Epidemiology of vertebral spine fractures in a hospital in são paulo in the two-year period 2017-2018 / Epidemiologia das fraturas da coluna vertebral em hospital de são paulo no biênio 2017-2018 / Epidemiología de las fracturas de la columna vertebral en un hospital de são paulo en el período de 2017-2018

ABSTRACT Objectives: To evaluate the epidemiological profile of patients with spinal fractures over a two-year period (2017 and 2018) in a quaternary hospital in the city of São Paulo. Methods: A cross-sectional study was carried out through the analysis of the electronic medical records of patients treated by the Spine group of the Department of Orthopedics and Traumatology at the Orthopedics and Traumatology Emergency Room of Hospital das Clínicas de São Paulo in the years 2017 and 2018. Results: A total of 185 patients were evaluated over two years. Males were the gender most frequently evaluated (69.19%), and the mean patient age was 43.95 years. The most common trauma mechanisms were falls from a height (45.95%) and traffic accidents (29.73%). The cervical spine, affected in 28.65%, was the most affected region, followed by the thoracolumbar region (26.56%). Most patients did not present deficits at the initial moment (71.89%) and 54.05% of patients underwent surgery for treatment. Conclusion: Most traumas involving the spine affect adults of working age (from 20 to 60 years old), with a predominance of males. Most injuries occurred in the cervical region, which is the region most commonly associated with severe trauma and neurological injuries. This study can help in planning prevention and precaution strategies for spinal trauma. Level of evidence III; Cross-sectional study.

RESUMO Objetivos: Avaliar o perfil epidemiológico dos pacientes com fraturas da coluna vertebral no período de dois anos (2017 e 2018) em hospital quaternário da cidade de São Paulo. Métodos: Foi realizado um estudo transversal mediante análise dos prontuários eletrônicos de pacientes atendidos pelo grupo de Coluna do Departamento de Ortopedia e Traumatologia no Pronto Socorro de Ortopedia e Traumatologia do Hospital das Clínicas de São Paulo nos anos de 2017 e 2018. Resultados: Um total de 185 pacientes foram avaliados ao longo de dois anos. O sexo masculino foi predominante na avaliação (69,19%), e a média de idade dos pacientes de foi de 43,95 anos. Os mecanismos de trauma mais comuns foram queda de altura (45,95%) e acidentes de trânsito (29,73%). A coluna cervical, acometida em 28,65%, foi a mais afetada, seguida pela região toracolombar (26,56%). A maioria dos pacientes não apresentava déficits no momento inicial (71,89%) e 54,05% dos pacientes foram submetidos a cirurgia para o tratamento. Conclusão: A maioria dos traumas envolvendo a coluna vertebral acometem a população economicamente ativa (dos 20 aos 60 anos), com predomínio no sexo masculino. A maioria das lesões ocorreram na região cervical, que é a região mais comumente associada a traumas graves e lesões neurológicas. Este estudo pode ajudar a planejar estratégias de prevenção e precaução dos traumas da coluna vertebral. Nível de evidência III; Estudo transversal.

RESUMEN Objetivos: Evaluar el perfil epidemiológico de pacientes con fracturas de columna vertebral en un período de dos años (2017 y 2018) en un hospital cuaternario de la ciudad de São Paulo. Métodos: Se realizó un estudio transversal mediante el análisis de historias clínicas electrónicas de pacientes atendidos por el grupo de Columna Vertebral del Departamento de Ortopedia y Traumatología de la Sala de Emergencias de Ortopedia y Traumatología del Hospital de Clínicas de São Paulo en 2017 y 2018. Resultados: Se evaluó a un total de 185 pacientes durante dos años. En la evaluación predominó el sexo masculino (69,19%), siendo la edad promedio de los pacientes de 43,95 años. Los mecanismos traumatológicos más frecuentes fueron las caídas de altura (45,95%), seguidos de los accidentes de tráfico (29,73%). La columna cervical, afectada en un 28,65%, fue la más afectada, seguida de la región toracolumbar (26,56%). La mayoría de los pacientes no tenían déficits al inicio del estudio (71,89%) y el 54,05% de ellos fueron sometidos a cirugía para su tratamiento. Conclusión: La mayoría de los traumatismos que involucran la columna afectan a la población económicamente activa (20 a 60 años), con predominio del sexo masculino. La mayoría de las lesiones se produjeron en la región cervical, que es la región más comúnmente asociada a los traumatismos graves ya las lesiones neurológicas. Este estudio puede ayudar a planificar estrategias de prevención y precaución de los traumatismos de la columna vertebral. Nivel de evidencia III; Estudio transversal.

Percutaneous Endoscopic Lumbar Discectomy Versus Microdiscectomy for the Treatment of Lumbar Disc Herniation: Pain, Disability, and Complication Rate-A Randomized Clinical Trial.

PURPOSE: The objective was to compare the traditional microdiscectomy with percutaneous endoscopic lumbar discectomy for the treatment of disc herniations regarding pain, disability, and complications. METHODS: Randomized clinical trial with 47 patients with disc herniations treated with 2 different surgical techniques: traditional microdiscectomy or percutaneous endoscopic lumbar discectomy. Forty-seven patients were divided into 2 groups and monitored for 12 months. Irradiated and low back pain were evaluated with the visual analog scale. Surgery complications were recorded. RESULTS: After surgery, the sciatica and disability improved significantly but without significant differences between the groups. Improvements in back pain were significant until the third month. There were no statistical differences between groups regarding recurrence, infection, and the need for reoperation. CONCLUSIONS: Endoscopic discectomy results are similar to those of conventional microdiscectomy regarding pain and disability improvement. Postoperative lumbar pain is less intense with endoscopic discectomy than conventional microdiscectomy only during the first 3 months. Endoscopic discectomy is a safe and efficient alternative to microdiscectomy. CLINICAL TRIALS: Trial protocol registration number: RBR-5symrd (http://www.ensaiosclinicos.gov.br).

Does Kyphectomy Improve the Quality of Life of Patients With Myelomeningocele?

BACKGROUND: Lumbar kyphosis is a complex spinal deformity occurring in approximately 8% to 20% of patients with myelomeningocele. The resulting gibbosity may cause pressure ulcers, difficulty lying down in the supine position and sitting on the ischia without support, decreasing quality of life (QOL). Surgery is generally performed to correct kyphosis and maintain vertebral alignment, but high complication rates have been reported. Despite satisfactory radiological results, the impact of surgery and its complications on health-related QOL (HRQOL) has not yet been established. QUESTIONS/PURPOSES: Among children with myelomeningocele undergoing corrective surgery for lumbar kyphosis: (1) What is the risk of complications and reoperation after this procedure? (2) Does this procedure improve HRQOL scores in these patients? METHODS: Between 2012 and 2013, five surgeons at three centers treated 32 patients for myelomeningocele-related kyphosis with kyphectomy and posterior instrumentation. During that period, all surgeons used the same indications for the procedure, which were progressive postural decompensation and chronic ulceration at the apex of the deformity. Data were prospectively collected, and all patients who underwent surgery were considered in this retrospective study. The legal guardians of one patient declined to sign the informed consent form, resulting in 31 patients included. A total of 9.7% (3 of 31) were lost to follow-up before the 2-year period, and the remaining 90.3% (28 of 31) were seen at a mean of 3 years (± 9 months) after surgery. The average age was 10 years, 7 months (± 21 months) at the time of surgery. The patients had a mean kyphosis angle of 130° ± 36° before surgery. This technique involved posterior fixation using S-shaped rods inserted through the foramina of S1 and pedicle screws inserted in the thoracic spine. The patients' caregivers answered both the generic and specific (neuromuscular module) Pediatric Quality of Life Inventory questionnaires preoperatively and 2 years postoperatively. The minimum clinically important difference (MCID) considered for the instruments used was 5. RESULTS: Reoperation was performed in 68% of patients (19 of 28), mostly to treat deep infection. In all, 18% of patients (five of 28) underwent implant removal to control infection. Eleven percent (three of 28) had a loss of reduction and pseudarthrosis. The HRQOL increased from 71 ± 11 preoperatively to 76 ± 10 postoperatively (p < 0.001), resulting in a 5-point increase (95% CI 3 to 7) in the generic questionnaire score and from 71 ± 13 to 79 ± 11 (p < 0.001), resulting in an 8-point increase (95% CI 5 to 10) in the neuromuscular Paediatric Quality of Life Inventory questionnaire score, mainly in the physical health domain on both questionnaires. CONCLUSIONS: Kyphectomy was associated with a high risk of complications and reoperations and did not seem to deliver a substantial clinical benefit for patients who underwent the procedure. Most of our HRQOL score improvements were below the minimum clinically important difference for the Pediatric Quality of Life Inventory questionnaires. Although it seems that surgeons lack a better surgical alternative when facing the challenging health impairments these patients suffer, efforts should be made to improve the technique and reduce surgical complications. Additionally, patients and caregivers should be advised of the high reoperation rate and notified that the procedure may not result in a better QOL and should thus be avoided when possible. Future studies should verify whether decreasing the complication rate could imply improvement in the HRQOL of these patients after surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Kyphectomy in patients with myelomeningocele: surgical results and complications / Cifosectomia em pacientes com mielomeningocele: resultados cirúrgicos e complicações / Cifosectomía en pacientes con mielomeningocele: resultados quirúrgicos y complicaciones

Objectives:The lumbar kyphosis in patients with myelomeningocele is a complex deformity whose treatment is mainly surgical. The objective of this study is to summarize the results and complications obtained by the group in 2012 with respect to this group of patients.Method:Performed a retrospective analysis of the medical records and radiographs of patients consecutively operated in 2012. The technique was originally described by Dunn-McCarthy and consists of kyphectomy and posterior fixation using S-shaped Luque rods through the foramina of S1 associated with pedicle screws in the thoracic spine.Results:Six patients were included in the study. The age at surgery was 11 years and 7±22 months and the weight was 29.1±11.9 kg. The procedure lasted 271±87 minutes, with the removal of one or two (mean 1.5) vertebrae from the apex of the kyphosis. Hospitalization time was 10±9 days. The lumbar kyphosis measuring 116.3±37 degrees preoperatively was reduced to 62.5±21 degrees. All patients began to sit without support and to lie in the supine position. Four patients developed postoperative infection and required surgical debridement at the follow-up. One patient had the implant removed after a year due to loosening of the rod in the sacrum.Conclusion:The surgical technique allows excellent functional results in the correction of lumbar kyphosis in patients with myelomeningocele despite high complication rates. It is necessary to conduct studies with a larger number of patients and duration of follow-up to assess whether the use of pedicle screws will decrease the rate of loosening and pseudoarthrosis.

Objetivos:A cifose lombar em pacientes com mielomeningocele é uma deformidade complexa cujo tratamento é eminentemente cirúrgico. O objetivo deste estudo é resumir os resultados e complicações obtidos pela equipe, em 2012, com relação a esse grupo de pacientes.Método:Foi feita análise retrospectiva dos prontuários e radiografias de pacientes operados consecutivamente em 2012. A técnica utilizada foi descrita originalmente por Dunn-McCarthy e consiste em cifosectomia e fixação posterior utilizando-se hastes moldadas em "S" através dos forames de S1 associados a parafusos pediculares na coluna torácica.Resultados:Foram incluídos seis pacientes no estudo. A idade à realização da cirurgia foi de 11 anos e 7 ± 22 meses e o peso foi 29,1 ± 11,9 kg. O procedimento durou 271 ± 87 minutos, com a retirada de uma ou duas (média de 1,5) vértebras do ápice da cifose. O tempo de internação foi de 10 ± 9 dias. A cifose lombar que media 116,3 ± 37 graus no pré-operatório foi reduzida para 62,5 ± 21 graus. Todos os pacientes passaram a sentar sem apoio e a deitar na posição supina. Quatro pacientes evoluíram com infecção pós-operatória e necessitaram de limpeza cirúrgica no seguimento. Um paciente teve o implante retirado após um ano, devido à soltura da haste no sacro.Conclusão:A técnica cirúrgica utilizada permite resultados funcionais excelentes na correção da cifose lombar em pacientes com mielomeningocele, apesar das altas taxas de complicações. É preciso realizar estudos com maior número de pacientes e tempo de seguimento para se avaliar se a utilização de parafusos pediculares diminuirá a taxa de soltura e pseudoartrose.

Objetivos:La cifosis lumbar en pacientes con mielomeningocele es una deformidad compleja cuyo tratamiento es principalmente quirúrgico. El objetivo de este estudio es resumir los resultados y complicaciones obtenidos por el equipo en 2012, con respecto a este grupo de pacientes.Método:Se realizó un análisis retrospectivo de las historias clínicas y las radiografías de los pacientes intervenidos consecutivamente en 2012. La técnica fue descrita originalmente por Dunn-McCarthy y constituye en cifosectomía y fijación posterior con los tallos en forma de "S" a través de los forámenes de S1 asociados con tornillos pediculares en la columna torácica.Resultados:Se incluyeron 6 pacientes en el estudio. La edad a la cirugía fue de 11 años y 7 ± 22 mmeses y el peso fue 29,1 ± 11,9 kg. El procedimiento duró 271 ± 87 minutos, con la eliminación de una o dos (media 1,5) vértebras desde el ápice de la cifosis. El tiempo de hospitalización fue de 10 ± 9 días. La cifosis lumbar midiendo 116,3 ± 37 grados antes de la operación se redujo a 62,5 ± 21 grados. Todos los pacientes empezaron a sentarse sin apoyo y acostarse en la posición supina. Cuatro pacientes desarrollaron infección postoperatoria y requirieron limpieza quirúrgica en el seguimiento. Un paciente tuvo el implante retirado después de un año debido al aflojamiento del tallo en el sacro.Conclusión: La técnica quirúrgica utilizada permite excelentes resultados funcionales en la corrección de la cifosis lumbar en pacientes con mielomeningocele a pesar de altas tasas de complicaciones. Es necesario realizar estudios con mayor número de pacientes y tiempo de seguimiento para evaluar si el uso de tornillos pediculares puede reducir el aflojamiento y la pseudoartrosis.

Resultado da neurotização do nervo ulnar para o músculo bíceps braquial na lesão do plexo braquial / Results of ulnar nerve neurotization to brachial biceps muscle in brachial plexus injury

OBJETIVO: Avaliar de forma crítica os fatores que influenciam os resultados da neurotização do nervo ulnar no ramo motor do músculo bíceps braquial, visando a restauração da flexão do cotovelo em pacientes com lesão do plexo braquial. MÉTODOS: 19 pacientes, 18 homens e uma mulher, com idade média de 28,7 anos foram avaliados entre fevereiro de 2003 e maio de 2007. Oito pacientes apresentavam lesão das raízes C5-C6 e 11, das raízes C5-C6-C7. O intervalo de tempo médio entre a injúria e o tratamento cirúrgico foi 7,5 meses. Quatro pacientes apresentavam fraturas cervicais associadas à lesão do plexo braquial. O seguimento pós-operatório foi de 15,7 meses. RESULTADO: Oito pacientes recuperaram força de flexão do cotovelo MRC grau 4; dois, MRC grau 3 e nove, MRC < 3. Não houve prejuízo da função prévia do nervo ulnar. CONCLUSÃO: Os resultados da cirurgia de neurotização do nervo ulnar no ramo motor no músculo bíceps braquial são dependentes: do intervalo decorrido entre a lesão do plexo e o tratamento cirúrgico, da presença de fraturas associadas da coluna cervical e côndilo occipital, da função residual das raízes de C8-T1 após o trauma e do acometimento da raiz de C7. Sinais de reinervação manifestados até 3 meses no pós cirúrgico mostram melhores resultados ao longo prazo. Nível de Evidência: IV, Série de Casos.

OBJECTIVE: To evaluate the factors influencing the results of ulnar nerve neurotization at the motor branch of the brachial biceps muscle, aiming at the restoration of elbow flexion in patients with brachial plexus injury. METHODS: 19 patients, with 18 men and 1 woman, mean age 28.7 years. Eight patients had injury to roots C5-C6 and 11, to roots C5-C6-C7. The average time interval between injury and surgery was 7.5 months. Four patients had cervical fractures associated with brachial plexus injury. The postoperative follow-up was 15.7 months. RESULTS: Eight patients recovered elbow flexion strength MRC grade 4; two, MRC grade 3 and nine, MRC <3. There was no impairment of the previous ulnar nerve function. CONCLUSION: The surgical results of ulnar nerve neurotization at the motor branch of brachial biceps muscle are dependent on the interval between brachial plexus injury and surgical treatment, the presence of associated fractures of the cervical spine and occipital condyle, residual function of the C8-T1 roots after the injury and the involvement of the C7 root. Signs of reinnervation manifested up to 3 months after surgery showed better results in the long term. Level of Evidence: IV, Case Series.

Estudo anatômico da via de acesso suprapatelar lateral para a haste intramedular bloqueada na fratura da tíbia / Anatomical study on the lateral suprapatellar access route for locked intramedullary nails in tibial fractures

OBJETIVO: A haste intramedular (HIM) é o padrão ouro no tratamento das fraturas diafisárias da tíbia. Uma das complicações frequentes é a dor no joelho após o procedimento. MÉTODOS: Vias alternativas, como a suprapatelar para a introdução da haste como opção para evitar a dor no joelho no período pós-operatório tardio, têm sido estudadas. A questão é se nesta nova via ocorre alguma lesão às estruturas intra-articulares do joelho. RESULTADOS: Este estudo analisa a via suprapatelar e o risco para as estruturas adjacentes através da sua reprodução em 10 joelhos de cinco cadáveres. CONCLUSÃO: Foi visto facilidade para a localização do ponto de entrada por esta via, lesando apenas a gordura de Hoffa. Em três dos nossos casos houve lesão da superfície condral, sendo um obstáculo de difícil transposição e indicando necessidade de fabricação de material específico para minimizar a lesão das estruturas intra-articulares por essa via.

OBJECTIVE: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. METHODS: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. RESULTS: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. CONCLUSION: There is a need to develop specific material to minimize injury to intra-articular structures when using this route.

ANATOMICAL STUDY ON THE LATERAL SUPRAPATELLAR ACCESS ROUTE FOR LOCKED INTRAMEDULLARY NAILS IN TIBIAL FRACTURES.

OBJECTIVE: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. METHODS: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. RESULTS: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. CONCLUSION: There is a need to develop specific material to minimize injury to intra-articular structures when using this route.

Results of ulnar nerve neurotization to biceps brachii muscle in brachial plexus injury.

OBJECTIVE: To evaluate the factors influencing the results of ulnar nerve neurotization at the motor branch of the brachii biceps muscle, aiming at the restoration of elbow flexion in patients with brachial plexus injury. METHODS: 19 patients, with 18 men and 1 woman, mean age 28.7 years. Eight patients had injury to roots C5-C6 and 11, to roots C5-C6-C7. The average time interval between injury and surgery was 7.5 months. Four patients had cervical fractures associated with brachial plexus injury. The postoperative follow-up was 15.7 months. RESULTS: Eight patients recovered elbow flexion strength MRC grade 4; two, MRC grade 3 and nine, MRC <3. There was no impairment of the previous ulnar nerve function. CONCLUSION: The surgical results of ulnar nerve neurotization at the motor branch of brachii biceps muscle are dependent on the interval between brachial plexus injury and surgical treatment, the presence of associated fractures of the cervical spine and occipital condyle, residual function of the C8-T1 roots after the injury and the involvement of the C7 root. Signs of reinnervation manifested up to 3 months after surgery showed better results in the long term. LEVEL OF EVIDENCE: IV, Case Series.