¿Cómo planifico una cirugía de escoliosis idiopática del adolescente? Sistematización de un método de planificación preoperatoria / How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method

La planificación preoperatoria resulta fundamental en la cirugía de escoliosis idiopática del adolescente (EIA) para determinar los niveles a fusionar y realizar el procedimiento con mayor precisión y diligencia. Sin embargo, su realización protocolizada no está tan extendida entre los especialistas en formación. El objetivo de este artículo es describir en detalle el método de planificación preoperatoria en la EIA empleado en una unidad especializada de raquis infantil y del adolescente de un centro de referencia, así como, la logística y la táctica, apoyado en un software gratuito de medición digital semiautomática y planificación. Se muestran 3 casos representativos de diferentes deformidades vertebrales, intervenidos mediante una artrodesis vertebral posterior tras una planificación preoperatoria según el método descrito. Este método resulta muy adecuado para el cirujano en formación al aunar las ventajas de los métodos tradicionales y los más modernos, y ser sencillo, de bajo coste, accesible, reproducible y con carácter formativo.(AU)

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialized pediatric and adolescent spine unit of a referral center, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low cost, accessible, reproducible and with an educational character.(AU)

[Translated article] How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method / ¿Cómo planifico una cirugía de escoliosis idiopática del adolescente? Sistematización de un método de planificación preoperatoria

La planificación preoperatoria resulta fundamental en la cirugía de escoliosis idiopática del adolescente (EIA) para determinar los niveles a fusionar y realizar el procedimiento con mayor precisión y diligencia. Sin embargo, su realización protocolizada no está tan extendida entre los especialistas en formación. El objetivo de este artículo es describir en detalle el método de planificación preoperatoria en la EIA empleado en una unidad especializada de raquis infantil y del adolescente de un centro de referencia, así como, la logística y la táctica, apoyado en un software gratuito de medición digital semiautomática y planificación. Se muestran 3 casos representativos de diferentes deformidades vertebrales, intervenidos mediante una artrodesis vertebral posterior tras una planificación preoperatoria según el método descrito. Este método resulta muy adecuado para el cirujano en formación al aunar las ventajas de los métodos tradicionales y los más modernos, y ser sencillo, de bajo coste, accesible, reproducible y con carácter formativo.(AU)

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialized pediatric and adolescent spine unit of a referral center, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low cost, accessible, reproducible and with an educational character.(AU)

[Translated article] How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method.

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialised paediatric and adolescent spine unit of a referral centre, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low-cost, accessible, reproducible and with an educational character.

Manejo de las metástasis vertebrales en la charnela cervico-occipital / Management of vertebral metastases in the cervico-occipital junction

Las metástasis a nivel occipito-cervical corresponden solo al 0,5% de las metástasis del raquis. El manejo de estas lesiones es complejo y conlleva múltiples estudios radiológicos, tales como la radiología simple, la tomografía computarizada (TAC) o la resonancia magnética (RM). Ante la sospecha de afectación vascular también será recomendable la realización de pruebas que valoren la permeabilidad vascular (angio-TC, angio-RM). Este tipo de lesiones, debido a su compleja localización, puede precisar distintos tipos de vías de abordaje; comúnmente será el abordaje posterior, pero en ocasiones se necesitarán abordajes anteriores o anterolaterales asistidos por cirujanos maxilofaciales u otorrinolaringólogos para una correcta exéresis de la tumoración. El dolor con los giros puede orientarnos al diagnóstico en una columna inestable. La RM es la prueba de elección para diagnosticar y estudiar estas lesiones. La presencia de inestabilidad o de clínica neurológica progresiva es indicación de cirugía.(AU)

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.(AU)

[Translated article] Management of vertebral metastases in the cervico-occipital junction / Manejo de las metástasis vertebrales en la charnela cervicooccipital

Las metástasis a nivel occipito-cervical corresponden solo al 0,5% de las metástasis del raquis. El manejo de estas lesiones es complejo y conlleva múltiples estudios radiológicos, tales como la radiología simple, la tomografía computarizada (TAC) o la resonancia magnética (RM). Ante la sospecha de afectación vascular también será recomendable la realización de pruebas que valoren la permeabilidad vascular (angio-TC, angio-RM). Este tipo de lesiones, debido a su compleja localización, puede precisar distintos tipos de vías de abordaje; comúnmente será el abordaje posterior, pero en ocasiones se necesitarán abordajes anteriores o anterolaterales asistidos por cirujanos maxilofaciales u otorrinolaringólogos para una correcta exéresis de la tumoración. El dolor con los giros puede orientarnos al diagnóstico en una columna inestable. La RM es la prueba de elección para diagnosticar y estudiar estas lesiones. La presencia de inestabilidad o de clínica neurológica progresiva es indicación de cirugía.(AU)

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.(AU)

[Translated article] Management of vertebral metastases in the cervico-occipital junction.

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or antero-lateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumour. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms is an indication for surgery.

Management of vertebral metastases in the cervico-occipital junction. / Manejo de las metástasis vertebrales en la charnela cervico-occipital.

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.

How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method. / ¿Cómo planifico una cirugía de escoliosis idiopática del adolescente? Sistematización de un método de planificación preoperatoria.

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialized pediatric and adolescent spine unit of a referral center, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low cost, accessible, reproducible and with an educational character.

Congenital knee dislocation. Therapeutic protocol and long-term functional results. / Luxación congénita de rodilla. Protocolo terapéutico y resultados funcionales a largo plazo.

BACKGROUND AND OBJECTIVE: Congenital knee dislocation is a very rare entity, characterised by deformity in knee recurvatum present at birth, and there is currently no consensus on the optimal treatment. The aim of the present study is to analyse the functional results and long-term complications after the application of a protocol of therapeutic action for the management of congenital knee dislocation (CKD) created in a reference centre for child orthopaedics. MATERIALS AND METHODS: Retrospective descriptive study of patients with congenital dislocation of the knee who followed CRPL between January 1997 and December 2010. Demographic variables, type of treatment, functional outcomes at the end of the follow-up, complications and relapses were studied. The conservative treatment consisted of serial casts, leaving the surgical treatment for cases in which passive flexion was not achieved above 30° or the conservative treatment failed. RESULTS: 9 patients (11 knees) met the inclusion criteria. The 66.7% were girls and the average follow-up was 15 years (9-22). In all cases, conservative treatment was initiated. Of the 11 knees treated, less than half (36%) required surgery. The average Lysholm questionnaire was 90.3 points, the WOMAC pain 0.4 (0-1), WOMAC stiffness 1.8 (0-6) and WOMAC function 3.8 (1-12). CONCLUSIONS: The existence and application of the PLCR protocol in a pathology as rare as congenital knee dislocation suggests good long-term functional results with few complications and no recurrences.

Intramuscular psoas lengthening at the pelvic brim plus proximal lengthening of the rectus femoris as a treatment for fixed knee flexion deformity in cerebral palsy. / Tenotomía intrapélvica del psoas y alargamiento proximal del recto anterior como tratamiento del flexo fijo de rodilla en parálisis cerebral infantil.

Although the correction of knee flexion by lengthening the hamstring musculature is traditionally contemplated in cerebral palsy, literature suggests that treatment of hip flexion also improves knee extension. The aim of the study was to first show the efficacy of the sequence of intrapelvic tenotomy of the psoas followed by intramuscular lengthening of the proximal rectus anterior and, later, that of both surgical soft tissue surgeries separately. For this, a prospective study was carried out in 10 patients with a mean age of 14 years, which presented 16 fixed knee flexes with a mean of deformity of 22°. The data was analyzed through means of an ANOVA of repeated measures and to determine the effect separately of each one of the techniques, the improvements obtained with respect to the previous level were contrasted. The mean extension achieved was 12°, 7° corresponding to the intrapelvic tenotomy of the psoas and, on the remaining knee flexion, a correction of 5° after intramuscular lengthening of the anterior rectus at the proximal level. Both the sequence of proposed gestures and those that form separately, showed statistically significant differences (P <0.001) in the correction of the deformity. In conclusion, the proposed techniques applied sequentially or separately are effective in reducing knee flexion in predominantly spastic cerebral palsy, facilitating or even being able to avoid the treatment that is directly needed.

[Evaluation of function and limiting factors of gait disorder treatment in cerebral palsy: development of the Walking Abilities Levels Classification System]. / Evaluación funcional y de factores limitantes del tratamiento de los trastornos de la marcha en la parálisis cerebral infantil: desarrollo del sistema de clasificación de niveles de deambulación funcional.

INTRODUCTION: The Gross Motor Function Classification System has allowed us to stratificate cerebral palsy patients, according to their walking abilities. The lack of sensitivity about detecting changes and the absence of a global patient evaluation, justify the search of new pre-operative evaluation tools. AIMS: To present the Walking Abilities Levels Classification System (WALCS) and to show the first inter-observer agreement study that has been carried out. This system uses first a different pattern for ordering gait functional skills, and after that, evaluates the reversibility of the contextual factors that may limit the result of a gait disorder treatment. SUBJECTS AND METHODS: A new evaluation frame was built by an interdisciplinary team with an average professional experience of more than 15 years, initially focused as part of the pre-surgical patient evaluation. An inter-observer agreement study was held to gain the first insight of it. 14 participants studied the medical reports and gait lab video images of 10 cases. RESULTS: The kappa index was 0.76 for the walking ability level, 0.79 for the biological type, 0.69 psychological type and 0.64 social type of limiting factors. CONCLUSIONS: The WALCS offers a new evaluation frame gathering patient walking skills and limiting factors treatment. The initial inter-observer agreement rate endorsed more intra- and inter-studies in order to achieve a more robust validation.

TITLE: Evaluación funcional y de factores limitantes del tratamiento de los trastornos de la marcha en la parálisis cerebral infantil: desarrollo del sistema de clasificación de niveles de deambulación funcional.Introducción. El Gross Motor Function Classification System ha permitido estratificar, según su habilidad para caminar, a los pacientes que padecen parálisis cerebral infantil. La falta de sensibilidad en la detección de cambios y la ausencia de una evaluación del paciente en el contexto en el que se encuentra justifican la búsqueda de alternativas de evaluación pretratamiento. Objetivos. Presentar y mostrar la concordancia interobservador inicial del sistema de clasificación de niveles de deambulación funcional. Con él se evalúa la destreza para caminar y la necesidad de asistencia para realizar transferencias desde la silla de ruedas, y, posteriormente se analiza el escenario que la salud y el entorno del paciente ofrecen como condicionantes en la corrección de la marcha o la bipedestación asistida. Sujetos y métodos. Se describe un nuevo marco de evaluación, elaborado por un grupo interdisciplinar con más de 15 años de experiencia media, enfocado inicialmente a la toma de decisiones antes de un tratamiento quirúrgico. Como control interno, 14 participantes evaluaron la historia clínica y los vídeos de marcha de 10 casos. Resultados. Se alcanzó un índice kappa de acuerdo de 0,76 en niveles funcionales y de 0,79 en el tipo de escenario biológico, de 0,69 en el psicológico y de 0,64 en el social. Conclusiones. El sistema de clasificación de niveles de deambulación funcional ofrece un marco para la evaluación conjunta de la deambulación y de los factores limitantes en la eficacia de un tratamiento. La concordancia interobservador avala iniciar su validación.

Spinal osteosarcoma in the paediatric age group: case series and literature review. / Osteosarcoma lumbar en edad pediátrica: reporte de casos y revisión de la literatura.

INTRODUCTION AND OBJECTIVE: Osteosarcoma is the most frequent malignant spinal tumour in the paediatric age group. Diagnosis and early treatment of this pathology is essential for a good prognosis. The aim of this study was to present the results of treatment of paediatric patients with lumbar osteosarcoma and conduct a literature review. MATERIAL AND METHODS: All the patients with lumbar osteosarcoma who were operated between 2012 and 2014 in the same centre were included. Demographic and radiological data (Enneking, WBB and Tomita classification), as well as anatomopathological (Broders classification) variables were analysed. All the patients were treated by surgical resection associated with adjuvant therapies (chemotherapy and radiotherapy); according to consensus with the tumour committee. The average follow-up was 62.53 months (47-70 months). RESULTS: A total of 3 patients were studied, two girls of 9 and 11, with L5 osteosarcoma, and a 15-year-old boy with L4 osteosarcoma. Two of the cases were initially treated as an osteoblastoma, supported by radiological and anatomopathological images. None of the patients had local recurrences or metastases during follow-up. CONCLUSIONS: Due to a lack of long series of cases of osteosarcoma in the mobile spine during childhood, the optimal treatment and prognosis in these patients is uncertain. Block resection improves local control of the disease, without demonstrating improvement in overall survival. Intralesional resection is associated with a higher rate of local recurrence. Oncological treatment is essential in the treatment of this pathology. A correct differential diagnosis of the tumour (osteosarcoma vs. osteoblastoma) is vital for its correct treatment.

Artrodesis lumbar circunferencial: autoinjerto frente a injerto liofilizado / Transforaminal lumbar interbody fusion: autograft vs freeze-dried allograft

Objetivo: Analizar y comparar los resultados radiográficos y clínicos de la fusión lumbar mediante autoinjerto frente a injerto liofilizado. Material y metodología: Se realizó un estudio prospectivo cuasi-experimental, con un seguimiento mínimo de 13 meses. Se incluyeron 72 pacientes, con una edad media de 48 años, siendo el 52,8%mujeres. Todos fueron intervenidos de artrodesis lumbar circunferencial de un nivel, que se dividieron en dos grupos: en uno se utilizó autoinjerto de cresta iliaca (AU) (n=41; 57,7%) y en el otro injerto liofilizado de banco (LI) (n=30; 42,3%). Se evaluaron factores sociodemográficos, la existencia o no de fusión tras la intervención y resultados clínicos mediante la escala EVA, antes y después de la cirugía. Resultados: El dolor lumbar medio fue de 7,5 en autoinjertos y de 8 en injertos liofilizados (p=0,146); tras la intervención el dolor lumbar medio mejoró en 4 puntos o más (AU = 3; LI = 1) (p= 0,196). No encontramos diferencias en los resultados de EVA, al igual que tampoco se encontraron diferencias con respecto a la fusión obtenida en los niveles intervenidos (p= 0,112). Conclusión: El injerto liofilizado, en la artrodesis circunferencial de un nivel, nos proporciona fusiones y resultado funcional similar al autoinjerto (AU)

Objective: The purpose of this study is to analyze and compare the radiographic and clinical results of lumbar fusion using autograft versus lyophilized graft. Methods: This was a prospective study quasi-experimental, with a minimum follow-up of 13 months. It included patients undergoing circumferential lumbar fusion level. We started with a population of 96 patients, of which, we had 8 losses and 16 were excluded, so the sample size was 72 patients, 52.8% of them women, with an average age of 48 years. They were divided into two groups: one that was used in the iliac crest autograft (AU) (n = 41; 57.7%) and other bank lyophilized graft (LI) (n = 30; 42.3%). We evaluated socio-demographic factors, the existence of fusion after surgery and clinical outcomes by VAS before and after surgery. Results: Low back pain in a scale of 1 to 10 was UA: 7.5, LI: 8 (p=0.146). After surgery, back pain improved in 4 points or more, AU: 3, LI: 1, (p=0.196). Then we found no statistically significant differences in the results of the visual analog scale, and we also found no differences with respect to the levels obtained in fusion surgery (p=0.112). Conclusion: The lyophilized graft in the circumferential fusion provides fusion and functional results similar to autograft (AU)