magerl e segundo critérios de seleção anatômicos, de diagnóstico por imagem e éticos. No acompanhamento, foram avaliados os resultados radiológicos, funcionais e neurológicos. RESULTADOS: Foram incluídos nove pacientes (8 homens, 1 mulher) com média de idade de 25 anos (faixa 21-34) e acompanhamento médio de 20 meses (faixa 12-24). Tanto os achados radiológicos quanto os neurológicos e funcionais foram excelentes em todos os casos, sem desvio ou deslocamento em cifose ântero-posterior e sem sintomas importantes ao longo do acompanhamento. Os dois casos tratados com fixação de três vértebras tinham certa rigidez cervical esporádica. Em nenhum caso os implantes foram removidos. CONCLUSÕES: Os benefícios obtidos sugerem que a técnica é útil, segura, eficiente e versátil para lesões traumáticas instáveis ​​da coluna cervical baixa tipo B.1, mesmo nas lesões multissegmentares, especialmente em pacientes mais jovens.

OBJECTIVE: To analyze retrospectively the short-term results of unstable traumatic injuries in the cervical subaxial region treated with posterior fixation by Magerl technique, using polyaxial screws and rods in the lateral masses. METHODS: We performed a review of patients with unstable subaxial cervical traumatic injury and involvement of the posterior tension band (AO type B.1) who underwent surgery with posterior fixation with polyaxial screws and rods in the lateral masses according to the Magerl technique using selection criteria based on anatomy, diagnostic images, and ethics. In the follow-up period, the radiological, functional, and neurological outcomes were assessed. RESULTS: We included 9 patients (8 men, 1 woman) with an average age of 25 years (range 21 - 34) and a mean follow-up of 20 months (range 12 - 24). The radiologicalas well as the neurological and functional findings were excellent in all cases, without deviation or displacement in anteroposterior kyphosis, and with no symptoms during the follow-up period. The two cases treated with fixation of three vertebrae had some sporadic cervical stiffness. In no case were the implants removed. CONCLUSIONS: The benefits obtained suggest that the technique is useful, safe, efficient and versatile for unstable traumatic injuries of the lower cervical spine type B.1, even in multisegmental lesions, especially in young patients.