Revisión sistemática de las aplicaciones y límites de la impresión 3D en la cirugía de raquis / Systematic review of the utility and limits of 3D printing in spine surgery

Objetivo: El objetivo principal de este estudio ha sido demostrar por qué la impresión aditiva permite hacer más visibles y entendibles los procesos patológicos quirúrgicos complejos que afectan al raquis, aumentando la precisión, la seguridad y la fiabilidad del procedimiento quirúrgico.MetodologíaSe realizó una revisión sistemática de los trabajos publicados en los últimos 10 años, sobre la cirugía de raquis asistida por impresión 3D, de acuerdo con la declaración PRISMA 2020. Con las palabras clave «printing 3D» y «spine surgery» se hicieron búsquedas en las bases de datos Pubmed, Embase, Cochrane Database of Systematic Reviews, Google Scholar y Opengrey, que se completó con la búsqueda manual a través de la lista de referencias bibliográficas de los artículos que fueron seleccionados siguiendo los criterios de inclusión y exclusión definidos.ResultadosDel análisis de los 38 estudios seleccionados resultó que la impresión 3D es útil en la planificación quirúrgica, en la enseñanza médica, en la relación médico-paciente, así como en el diseño de plantillas de navegación e implantes de raquis y, en investigación, ofreciendo un magnífico apoyo al proceder quirúrgico.ConclusionesEl uso de biomodelos impresos de forma tridimensional permite: hacer más visibles y entendibles los procesos patológicos quirúrgicos complejos que afectan al raquis; aumentar la exactitud, precisión y seguridad del procedimiento quirúrgico; y abrir la posibilidad de poner en práctica tratamientos personalizados, fundamentalmente en la cirugía tumoral. (AU)

Objective: The main objective of this study has been to demonstrate why additive printing allows to make complex surgical pathological processes that affect the spine more visible and understandable, increasing precision, safety and reliability of the surgical procedure.MethodsA systematic review of the articles published in the last 10 years on 3D printing-assisted spinal surgery was carried out, in accordance with PRISMA 2020 declaration. Keywords «3D printing» and «spine surgery» were searched in Pubmed, Embase, Cochrane Database of Systematic Reviews, Google Scholar and Opengrey databases, which was completed with a manual search through the list of bibliographic references of the articles that were selected following the defined inclusion and exclusion criteria.ResultsFrom the analysis of the 38 selected studies, it results that 3D printing is useful in surgical planning, medical teaching, doctor–patient relationship, design of navigation templates and spinal implants, and research, optimizing the surgical process by focusing on the patient, offering magnificent support during the surgical procedure.ConclusionsThe use of three-dimensional printing biomodels allows: making complex surgical pathological processes that affect the spine more visible and understandable; increase the accuracy, precision and safety of the surgical procedure, and open up the possibility of implementing personalized treatments, mainly in tumor surgery. (AU)

Systematic review of the utility and limits of 3D printing in spine surgery.

OBJECTIVE: The main objective of this study has been to demonstrate why additive printing allows to make complex surgical pathological processes that affect the spine more visible and understandable, increasing precision, safety and reliability of the surgical procedure. METHODS: A systematic review of the articles published in the last 10 years on 3D printing-assisted spinal surgery was carried out, in accordance with PRISMA 2020 declaration. Keywords "3D printing" and "spine surgery" were searched in Pubmed, Embase, Cochrane Database of Systematic Reviews, Google Scholar and Opengrey databases, which was completed with a manual search through the list of bibliographic references of the articles that were selected following the defined inclusion and exclusion criteria. RESULTS: From the analysis of the 38 selected studies, it results that 3D printing is useful in surgical planning, medical teaching, doctor-patient relationship, design of navigation templates and spinal implants, and research, optimizing the surgical process by focusing on the patient, offering magnificent support during the surgical procedure. CONCLUSIONS: The use of three-dimensional printing biomodels allows: making complex surgical pathological processes that affect the spine more visible and understandable; increase the accuracy, precision and safety of the surgical procedure, and open up the possibility of implementing personalized treatments, mainly in tumor surgery.

Spinal health in 40 patients in the initial stage of laboural life. Morfogeometric, biological and environmental study.

INTRODUCTION: Assuming that spinal shape is a genetic expression, its analysis and acquired factors could assess their respective contribution to early spine deterioration. MATERIAL AND METHODS: A geometric morphometric analysis was retrospectively performed on sagittal lumbar MRI of young patients with back pain to identify lumbar spine shape changes. Using Geometric Morphometrics, findings were analyzed with anthropometric, radiological, and clinical variables. RESULTS: 80 cases under 26 years of age were collected, 55 men (mean age 22.81) and 25 women (mean age 23.24). MRI abnormalities were reported in 57.5%: single altered disc (N=17), root compromises (N=8), and transition anomalies (35%).In the non-normal MRI subgroup, shape variation included: increased lordosis, enlarged vertebral body, canal stenosis, and lumbarization of S1. In non-Spanish origin patients, lumbar straightening and segmental deformities were prevalent. Morphometrics findings showed that lumbosacral transition anomalies are frequently underreported. CONCLUSIONS: Genetic factors could be the main determinants of abnormality in MRIs under 26 years. The primary markers are transitional abnormalities, segmental deformities, and canal stenosis. In foreign populations, shape changes could suggest spine overload at an early age.

Embolismo pulmonar diferido de material de refuerzo vertebral. Consideraciones clínicas y médico-legales a propósito de un caso / Delayed pulmonary embolism from vertebral reinforcement material. Clinical and medico-legal considerations of a case

La vertebroplastia y la cifoplastia son procedimientos de punción percutáneos que precisan de la inyección de cemento en el soma de una vértebra fracturada, con el fin de refuerzo y alivio del dolor. Con ocasión de un caso de cifoplastia del soma de L2 que desarrolló una infrecuente embolización diferida de cemento a la arteria pulmonar, se revisa la literatura y analizan los principales problemas médico-legales de estas complicaciones. Se subraya la necesidad de un consentimiento informado detallando la frecuencia y riesgos de estas complicaciones, así como un adecuado control radiológico postoperatorio, no solo local, sino torácico. Igualmente, se enfatiza la posibilidad de repetir el estudio radiológico local y torácico, ante cualquier cambio de la morfología de la fuga local o desaparición de la fuga local, ante la posibilidad de migraciones tardías. (AU)

Vertebroplasty and kyphoplasty are percutaneous puncture procedures that require the injection of cement into the soma of a fractured vertebra for reinforcement and pain relief.As the result of a case of kyphoplasty of the soma of L2 that developed a rare, delayed embolization of cement to the pulmonary artery, we undertook a literature review, and the main medico-legal problems of these complications were analysed.The need for informed consent is stressed, detailing the frequency and risks of these complications, as well as adequate postoperative local and chest X-ray control. Likewise, the possibility is highlighted of repeat local and chest X-rays in the event of any change in the morphology of local leakage or disappearance of local leakage in the event of late migration. (AU)

"Prometo ejercer mi profesión a conciencia y dignamente" (Juramento Hipocrático) / I will practice my profession with conscience and dignity (Hipocratic oath)

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Storytelling as instrument of communication in healthcontexts / Storytelling como instrumento de comunicación en contextosde salud

Storytelling (ST) has emerged as an instrument that helps us in the learning and management of the disease, by taking advantage of the teachings transmitted by other patients who have gone through the same illness: sharing experiences. It requires an interaction between the one who relates (implicit emotional and corporal language: visual, auditory and gestural) and the listener, allowing the listener to conceptualize and create more valuable ideas. The use of ST can serve as a means, establishing a network of trust and equality among participants, allowing a way of expression that would eliminate the stigmatization of suffering from a disease. In addition, telling stories can be a vehicle that breaks resistance to the messages promoting a healthy lifestyle, or that dilutes them to face behavioral changes facilitating the incorporation of new behaviors that improve health or overcome the disease. ST facilitates support for the disease by allowing the patient to examine their emotions and problem-solving strategies, set objectives and exchange social support. With this article we intended to conduct a review of empirical studies on ST and health education, considering contexts, purposes, learning, attitudes and behaviors improvements related to the use of this tool of communication

Lo que podríamos denominar "contar historias", Storytelling (ST), se ha convertido en un instrumento que nos ayuda en el aprendizaje y el manejo de la enfermedad, aprovechando las enseñanzas transmitidas por otros pacientes que han pasado por la misma enfermedad: compartiendo experiencias. Requiere una interacción entre el relator (lenguaje emocional y corporal implícito: visual, auditivo y gestual) y el oyente, lo que le permite conceptualizar y crear ideas más valiosas. El uso de ST puede servir como un medio, estableciendo una red de confianza e igualdad entre los participantes, permitiendo una forma de expresión que eliminaría la estigmatización del sufrimiento de una enfermedad. Además, contar historias puede ser un vehículo que rompa la resistencia a los mensajes que promueven un estilo de vida saludable, o que los diluya para enfrentar cambios conductuales que faciliten la incorporación de nuevos comportamientos que mejoren la salud o superen la enfermedad. ST facilita el apoyo a la enfermedad al permitir al paciente examinar sus emociones y estrategias de resolución de problemas, establecer objetivos e intercambiar apoyo social. Con este artículo intentamos realizar una revisión de estudios empíricos sobre ST y educación para la salud, considerando contextos, propósitos, aprendizaje, actitudes y mejoras de comportamiento relacionadas con el uso de esta herramienta de comunicación

Follow-up of a new titaniumcoated polyetheretherketone cage for the cervical spine.

Poly-ether-ether-ketone (PEEK) cages have lower modulus of elasticity when compared with Titanium (TTN) cages. This suggests that PEEK-cages could show a lower rate of subsidence after anterior cervical discectomy-fusion (ACDF) and might lead to a lower loss of correction. We investigated the one to five year-results of standalone PEEK-TTN-porous coated cages in a patient cohort from 2014 to 2017. The patients underwent single-level ACDF for disc herniation and degenerative discopathy. Clinical and radiological outcome were assessed in 50 eligible patients after a mean of 27 months. Results: Solid arthrodesis was found in 84%. Neck disability index (NDI), and visual analogue scale (VAS) of neck and arm show comparable results to the literature. Conclusions: Clinical and radiological outcomes of ACDF with PEEK-body-cages with a porous coated surface show good bony integration. The modulus of elasticity, design, shape, size, cage surface architecture, as well as bone density, endplate preparation, radical microdiscectomy and distraction during surgery should be considered as important factors influencing the clinical results. One main advantage, over titanium cages, is the absence of MRI artifacts, allowing an excellent postoperative follow-up.

Monitorización neurofisiológica intraoperatoria en cirugía raquimedular. Aspectos clínicos y médico-legales / Neurophysiological monitoring during spine and spinal cord surgery. Clinical and medico-legal issues

El objetivo de la monitorización neurofisiológica intraoperatoria es la detección de daño o alteración funcional en el sistema nervioso lo más precozmente posible, asegurando la funcionalidad medular, evitando las complicaciones neurológicas. Sin embargo, la falta de estandarización en la metodología, junto con cierta inconsistencia en los estudios sobre su utilidad, limita el establecimiento de unas recomendaciones universales para su utilización. El presente trabajo pretende revisar los procedimientos de monitorización neurofisiológica, sus fortalezas y debilidades, así como la conveniencia de su empleo en cirugía espinal. Concluimos que, con carácter general, su falta de uso en dicha cirugía no contraviene la «lex artis», pues no existe evidencia de que pueda ayudar en revertir el daño neurológico. Sin embargo, puede emplearse como elemento de prueba tanto para detectar el momento y el tipo de daño neurológico como para aumentar la defensibilidad. Se requieren protocolos de uso, bien por las sociedades científicas o por los propios centros hospitalarios

The purpose of neurophysiological monitoring during surgery is to identify damage or functional neurological disturbances as soon as possible, ensuring spinal cord functionality and avoiding neurological complications. However, the lack of standardisation of the methodology, together with some inconsistencies in the studies on its usefulness, limit the establishment of universal recommendations for its use. The present paper intends to review neurophysiological monitoring procedures during surgery, including their strength and weaknesses, as well as to assess the convenience of their use during spinal surgery. It is concluded that, in general, the lack of its use in this surgery does not legally contravene the standard of care, as there is no evidence it could result in reverting neurological damage. Nevertheless, it can be used as evidence both in detecting the time and kind of neurological injury, and for increasing the defensibility. Protocols of use, provided either by scientific societies or hospitals themselves, are required

Primer programa español de donación corporal virtual. Aspectos médico-legales e interés en docencia, asistencia e investigación / First Spanish program of virtual body donation. Medico-legal issues and academic, clinical care and research interest

La donación corporal es la base de los programas de trasplantes, cuya regulación se fundamenta en los derechos del donante y receptor. Sin embargo, si su objetivo no es asistencial, la normativa difiere tanto en vivos como en fallecidos. Las llamadas «técnicas de imagen» permiten obtener ficheros digitales con el cuerpo virtual del paciente, lo que brinda una nueva posibilidad: la donación corporal virtual, no regulada en España y tampoco ajustada a la normativa del resto de las donaciones. Presentamos un programa de donación corporal, analizando sus características, aspectos médico-legales, clínicos, de organización y funcionamiento. Contar con un número ilimitado de especímenes virtuales impulsa una nueva forma de docencia e investigación. Tiene, además, ventajas para la formación de los profesionales en técnicas de autopsia virtual. Creemos que este programa, pionero en España, puede servir para extender iniciativas similares de utilidad ilimitada en docencia e investigación en ciencias forenses, morfológicas y afines

Body donation is in the basis of transplantation programs, founded on receptor and donor rights. Nevertheless, if the purpose is not directed to healthcare, the regulation is different both in live or deceased individuals. "Imaging techniques" generates digital files containing the «virtual body» of the patient, raising a new possibility: virtual body donation, which is not regulated in Spain and would not be compliant with legal requirements for other ways of donation. A pioneer program for virtual body donation is presented, analysing its characteristics, medico-legal issues, organisation and functioning. Having an unlimited number of virtual specimens (normal and pathological) could support a new way for teaching and research. These resources would also have the advantage of learning virtual biopsy (virtopsy). It is thought that these programs, pioneers in Spain, could be useful for introducing similar initiatives that would have unlimited applications in teaching and research both in forensic and morphological sciences

Delay in diagnosis of thoracolumbar fractures.

The time interval between the date of trauma and the diagnosis of vertebral column fractures hinders management and increases liability. We have examined the features and implications of this delay. 585 consecutive thoracolumbar fractures (2005-2016), were considered; 382 (65.30%) were males and 203 (34.70%) females. Mean age was 51 yr. Fall from a height (187; 31.97%), simple fall (147; 25.13%) and road accidents (111; 18.97%) were the most frequent causes of trauma. Physical exertion caused 8.38% (N=49). 142 patients (24.27%) were not diagnosed on the injury day (mean = 3.2 days). Delay was longer in females (mean = 5.5 vs. 2.7 days) and shorter in falls from a height (mean = 2.3) or road accidents (2.8). Mean age of diagnosed on the injury day differed from those diagnosed in the first month (49.2 vs 60.1). Plain X-ray signs were found in 7 misdiagnosed cases (46.6%). Delay was more frequent in low mineralization cases. Diagnostic delay of spine fractures is frequent. Some risk profiles can help to reduce it. Careful emergency X-ray examination is encouraged, as well as early magnetic resonance imaging in risk profiles.

Sinostosis cervical asociada a síndromes de Down y de Schneider. Implicaciones clínicas y médico-legales a propósito de un caso autópsico / Cervical synostosis associated with Down's syndrome and Schneider syndrome. Clinical and medico-legal implications of an autopsy case

Con ocasión de un caso de asociación entre síndrome de Down y sinostosis vertebral congénita que sufrió lesión medular traumática, se revisa la asociación de estos cuadros y sus implicaciones clínicas y forenses. La literatura no ha comunicado hasta ahora una asociación prevalente entre síndrome de Down y sinostosis cervicales. Ambos cuadros por separado propenden a la mielopatía cervical, bien de manera degenerativa, bien traumática. En consecuencia, la asociación de ambos debe verse como un factor de riesgo de daño medular o de manera espontánea o, sobre todo, después de traumatismos. En estos casos, la exploración radiológica debe ser exhaustiva incluyendo RMN ya que pueden existir lesiones medulares incluso ante traumatismos mínimos. En caso de fallecimiento, la autopsia medular es obligada ya que puede revelar lesiones subclínicas, clarificar la naturaleza y extensión de las lesiones medulares y esqueléticas, así como ayudar a establecer una mejor correlación anatomoclínica

This paper reviews the association of clinical symptoms and their clinical and forensic implications in a patient with Down's syndrome and congenital cervical synostosis who experienced a traumatic spinal cord injury. To date, no prevalent association between Down's syndrome and cervical synostosis has been reported in the literature. Given that both entities are prone to cause degenerative or traumatic cervical myelopathy, the combination of both conditions must be seen as a risk factor for spontaneous, and particularly traumatic, spinal cord damage. In these cases, radiological examination must be exhaustive, including MRI, given the possibility of spinal cord injury even after minimal trauma. In the event of death, spinal cord autopsy is mandatory as it may reveal subclinical lesions, clarify the nature and extension of the spinal cord and skeletal injuries and help to establish an improved anatomo-clinical correlation

Lesión medular con normalidad radiológica. Etiología, diagnóstico y problemática médico-legal / Spinal cord injury and normal neuroimaging. Aetiology, diagnosis and medico-legal issues

La objetivación de las lesiones espinales o medulares en accidentes es un tema clásico de discusión tanto en Medicina Asistencial como en Medicina Forense. Un problema particular son los pacientes con daño medular sintomático y neuroimagen normal. Estos casos se denominan con los acrónimos SCIWORA («spinal cord injury without radiographic abnormality»), SCIWNA («spinal cord injury without neuroimaging abnormality») y SCIWORET («spinal cord injury without radiologic evidence of trauma»). Nuestro propósito es revisar los aspectos clínicos, radiológicos y médico-legales de estos cuadros, desconocidos muchas veces para quien no trata habitualmente lesionados medulares. El objetivo principal está centrado en los aspectos médico-legales de estos cuadros. Nuestros resultados cuestionan algunos aspectos del reciente sistema para la valoración de los daños y perjuicios causados a las personas en accidentes de circulación (Ley 35/2015), en los llamados traumatismos cervicales menores. En consecuencia, el tratamiento que la reciente legislación española da a dichos traumatismos podría necesitar ser revisada (AU)

The objective demonstration of minor spinal and spinal-cord lesions following accidents is a classic discussion issue in both Clinical and Forensic Medicine. Particular problems are the patients with symptomatic spinal cord damage and normal neuroimaging. These situations are usually named with acronyms: SCIWORA ("spinal cord injury without radiographic abnormality"), SCIWNA ("apinal cord injury without neuroimaging abnormality"), and SCIWORET ("spinal cord injury without radiological evidence of trauma"). Our purpose is to review the main clinical, radiological, and medico-legal features of these conditions, often unknown by those who are not used to treating spinal cord lesions. The main objective is focused on the medico-legal problems of these conditions. The results of our review places under question some aspects of the recent 35/2015 Spanish Law on accidents compensation, in particular when dealing with minor spinal injuries. Therefore, a review of the recent Spanish law's statements about spinal minor injuries compensation is required (AU)

El esguince cervical como accidente laboral. Epidemiología y resultados de un protocolo de abordaje multiaxial / Whiplash as a work-related injury. Epidemiology and results of a multiaxial management protocol

Introducción. En España más de un 10% de los accidentes de circulación tienen la consideración de accidentes de trabajo. Entre sus consecuencias un buen número son esguinces cervicales. Sin embargo, pese a su incidencia y repercusión socioeconómica existe poca literatura sobre el esguince cervical laboral. En el presente trabajo revisamos una extensa muestra de estos casos con el objetivo de aportar información sobre el tema, hasta ahora escasa, así como valorar si el perfil de los traumatismos cervicales menores laborales difiere de los no laborales. Material y métodos. Se analizan 690 casos de esguinces cervicales que tuvieron la consideración de accidente laboral, valorados y tratados según un protocolo multiaxial recientemente publicado. El análisis se extiende a la revisión de la literatura al respecto. Resultados. Los resultados muestran particularidades en el grupo laboral, como cifras de baja laboral superiores en conductores, plazos de incapacidad temporal diferentes por profesiones o día del accidente. Algunas lesiones concurrentes como: hernia de disco, síndrome de encrucijada cervicotorácica y afección de hombro se asociaron a periodos de incapacidad temporal más prolongados. La existencia de accidentes laborales previos se asoció también a periodos de baja más dilatados. Conclusiones. Se enfatiza la necesidad de compartir las bases de datos existentes para identificar la incidencia y repercusión de los esguinces cervicales laborales dentro del total de accidentes de circulación. Se detectan algunas deficiencias como falta de información, dispersión de las bases institucionales y discrepancias entre las fuentes en la literatura. Se subraya la importancia de las enfermedades posganglionares y extracervicales, así como de la hernia discal en las evoluciones más prolongadas. Se resalta la utilidad del modelo multiaxial en el diagnóstico, tratamiento y valoración del esguince cervical para reducir el periodo de baja, las secuelas y también para entender la singularidad de los esguinces cervicales laborales (AU)

Introduction. In Spain, more than 10% of road traffic accidents are legally deemed work-related accidents, with whiplash being one of the main resulting injuries. Nevertheless, despite its high incidence and socio-economic repercussions, there are very few studies of work-related whiplash in the literature. In this paper, we review a large sample of these cases with the aim of broadening our scarce knowledge of the subject, and to ascertain whether the profile of work-related whiplash differs from non-work-related whiplash. Material and methods. We studied 690 cases of whiplash deemed to be workplace accidents that were assessed and treated following a recently-published multiaxial protocol. The analysis extended to a review of the applicable literature. Results. The results revealed several peculiarities in the work-related whiplash group, such as higher rates of sick leave for drivers and differing length of temporary disability according to profession or day of the accident. Some whiplash-related injuries, such as disc herniation, thoracic outlet syndrome or shoulder injuries, were associated with longer periods of temporary incapacity. A history of previous work-related accidents was also associated with longer sick leave. Conclusions. We emphasise the need to share the existing databases in order to identify the rate and repercussion of work-related whiplash compared to all road traffic accidents. Certain deficiencies were found, such as a lack of information, dispersion of the institutional databases and discrepancies between the available sources. The relevance of postganglionic and extracervical conditions are underlined, together with disc herniation, in cases with longer clinical courses. A multiaxial model for diagnosing, treating and assessing work-related whiplash is proposed as a method to minimise sick leave, sequelae and to understand the singular profile of work-related whiplash (AU)

Hernias encefálicas. Clasificación, neuropatología y problemas medicolegales / Brain herniations. Classification, Neuropathology and medico-legal problems

Las hernias cerebrales son la causa inmediata del fallecimiento en muchas lesiones neurológicas. Algunos protocolos recientes de actuación neuroquirúrgica han originado nuevas modalidades, como por ejemplo en el llamado síndrome del trefinado. Se requiere, pues, una revisión actualizada del tema, máxime cuando tiene importantes implicaciones medicolegales. Nuestro objetivo es revisar las clasificaciones, adaptarlas a los avances en Neurorradiología y Neurocirugía, y analizar su problemática medicolegal. La actualización de la clasificación y un conocimiento detallado de la fisiopatología de las hernias cerebrales constituyen la mejor orientación para la resolución de problemas forenses en lo relativo a etiología, causalidad y secuelas de las lesiones encefálicas (AU)

Brain herniation is the immediate cause of death in most of neurological lesions. Some recent neurosurgical protocols have promoted new kinds of herniation, like those that occur in the so-called syndrome of the threphined. Therefore, an up-to-date revision of this subject is required in regard of its important medico-legal implications. Our aim is to review the present classifications, adapting them to Neuroimaging and Neurosurgical advances, and analyzing the medical-legal issues of brain herniation. The problems extend not only to Pathology, but also to Clinical Forensic subjects. An up-to-date classification and a more detailed knowledge of the brain herniations physiology and pathology are the best tools to address their forensic problems, in particular those related with etiology, causation and sequels of brain lesions (AU)

Dispositivos interespinosos y hernia discal. Estudio morfogeométrico y clínico de 71 casos tratados con microdiscectomía L4-L5 asociada a colocación de espaciador / Interspinous spacers and disc herniation. Geomorphometric and clinical study of 71 cases treated by L4-L5 microdiscectomy associated to spacer placement

Objetivo: Una indicación controvertida de los espaciadores interespinosos es su utilización complementaria a la discectomía. Actualmente, no existen evidencias sólidas de la eficacia de dicha asociación, lo que podría derivar de la variabilidad en la colocación del espaciador, limitando su labor biomecánica. El presente trabajo busca identificar y analizar la variabilidad de emplazamiento de un espaciador interespinoso, y determinar su relación con el resultado clínico. Material y método: Se estudiaron 71 casos de hernia discal L4-L5 intervenidos en nuestro hospital mediante discectomía y colocación de espaciador interespinoso. Se utilizaron técnicas de morfometría geométrica: análisis procrustes y componentes principales. Se comparan los resultados morfológicos con la lordotización, distracción quirúrgica, así como con variables clínicas (índice de Herron y Turner). Resultados: Se identificó significativa variabilidad morfológica tanto en forma de traslación cráneo-caudal como rotación horaria-antihoraria en la posición del implante. Esta variación no se correlacionó con el resultado clínico, pero sí con variables anatómicas (grado de lordosis), y con aspectos quirúrgicos (distracción adicional del implante). Se detectó, igualmente, un emplazamiento ligeramente diferente en los casos con recidiva. Conclusiones: La morfometría geométrica permite objetivar una elevada variabilidad morfológica en el emplazamiento de los espaciadores interespinosos, que, sin embargo, no parece influir en el resultado clínico, dependiendo más bien del grado de lordosis y distracción. Se apreciaron diferencias de emplazamiento en los casos que recidivaron. Para valorar la eficacia de los espaciadores como complemento de la cirugía discal se requieren estudios con mayor número de casos, que necesariamente deben incluir análisis de variables morfológicas

Objective: A controversial indication of interspinous spacers is their use as a complement to discectomy. At the present time, there is no solid clinical evidence of effectiveness of that association, which might result from variability in spacer positioning, restricting its correct biomechanical actions. In this study our goal was to identify and analyse the variability in the placement of an interspinous spacer, and to investigate its relationship with the clinical results. Materials and methods. We performed a retrospective study on X-ray films from 71 patients suffering from disc herniation in L4-L5 who underwent surgery in our hospital, consisting of: microdiscectomy and biomed interspinous spacer implantation. The geomorphometric techniques used to analyse the data were procrustes superimposition and principal components analysis. We compared the clinical results (using the Herron and Turner scale), segmental lordosis and surgical distraction with the geomorphometric parameters. Results. Significant morphological variability was found in the implant position showing cephalo-caudal translation and clockwise-counterclockwise rotations. This variability did not correlate with clinical results. A relationship with anatomical features (lordosis) and additional surgical distraction was identified. A different morphology of implant-segment configuration was identified in cases with recurrence of disc herniation. Conclusions: Geometric morphometrics allowed identifying high variability in the final placement of interspinous spacers. Nevertheless, it seems not to be related to the clinical outcome, depending rather on the degree of lordosis and distraction. Some differences in segment-implant morphology were identified in cases with recurrences. To assess the effectiveness of spacers, larger studies including morphological and clinical variables are required

[Interspinous spacers and disc herniation. Geomorphometric and clinical study of 71 cases treated by L4-L5 microdiscectomy associated to spacer placement]. / Dispositivos interespinosos y hernia discal. Estudio morfogeométrico y clínico de 71 casos tratados con microdiscectomía L4-L5 asociada a colocación de espaciador.

OBJECTIVE: A controversial indication of interspinous spacers is their use as a complement to discectomy. At the present time, there is no solid clinical evidence of effectiveness of that association, which might result from variability in spacer positioning, restricting its correct biomechanical actions. In this study our goal was to identify and analyse the variability in the placement of an interspinous spacer, and to investigate its relationship with the clinical results. MATERIALS AND METHODS: We performed a retrospective study on X-ray films from 71 patients suffering from disc herniation in L4-L5 who underwent surgery in our hospital, consisting of: microdiscectomy and biomed interspinous spacer implantation. The geomorphometric techniques used to analyse the data were procrustes superimposition and principal components analysis. We compared the clinical results (using the Herron and Turner scale), segmental lordosis and surgical distraction with the geomorphometric parameters. RESULTS: Significant morphological variability was found in the implant position showing cephalo-caudal translation and clockwise-counterclockwise rotations. This variability did not correlate with clinical results. A relationship with anatomical features (lordosis) and additional surgical distraction was identified. A different morphology of implant-segment configuration was identified in cases with recurrence of disc herniation. CONCLUSIONS: Geometric morphometrics allowed identifying high variability in the final placement of interspinous spacers. Nevertheless, it seems not to be related to the clinical outcome, depending rather on the degree of lordosis and distraction. Some differences in segment-implant morphology were identified in cases with recurrences. To assess the effectiveness of spacers, larger studies including morphological and clinical variables are required.

Simulación en patología espinal / Simulation in spinal diseases

La columna es terreno abonado para la simulación, involucrando a diferentes Especialistas (traumatólogos, neurocirujanos, rehabilitadores, médicos de familia, etc.). La simulación requiere la producción intencional de síntomas exagerados o falsos respondiendo a un incentivo externo. Sin embargo, en la práctica, hay dificultades en la demostración de dichos requisitos. Esto origina que algunos simuladores no resulten identificados y que pacientes no simuladores con actitud incongruente sean etiquetados de rentistas, originando distrés iatrógeno y exposición a litigación. Se analiza la simulación en el raquis, proponiendo una modificación terminológica, así como una nueva estrategia de diagnóstico, para evitar errores y reducir tanto el distrés iatrógeno como la ligitabilidad. Basándonos en la experiencia clínico-forense de los autores, se analiza la bibliografía y se propone una semiología uniforme. El abordaje es multidimensional y la estrategia de diagnóstico basada en: anamnesis, exploración y pruebas complementarias, adaptando sus resultados a una terminología uniforme con significado preciso de signos y síntomas (AU)

Simulation is frequent in spinal disease, resulting in problems for specialists like Orthopedic Surgeons, Neurosurgeons, Reumatologists, etc. Simulation requires demonstration of the intentional production of false or exaggerated symptoms following an external incentive. The clinician has difficulties in demonstrating these criteria, resulting in misdiagnosis of simulation or misinterpretation of the normal patient as a simulator, with the possibility of iatrogenic distress and litigation. We review simulation-related problems in spine, proposing a terminological, as well as a diagnostic strategy including clinical and complementary diagnosis, as a way to avoid misinterpretation and minimize the iatrogenic distress and liability. Based on the clinical-forensic author's expertise, the literature is analyzed and the terminology readdressed to develop new terms (inconsistencies, incongruences, discrepancies and contradictions). Clinical semiology and complementary test are adapted to the new scenario. Diagnostic strategy relies on anamnesis, clinical and complementary tests, and adapting them to a uniform terminology with clear meaning of signs and symptoms (AU)