Characteristics of Spinopelvic Sagittal Alignment in Lumbar Degenerative Disease.

BACKGROUND: Normal sagittal alignment shows a range of variations and normal values. This study compared sagittal vertebral alignment in patients with different degenerative lumbar diseases. METHODS: This cross-sectional study evaluated 300 patients who were enrolled between June 2016 and June 2017. Of these patients, 213 met the study criteria and were included. RESULTS: Of the 213 patients, 66 were men (31%) and 147 were women (68.2%). The mean age was 62.7 years. Diagnoses included degenerative spondylolisthesis in 116 patients (52.7%), lumbar disk degeneration in 76 patients (34.5%), lumbar spinal stenosis in 19 patients (8.6%), and lytic spondylolisthesis in 7 patients (3.2%). The most frequent Roussouly type of sagittal alignment was type 3 (33.6%), followed by type 4 (25.9%). No significant correlation was associated with Roussouly type of sagittal alignment and lumbar degenerative disease. Median sagittal vertebral alignment parameters in the series were as follows: pelvic incidence (PI), 60.55° ± 15.62°; sacral slope, 39.09° ± 12.48°; pelvic tilt, 20.92° ± 8.99°; lumbar lordosis, 33.15° ± 18.49°; and sagittal balance, 19.64 ± 55.27 mm. One hundred sixteen patients with degenerative spondylolisthesis had significant greater PI than those with other diagnoses (61.56° vs. 58.3°, respectively; P = 0.005), and patients with lumbar spinal stenosis had significantly lower PI than those with other diagnoses (55.89° vs. 60.44°, respectively; P = 0.005). CONCLUSIONS: Pelvic incidence may play a predisposing role in the pathogenesis of lumbar degenerative disease. Patients with degenerative spondylolisthesis have greater pelvic incidence with increased lumbar lordosis. In contrast, patients with spinal stenosis have lower pelvic incidence with flatter lumbar lordosis.

[Results to 4-year follow-up of the treatment of the cervical stenosis by corpectomy, titanium mesh cage and anterior plate fixation]. / Resultados a 4 años de seguimiento del tratamiento del conducto cervical estrecho mediante corpectomía, malla de titanio y fijación anterior con placa.

BACKGROUND: Cervical spondylotic myelopathy is caused by cervical stenosis. Several techniques have been described for the treatment of multilevel disease, such as the anterior corpectomy with titanium mesh cage and anterior cervical plate placement, which has the advantage of performing a wider decompression and using the same bone as graft. However, it has caused controversy since the collapse of the mesh cage continues being a major limitation of this procedure. MATERIAL AND METHOD: A prospective 4-year follow-up study was conducted in 7 patients diagnosed with cervical stenosis, who were treated surgically by one level corpectomy with titanium mesh cage and anterior cervical plate placement, evaluating them by radiographs and clinical scales. RESULTS: 7 patients, 5 women and 2 males were studied. The most common level was C5 corpectomy (n=4). The Neck Disability Index (NDI) preoperative average was 30.01±24.32 and 4-year postoperative 16.90±32.05, with p=0.801. The preoperative and 4-year postoperative Nürick was 3.28± 48 and 3.14±1.21 respectively, with p=0.766. Preoperative lordosis was 14.42±8.03 and 4-year postoperative 17±11.67 degrees, with p=0.660. The immediate postoperative and 4-year postoperative subsidence was 2.69±2.8 and 6.11±1.61 millimeters respectively, with p=0.0001. CONCLUSIONS: Despite the small sample, the subsidence of the mesh cage is common in this procedure. No statistically significant changes were observed in the lordosis or Nürick scale and NDI.

Detección temprana de la escoliosis idiopática del adolescente: una estrategia en controversia / Early detection of adolescent idiopathic scoliosis: Strategy in controversy

Resumen La escoliosis idiopática del adolescente (EIA) consiste en una deformidad tridimensional de la estructura de la columna vertebral en los planos coronal, sagital y rotacional, que afecta a sujetos sanos a partir de los 10 años de edad hasta la madurez ósea o al término del crecimiento. Esta enfermedad puede comprometer el estado físico, emocional y, por lo tanto, la calidad de vida de quienes la padecen, por lo que debe ser considerada un problema de salud significativo. La EIA se puede sospechar con un examen físico de columna, mediante el cual se evalúa el nivel de los hombros, el nivel de las escápulas, el nivel de la pelvis, la prueba de Adams y el signo de Pitres. A pesar de que en México no se han establecido oficialmente programas para la detección temprana de la enfermedad, la prueba de Adams puede ser la pauta para identificar y prevenir el desarrollo de esta deformidad. La aplicación de esta prueba de tamizaje está al alcance de todos. A pesar de que se podría considerar que su detección oportuna desde etapas tempranas sería la mejor estrategia para combatirla a tiempo, existen grupos de investigación a nivel internacional que opinan distinto, lo que ha colocado a la detección temprana como un tema controversial. Por lo anterior, el objetivo de este trabajo es ofrecer al lector un panorama general y actualizado de las diferentes perspectivas del tema, esperando que sea de utilidad para la práctica profesional.

Abstract Adolescent idiopathic scoliosis (EIA), consists of a three-dimensional deformity of the structure of the spine in the coronal, sagittal and rotational planes affecting healthy subjects ranging from 10 years of age until skeletal maturity or term of growing. This disease can compromise physical and emotional state, therefore, the quality of life of those who suffer it, so the EIA must be considered as significant health problem. The EIA can be suspected by a physical examination of the spine on whichshoulders level, shoulder blades level, pelvis level, Adams Test and Pitres sign are evaluated. Even though, it hasn't been officially established a program for an early detection of the disease in Mexico, evidence through Adams Test can be a guideline to identify and prevent the development of this deformity. The application of this screening test is available to all. Although it could be considered that early detection of this deformity at young ages would be the best strategy to get on time for treatment, there are international research groups that have a different opinion, which has placed early detection of EIA as a controversy topic. Therefore, the aim of this paper is to provide a general and updated overview of the different perspectives of this issue, hoping it will be useful for the professional practice.

[Clinical presentation of a dorsal epidural arachnoid cyst after an epidural anesthesia]. / Presentación clínica de quiste aracnoideo epidural dorsal posterior a anestesia epidural.

BACKGROUND: Arachnoid cysts are dural diverticula with liquid content similar to cerebrospinal fluid, with 1% occurring in the spinal cord. They locate mainly in the dorsal region of the thoracic spine, and are unusual causes of spinal cord compression. CLINICAL CASE: The case is presented of a previously healthy 15-year-old boy, with a 20-month history of spastic paraparesis that started apparently after epidural block for ankle osteosynthesis. There was decreased sensitivity and strength of the pelvic limbs and gradually presented with anaesthesia from T12 to L4 dermatomes, L5 and S1 bilateral hypoaesthesia and 4+/5 bilateral strength, in the L2 root and 2+/5 in L3, L4, L5, S1, hyperreflexia, Babinski and clonus, but with no alteration in the sacral reflexes. In the magnetic resonance it was diagnosed as an extradural arachnoid cyst from T6 to T9. The patient underwent a T6 to T10 laminotomy, cyst resection, dural defect suture, and laminoplasty. One year after surgery, the patient had recovered sensitivity, improvement of muscle strength up to 4+/5 in L2 to S1, and normal reflexes. CONCLUSIONS: After the anaesthetic procedure, increased pressure and volume changes within the cyst could cause compression of the spinal cord, leading to symptoms. Despite being a long-term compression, the patient showed noticeable improvement.

[Spinal osteochondroma: diagnostic imaging and treatment. Case reports]. / Osteocondroma espinal: diagnóstico por imagen y tratamiento. Reporte de casos.

BACKGROUND: Osteochondromas are benign bony tumours, with only 1 to 4% being located in the spine. It occurs more frequently in the cervical spine, with C2 being the vertebra most affected. The neurological presentation is slow due to the growth characteristics of the tumour. Computed axial tomography is the reference method for diagnosis. Surgical management is indicated for patients with neurological impairment or pain. CLINICAL CASE: The first case presents a 21-year-old male with osteochondroma located in the spinous processes of L2, L3 and L4. The second case is a 20-year-old female with multiple osteochondromatosis with tumours at the right lateral mass of C1, with extension to C2 and tumours on the spinous processes of C5 and C7. Both patients presented with painful symptoms, which were resolved after surgical resection of the tumours. CONCLUSIONS: The rarity of these conditions, relevance of a clinical-radiographic diagnosis, and considerations required for surgical treatment are discussed here.

[Profile of the patient with failed back surgery syndrome in the National Institute of Rehabilitation. Comparative analysis]. / Perfil del paciente con síndrome de columna multioperada en el Instituto Nacional de Rehabilitación. Análisis comparativo.

BACKGROUND: Failed back surgery syndrome is a complication of spine surgery that leads to chronic pain and disability, often with disastrous emotional consequences to the patient. AIM: To compare the profile of patients whose first surgery was performed in our hospital versus a group that underwent first spine surgery in a different centre. METHODS: Retrospective study with 65 patients; 18 formed group I (first spine surgery performed in our institution), and 47 patients in group II (first surgery performed in another hospital). Background, demographic, clinical features and functional status were compared. In group I the majority of the cases had a previous diagnosis of lumbar stenosis (group I 44.4% vs group II 25.5% p = 0.22), whereas disk herniation was the main diagnosis in group II (group I 22.2% vs group II 61.7% p = 0.001). The main cause of the syndrome in group I was technical error during surgery (61.1%), while in group II this cause represented only 6.3% (p=.001). Among the patients of this latter group, misdiagnosis was highly prevalent (57.4%), against no cases in group I (p=.001). The preoperative functional status between both groups and their recovery in the immediate postoperative period was similar (p = 0.68). CONCLUSIONS: This study suggests that the diagnostic and treatment standards are different between healthcare centres, specifically between academic centres vs. private practice.

[Use of the PEEK cage in cervical spondylosis treatment]. / Uso de caja de PEEK (Poli-ether-ether-ketona) parael tratamiento de la espondilosis cervical.

BACKGROUND: Decompression and fusion with autograft is the gold standard technique in the treatment of cervical canal strait. Using PEEK cages or boxes of non-absorbable polymer with elasticity similar to bone, radiolucent, reduces morbidity and same degree of fusion. METHODS: A case series, prospective, longitudinal, deliberate intervention, evaluation panel before and after 2 years follow-up. Discectomy and PEEK housing placement with autologous graft. Arthrodesis were evaluated, cervical lordosis, intervertebral space height, pain evaluated with Visual Analogue Scale, Neck Disability Index, operative time, intraoperative bleeding, hospital stay and complications. Statistical analysis with t Sudent, Wilcoxon and Fisher's exact text. RESULTS: Of 17 patients studied, 9 (53%) were female. Average age 62 years. The most affected level was C5-6, C6-7 with 5 patients. Melting was found at 100%. There was no sag or migration of the box, space height was conserved, but segmental lordosis was not retained. Clinical improvement in all patients as well as disability index was seen. Bleeding was on average 187 mL. CONCLUSION: With regard to symptom improvement, conservation of interspace height and back, no segmental lordosis conservation and fusion using PEEK box is consistent with the literature. We suggest using anterior plate to maintain cervical lordosis. We found a melt index of 100%. We found clinical improvement of symptoms, pain and disability, and a global loss of cervical lordosis.

Antecedentes: la descompresión y artrodesis con auto-injerto es el patrón de referencia para el tratamiento del conducto cervical estrecho. El uso de cajas de PEEK polímero no reabsorbible, con elasticidad similar al hueso, radiolúcido, y mismo grado de fusión reduce la morbilidad. aterial y métodos: estudio de serie de casos, prospectivo, longitudinal, de intervención deliberada, evaluación en grupol antes y después, seguimiento a dos años. Discoidectomía y colocación de caja de PEEK con injerto autólogo. Se evaluaron artrodesis, lordosis cervical, altura del espacio intervertebral, dolor mediante escala visual análoga, índice de discapacidad cervical, tiempo quirúrgico, sangrado transoperatorio, estancia intrahospitalaria y complicaciones. Análisis estadístico con t de Student, Wilcoxon y exacta de Fisher. Resultados: de 17 pacientes estudiados, 9 (53%) eran del sexo femenino. La edad promedio 62 años. Sangrado promedio de 187 mL. El nivel más afectado fue C5-C6, C6-C7 en cinco pacientes. Se encontró fusión al 100% sin hundimiento ni migración de la caja, altura del espacio conservada, pero no se conservó la lordosis segmentaria. Mejoría clínica en todos los pacientes, y del índice de discapacidad. Conclusión: la disminución de los síntomas, la conservación de la altura del espacio anterior y posterior, la no conservación de la lordosis segmentaria y la fusión con caja de PEEK fueron congruentes con lo reportado en la bibliografía. Se sugiere utilizar la placa anterior para mantener la lordosis cervical. El índice de fusión encontrado fue de 100%, con disminución de los síntomas de dolor y discapacidad. Pérdida de lordosis cervical global.

Evaluacion de la biopsia transpedicular guiada por TAC / Avaliação da biópsia transpedicular guiada por TC / Evaluation of transpedicular percutaneous biopsy guided by CT

OBJETIVO: Valorar la utilidad de la biopsia transpedicular percutánea guiada por Tomografía Axial Computarizada en conjunto con la sistematización de estudios como pruebas diagnósticas de la etiología de la destrucción vertebral. MÉTODOS: Estudio de serie de casos prospectivo transversal de 21 pacientes a los que se les realizó biopsia transpedicular percutánea guiada por Tomografía Axial Computarizada y estudios de laboratorio y gabinete de marzo a julio del 2011, para evaluar su utilidad en el diagnóstico de destrucción vertebral. RESULTADOS: Fueron 21 pacientes, 14 hombres y 7 mujeres, con edad media de 59,2 años, cuyos niveles más afectados estuvieron en L1, L2 y L3. El reporte de la biopsia tuvo una precisión diagnóstica del 90,4%. En 2 casos se realizó correlación clínica entre biopsia y sistematización de estudios para obtener el diagnóstico. CONCLUSIÓN: La biopsia guiada por Tomografía Axial Computarizada es una técnica sencilla, útil, de bajo costo y eficaz en el estudio de la destrucción vertebral; la sistematización de estudios permite corroborar el diagnóstico de la biopsia.

OBJETIVO: Avaliar a utilidade da biópsia transpedicular percutânea guiada por tomografia axial computadorizada em conjunto com a sistematização de estudos, como exames diagnósticos da etiologia da destruição vertebral. MÉTODOS: Estudo de série de casos, prospectivo e transversal de 21 pacientes submetidos à biópsia transpedicular percutânea guiada por tomografia axial computadorizada e exames laboratoriais e radiológicos, de março a julho de 2011, para avaliar sua utilidade no diagnóstico de destruição vertebral. RESULTADOS: Foram analisados 21 pacientes, 14 homens e 7 mulheres, com média de idade de 59,2 anos, cujos níveis mais afetados foram L1, L2 e L3. O laudo da biópsia teve precisão diagnóstica de 90,4%. Em dois casos, realizou-se a correlação clínica entre biópsia e sistematização de exames para obter o diagnóstico. CONCLUSÃO: A biópsia guiada por tomografia axial computadorizada é uma técnica simples, útil, de baixo custo e eficaz para o estudo da destruição vertebral; a sistematização de estudos permite corroborar o diagnóstico da biópsia.

OBJECTIVE: To evaluate the usefulness of percutaneous transpedicular biopsy guided by CT together with systematic studies such as diagnostic tests of the etiology of vertebral destruction. METHODS: Case series, prospective and crossover study of 21 patients who underwent percutaneous transpedicular biopsy guided by CT and laboratory tests and radiological studies from March to July 2011, to evaluate its usefulness in the diagnosis of vertebral destruction. RESULTS: We analyzed 21 patients, 14 men and 7 women, mean age 59.2 years, whose most affected levels were L1, L2, and L3. The biopsy report had diagnostic accuracy of 90.4%. In 2 patients the clinical correlation between biopsy and systematization of diagnostic studies was carried out. CONCLUSION: CT-guided biopsy is a simple, useful, inexpensive, and effective technique for the study of vertebral destruction; the systematic studies allow us to corroborate the diagnosis made by biopsy.

Evolución clínica y radiológica en el tratamiento de hernia discal con prótesis PDN-SOLO con ancla: seguimiento mínimo a tres años / Clinical and radiological development in the treatment of intervertebral disc with prosthesis PDN-SOLO with anchors: follow-up to a minimum of three years / Evolução clínica e radiológica no tratamento da hérnia discal com prótese PDN-SOLO com ancora: seguimento mínimo por três anos

OBJETIVO: las prótesis de núcleo (PDN-SOLO) reconstruyen la anatomía y preservan la biomecánica del disco intervertebral con un índice de migración de 10 por ciento y de hundimiento de 19 por ciento. Por eso, proponemos un sistema de fijación para evitar estas complicaciones. MÉTODOS: fueron utilizados veinte pacientes con seguimiento mínimo de tres años. La valoración de dolor con EVA, función con Escala de Oswestry (EO) y disco por estudios radiográficos y resonancia magnética fueron aplicadas. El análisis estadístico fue por t de Student. RESULTADOS: El grupo comprende 8 mujeres y 12 hombres con una edad promedio de 37.6 años. Los valores preoperatorios de EVA fueron 7.6 puntos y EO de 67 por ciento, la altura del espacio intervertebral (El) de 7.67 mm. A tres años, EVA de dolor de 0.7 y EO a menos de 6 por ciento (p<0.000). Incremento altura disco promedio 2 mm. La prótesis presentó movilidad en rotación con respecto a colocación inicial en 12 pacientes. En dos casos, el implante migró con necesidad de retiro. La evaluación de EVA y EO fue de 0.7 puntos y 1.4 por ciento. La ganancia de altura del espacio intersomático mejoró 2.5 mm. Una migración a los 23 meses por esfuerzo físico no indicado representando un 5 por ciento y no existiendo ningún hundimiento. CONCLUSIÓN: se puede concluir que había una reducción del dolor y el grado de discapacidad asociada a las plataformas de menor edema y aumento del espacio intervertebral.

OBJETIVO: as próteses de núcleo (PDN-SOLO) reconstituem a anatomia e preservam a biomecânica do disco intervertebral, com um índice de migração de 10 por cento e de afundamento de 19 por cento. Por isso, foi proposto um sistema de fixação para evitar essas complicações. MÉTODOS: foram utilizados 20 pacientes com seguimento mínimo de três anos. A avaliação da dor com EVA, função com Escala de Oswestry (EO) e disco por estudos radiológicos e ressonância magnética foram aplicados. A análise estatística foi por teste t de Student. RESULTADOS: Fizeram parte do estudo 12 homens e 8 mulheres, com média de idade de 37,6 anos. Valores pré-operatórios da EVA foram de 7,6 pontos e EO de 67 por cento, a altura do espaço intervertebral (EI) de 7,67 mm. Durante três anos, a EVA de dor foi de 0,7 e a EO foi menos de 6 por cento (p<0,000). Houve aumento da altura discal média de 2 mm. A prótese apresentou mobilidade em rotação durante a colocação inicial em 12 pacientes. Em dois casos o implante migrou com necessidade de remoção. A avaliação de EVA e EO foi de 0,7 pontos e 1,4 por cento. A ganância de altura do espaço intersomático melhorou 2,5 mm. Uma migração aos 23 meses por esforço físico não-indicado representou 5 por cento. Não houve nenhum afundamento. CONCLUSÃO: pode-se concluir que houve uma redução da dor e do grau de incapacidade associados com menos edema das plataformas e aumento do espaço intervertebral.

OBJECTIVE: The prosthetic nucleus (PDN-SOLO) reconstruct the anatomy and preserve the biomechanics of intervertebral disc with a migration rate of 10 percent and sinking rate of 19 percent. Therefore, a fixing system to avoid these complications was proposed. METHODS: A total of 20 patients were followed-up for at least three years. The assessment of pain with VAS, Oswestry Scale function (OS) and disk by radiological studies and magnetic resonance imaging were applied. Statistical analysis was made by Student's t-test. RESULTS: The subjects were 12 men and 8 women with a mean age of 37.6 years. VAS preoperative values were 7.6 points and OS 67 percent, the height of intervertebral space was 7.67 mm. For three years, the VAS pain score was 0.7 and OS less than 6 percent (p<0.000). There was an increase of average disc height of 2 mm. Prosthesis showed mobility in rotation during the initial placement in 12 patients. In 2 cases the implant migrated and it was necessary to remove it. The VAS evaluation and OS were 0.7 points and 1.4 percent. The height greed of intersomatic space improved in 2.5 mm. A migration in 23 months by non-indicated physical exertion represented 5 percent. There was no sinking. CONCLUSION: We can be concluded that there was a reduction of pain and degree of disability associated with less edema platforms and increase the intervertebral space.

[Results of the surgical treatment of atlantoaxial instability]. / Resultado en el tratamiento quirúrgico de la inestabilidad atlantoaxoidea.

BACKGROUND: Instability of the cervical spine is defined as an increase in flexibility farther than the physiological limits of one vertebra over another in some of its axes, conditioning symptoms for the patient. Traumatic, degenerative, metabolic and neoplastic causes have all been identified. METHODS: A retrospective, longitudinal, observational and descriptive study was carried out on patients surgically intervened specifically for atlantoaxial instability from January 1993 to May 2002, with a minimum 5-year follow-up. RESULTS: Eleven patients were evaluated. Ages ranged from 25 to 75 years (average age 56 years) with a female predominance. Etiology was iatrogenic in six cases, and there were four cases of rheumatoid arthritis and one case due to trauma. In all cases, fixation was accomplished with occipitocervical arthrodesis with posterior arch resection. Predominant preoperative neurologic deficit according to Ranawat was grade II and postoperatively was grade I. CONCLUSIONS: The average age of patients in our series was discreetly lower in regard to what has been reported in the literature. Female predominance was in accordance with previous publications. Eight of 11 patients showed improvement as in other series. A higher impact was observed in patients between 30 and 64 years of age. The occupational activity with the highest frequency was homemaker, and the neurologic deficit according to Ranawat showed improvement in 72% of the patients.

[Vertebral hemangioma of the posterior arch with subsequent extraosseous extension and neurological symptoms. Case report and literature review]. / Hemangioma vertebral del arco posterior con extensión extraósea y sintomatología neurológica. Informe de un caso y revisión de la literatura.

BACKGROUND: Vertebral hemangioma is the most common benign spinal tumor and is found in 11% of postmortem studies as a slow-growing benign vascular malformation. It usually involves the vertebral body and sometimes the posterior vertebral elements. When the posterior elements are involved, spinal cord compression with neurological symptoms are seen more often. Vertebral hemangiomas exist as a continuum of manifestations and lesions ranging from the common asymptomatic forms to the rare compression lesion. Extraosseous extension of vertebral hemangioma with cord compression and neurological symptoms is a rare condition and represents a treatment challenge. Surgical options are open resection, embolization or vertebroplasty. CLINICAL CASE: We report a case of a vertebral hemangioma with extraosseous extension to the spinal canal with an unusual size and osseous component in the posterior elements. This tumor caused neurological manifestations and was surgically treated with posterior decompression and stabilization with transpedicular screws and rods. Clinical outcome was good. CONCLUSIONS: Vertebral hemangioma is normally an asymptomatic benign lesion not requiring specific treatment. Only in a few cases is surgical treatment required. When neurological compromise is present, early treatment should be carried out before the presence of permanent paralysis.

[Whiplash syndrome. Proposal of treatment]. / Esguince cervical. Propuesta de tratamiento.

The cervical sprain, also known as Whiplash Syndrome, is a frequent pathology that produces high economic losses by year in the big cities. The most common mechanism most for whiplash, is the automobile accident with collision in the backside of the car, although it can be caused by other mechanisms. The pathophysiology of the whiplash syndrome is poorly understood, therefore the treatment is controversial and poorly described in the literature. Many signs and symptoms are reported, some of which are related to poor prognosis and are rarely reported. While making the diagnosis work-up, plain X-rays have low sensibility compared to Magnetic Resonance Imaging (MRI) in the detection of changes. The electroneurophysiology studies should be considered for using them in a routine basis, and when alterations appear, it is recommended to use MRI. Unfortunatelly, the rehabilitation treatments for whiplash syndrome have not been scientifically evaluated, thus there is few supportive evidence of the benefits and effectiveness from said treatments. It is very important to mention the treatment could be surgical.

Hemangioma vertebral del arco posterior con extensión extraósea y sintomatología neurológica: informe de un caso y revisión de la literatura / Vertebral hemangioma of the posterior arch with subsequent extraosseous extension and neurological symptoms: case report and literature review

Introducción: El hemangioma vertebral es el tumor más común de la columna vertebral, se identifica hasta en 11 % de las autopsias. Es tipificado como una malformación benigna vascular de crecimiento lento; en ocasiones involucra los elementos posteriores, asociándose a compromiso neurológico. Por lo general es asintomático, encontrándose de forma incidental al estudiar el dolor de origen espinal en busca de otra patología; ocasionalmente produce manifestación neurológica. La extensión extraósea intrarraquídea con compromiso neurológico ha sido poco informada y representa un reto terapéutico. Caso clínico: Adolescente femenina con hemangioma vertebral de tamaño inusual del arco posterior con extensión hacia el conducto raquídeo que ocasionó manifestaciones neurológicas y ameritó tratamiento quirúrgico para su resección y fijación transpedicular. Conclusiones: El hemangioma vertebral es una lesión asintomática que no requiere tratamiento específico. Solo en algunos casos es necesario el tratamiento quirúrgico, que debe llevarse a cabo oportunamente cuando hay compresión neurológica, para evitar secuelas permanentes. El crecimiento extraóseo intrarraquídeo con deterioro neurológico es una presentación inusitada.

BACKGROUND: Vertebral hemangioma is the most common benign spinal tumor and is found in 11% of postmortem studies as a slow-growing benign vascular malformation. It usually involves the vertebral body and sometimes the posterior vertebral elements. When the posterior elements are involved, spinal cord compression with neurological symptoms are seen more often. Vertebral hemangiomas exist as a continuum of manifestations and lesions ranging from the common asymptomatic forms to the rare compression lesion. Extraosseous extension of vertebral hemangioma with cord compression and neurological symptoms is a rare condition and represents a treatment challenge. Surgical options are open resection, embolization or vertebroplasty. CLINICAL CASE: We report a case of a vertebral hemangioma with extraosseous extension to the spinal canal with an unusual size and osseous component in the posterior elements. This tumor caused neurological manifestations and was surgically treated with posterior decompression and stabilization with transpedicular screws and rods. Clinical outcome was good. CONCLUSIONS: Vertebral hemangioma is normally an asymptomatic benign lesion not requiring specific treatment. Only in a few cases is surgical treatment required. When neurological compromise is present, early treatment should be carried out before the presence of permanent paralysis.

Resultado en el tratamiento quirúrgico de la inestabilidad atlantoaxoidea / Results of the surgical treatment of atlantoaxial instability

Introducción: La inestabilidad de la columna cervical es el aumento en la movilidad más allá de los límites fisiológicos de una vértebra sobre otra en alguno de sus ejes, que condiciona síntomas en el paciente. Existen causas traumáticas, degenerativas, metabólicas y neoplásicas. Material y métodos: Se realizó estudio retrospectivo, longitudinal, observacional y descriptivo, de intervención deliberada, en pacientes con cirugía por inestabilidad atlantoaxoidea, de enero de 1993 a mayo de 2002, con un seguimiento mínimo de cinco años. Resultados: Se evaluaron 11 pacientes, con edades de 25 a 75 años, media de 56 años. El sexo predominante fue el femenino. La etiología fue iatrogénica en seis casos, cuatro por artritis reumatoide y uno postraumática. En todos se realizó fijación y artrodesis occipitocervical con resección del arco posterior. El déficit neurológico preoperatorio predominante según la escala de Ranawat fue grado II, y en el posoperatorio fue grado I. Conclusiones: La edad media de nuestra serie fue discretamente menor respecto a la indicada en la literatura; el sexo predominante correspondió a lo informado en la literatura. Existió mejoría en ocho de los 11 pacientes, como en otras series. La mayor incidencia se observó entre los 30 y 64 años. La actividad ocupacional con mayor frecuencia fue la del hogar. El déficit neurológico según la escala de Ranawat mejoró en 72 % de los pacientes.

BACKGROUND: Instability of the cervical spine is defined as an increase in flexibility farther than the physiological limits of one vertebra over another in some of its axes, conditioning symptoms for the patient. Traumatic, degenerative, metabolic and neoplastic causes have all been identified. METHODS: A retrospective, longitudinal, observational and descriptive study was carried out on patients surgically intervened specifically for atlantoaxial instability from January 1993 to May 2002, with a minimum 5-year follow-up. RESULTS: Eleven patients were evaluated. Ages ranged from 25 to 75 years (average age 56 years) with a female predominance. Etiology was iatrogenic in six cases, and there were four cases of rheumatoid arthritis and one case due to trauma. In all cases, fixation was accomplished with occipitocervical arthrodesis with posterior arch resection. Predominant preoperative neurologic deficit according to Ranawat was grade II and postoperatively was grade I. CONCLUSIONS: The average age of patients in our series was discreetly lower in regard to what has been reported in the literature. Female predominance was in accordance with previous publications. Eight of 11 patients showed improvement as in other series. A higher impact was observed in patients between 30 and 64 years of age. The occupational activity with the highest frequency was homemaker, and the neurologic deficit according to Ranawat showed improvement in 72% of the patients.

[Surgical treatment of craniocervical instability. Review paper]. / Tratamiento quirúrgico para la inestabilidad craneocervical. Trabajo de revisión.

The concept of spinal instability is still controversial. Anatomical, biomechanical, clinical and radiographic variants are involved and make the definition complicated. There are solid diagnostic bases in cases of fractures and degenerative disorders; however, pure spinal instability is still under study. The latter may be defined as increased mobility that goes beyond the physiological limits of one vertebra over another in at least one of the three spinal planes of motion. In the case of the craniocervical region, its understanding becomes even more challenging, since its anatomy and physiology are more complex and it is more mobile. Surgical treatment is possible with either an anterior or a posterior approach. Best results are obtained with occipitocervical or atlantoaxial stabilization through a posterior approach, since the anterior one has its limitations. For example, a transoral approach with a bone graft provides compression strength but does not enable immediate appropriate fixation and involves the risk of infection. The choice of the surgical approach must consider the patient's medical status, the specific spine levels involved, the extent of neurological compromise, the X-ray abnormalities and the individual pathology. The goals of surgery are achieved through an appropriate anatomical alignment, assuring the protection of the neural elements and achieving proper spine stabilization with as much preservation of the mobile vertebral segments as possible.

[Surgical treatment for scoliosis. Minimal evolution control at 5 years]. / Tratamiento quirúrgico de la escoliosis. Control de evolución mínimo de 5 años.

BACKGROUND: We undertook this study to determine the surgical treatments results performed often to correct scoliosis in the Spinal Surgery Service in the INR/Orthopedics (National Institute of Rehabilitation/Orthopedics), Mexico City. METHODS: We conducted a longitudinal, prospective, descriptive, and clinical study with a deliberated intervention controlled from a historical cohort. One hundred twenty patients with scoliosis were reviewed in whom surgery was performed during 1990-1999. For quantitative variables, pre- vs. postoperative measures were compared using non-parametric means with chi(2) or in this case with ANOVA by Kruskall-Wallis test. Differences are considered significant if p <0.05. RESULTS: Age average of patients was 12 years. There were 75 females and 45 males. There were 59 idiopathic scoliosis cases and 54 congenital scoliosis cases. Anterior approach was accomplished in 61 cases with posterior fixation. Posterior approach was used in 54 cases. There were 76 cases of Luque segmental instrumentation. Pre-operatively, scoliosis was ranked (18 to 110 grades) and postoperatively (5 to 90 grades) (p = 0.00001). There were 21 complications, 9 due to injuries or infection. In 76 patients, different fixation techniques were used, obtaining a correction average of 14.47 grades. Forty four patients were structured with bars, four distal screws, two compression screws, proximal hooks with sublaminar wire, and the angle was reduced on average 23.11 grades. CONCLUSIONS. Average reduction of scoliosis was higher with the modified Luque III instrumentation (p <0.045). There was no difference between etiology and preoperative angle.

[Experience with prosthetic disc nucleus device in Mexico. Final report of a 4-year follow-up]. / Experiencia en México con prótesis discal de núcleo. Reporte final a 4 años de seguimiento.

BACKGROUND: Discal hernia is generally treated by discectomies that are mutilating and cause instability and low back pain in 50% of the patients. Partial arthroplasty is used in an attempt to avoid degeneration after a discectomy. METHODS: Nineteen patients from the INR (National Institute of Rehabilitation) were selected with extruded discal hernia. All inclusion criteria were met, with a minimal follow-up of 4 years. Evolution was evaluated with the Oswestry scale (OS) and x-ray studies. Statistical analysis was done with Student's t-test. RESULTS: Sixteen men and three women were included in the study, with an average age of 35.4 years. OS before surgery was 57.37% and improved to 22% (p < 0.001). The results obtained in the Prolo scale 4 years later were for the economy scale, p < 0.001 (Wilcoxon Z = 3.87) and for the functional scale, p < 0.001 (Wilcoxon Z = -3.94). The intervertebral space height (IS) before surgery was 6 and 8 mm, and 4 years later, in 12 patients it remained between 8 and 10 mm. The prosthesis had variations according to its initial placement in seven patients, and in all there was subsidence. In two cases migration surpassed the limits of the vertebral body without clinical repercussion. None of the patients required re-operation. CONCLUSIONS: Prosthetic disc nucleus device improved clinical conditions and x-rays of the patients using Oswestry, Prolo and intersomatic space height enhancement after 4 years of follow-up in 12/19 patients.

[Stability effect of the suprajacent vertebrae after fixation in spondylolisthesis. Comparative study of two systems]. / Repercusión en la estabilidad del segmento suprayacente después de la fijación de la espondilolistesis. Estudio comparativo de dos sistemas.

BACKGROUND: This study was undertaken to evaluate vertebral stability after two different types of fusion fixation (rigid and semirigid) in spondylolisthesis. MATERIAL AND METHODS: Ambispective study of a dynamic cohort constituted by 42 patients that underwent surgery between 1990 and 2000 for a spondilolistesis treatment. According to the fixing type, they were divided into two follow-up groups: to group 1, plate INO (semirigid system) was placed + posterolateral fusion (PLF), 20 cases; to group 2, plate INO was installed + intersomatic screw + PLF, 22 cases. RESULTS: Both groups achieved better listhesis, reduced pain according to Oswestry and SF36 Index (p <0.05), and less intervertebral height was lost. Group 1 lost the least amount (-0.61 mm) of invertebral height if grades of presurgical listhesis were 1-2, and higher (-2.0 mm) if grades of presurgical listhesis were 3-4. Inversely, group 2 lost the least (0.50 mm) if grade of listhesis was 3 or 4, and higher (-1.25 mm) if grades of listhesis were 1-2. From 4 to 7 years, in group 2 there was altered bending of 5.8 degrees to 8.3 degrees (p = 0.05), a significant difference from group 1. Group 2 showed higher flexion grades (p = 0.01) at 4-7 years postoperatively and a significant reduction in EVA (p = 0.04) at more than 7 years. The remaining patients showed no significant differences between groups. But loss of intervertebral height was higher in group 2 (-1.18 mm) than group 1 (-0.75 mm). Plate INO + PLF favored flexibility and reduced loss of intervertebral height in grades 1-2 of presurgical listhesis, INO + screw + PLF showed reduced listhesis and decrease of height lost in grades 3-4 of presurgical listhesis. CONCLUSIONS: We recommended the use of INO + PLF in grades 1-2 of presurgical listhesis and INO + screw + PLF in grades 3-4 of listhesis presurgically.