Is Shoulder Imbalance a Useful Parameter in the Screening of Idiopathic Scoliosis? A Preliminary Study.

Objective The present study aims to analyze the use of shoulder imbalance as a parameter for scoliosis screening as well as its relationship with other parameters of physical examination. Methods This study assesses a smartphone application that analyzes several parameters of the physical examination in adolescent idiopathic scoliosis. Medical and non-medical examiners applied the screening tool in students in a public school and in a private sports club. After data collection, interobserver correlation was done to verify shoulder imbalance and to compare shoulder imbalance with Adam's bending test and with trunk rotation. Results Eighty-nine participants were examined, 18 of whom were women and 71 of whom were men. Two subjects were excluded from the analysis. The mean age of subjects from the public school was 11.30 years and, for those from the sports club, it was 11.92 years. The examiners had poor-to-slight interobserver concordance on shoulder asymmetry in the anterior and posterior view. No significant statistical correlation was found between shoulder asymmetry and positive Adam's forward bending test. Conclusion Our preliminary study shows that the shoulder asymmetry has a poor correlation with the Adam's forward bending test and measuring trunk rotation using a scoliometer. Therefore, the use of shoulder imbalance might not be useful for idiopathic scoliosis screening. Level of Evidence III; Diagnostic Study.

Is Shoulder Imbalance a Useful Parameter in the Screening of Idiopathic Scoliosis? A Preliminary Study / O desequilíbrio do ombro é um parâmetro útil na triagem da escoliose idiopática? Um estudo preliminar

Abstract Objective The present study aims to analyze the use of shoulder imbalance as a parameter for scoliosis screening as well as its relationship with other parameters of physical examination. Methods This study assesses a smartphone application that analyzes several parameters of the physical examination in adolescent idiopathic scoliosis. Medical and non-medical examiners applied the screening tool in students in a public school and in a private sports club. After data collection, interobserver correlation was done to verify shoulder imbalance and to compare shoulder imbalance with Adam's bending test and with trunk rotation. Results Eighty-nine participants were examined, 18 of whom were women and 71 of whom were men. Two subjects were excluded from the analysis. The mean age of subjects from the public school was 11.30 years and, for those from the sports club, it was 11.92 years. The examiners had poor-to-slight interobserver concordance on shoulder asymmetry in the anterior and posterior view. No significant statistical correlation was found between shoulder asymmetry and positive Adam's forward bending test. Conclusion Our preliminary study shows that the shoulder asymmetry has a poor correlation with the Adam's forward bending test and measuring trunk rotation using a scoliometer. Therefore, the use of shoulder imbalance might not be useful for idiopathic scoliosis screening. Level of Evidence III; Diagnostic Study

Resumo Objetivo O objetivo deste estudo é analisar o uso da assimetria de ombros como parâmetro para a triagem de escoliose e sua relação a outros parâmetros do exame físico. Métodos Este estudo avalia um aplicativo para smartphone que analisa diversos parâmetros do exame físico de adolescentes com escoliose idiopática. Examinadores médicos e não médicos utilizaram o instrumento de triagem em alunos de uma escola pública e de um clube esportivo privado. Após a coleta de dados, a correlação interobservador foi determinada para verificar a assimetria de ombros e compará-la ao teste de inclinação de Adam e à medição da rotação do tronco. Resultados Oitenta e nove participantes foram examinados, sendo 18 do sexo feminino e 71 do sexo masculino. Dois indivíduos foram excluídos da análise. A média de idade dos participantes da escola pública foi de 11,30 anos e do clube esportivo, 11,92 anos. Os examinadores apresentaram concordância interobservador baixa a branda quanto à assimetria de ombros em incidência anterior e posterior. Não houve correlação estatística significativa entre a assimetria de ombros e o resultado positivo no teste de inclinação do tronco de Adam. Conclusão Nosso estudo preliminar mostra que a assimetria de ombros tem baixa correlação com o teste de inclinação de Adam e assim como com a medição de rotação do tronco com escoliômetro. Portanto, o uso da assimetria de ombros pode não ser útil na triagem da escoliose idiopática. Nível de Evidência III; Estudo Diagnóstico

Surgical timing in traumatic spinal cord injury: current practice and obstacles to early surgery in Latin America.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To evaluate current practice of Latin American spine surgeons regarding surgical timing in patients with traumatic spinal cord injury (tSCI) and to identify potential barriers for early surgery. SETTING: Web-based. METHODS: A web-based questionnaire was sent to members of AOSpine Latin America. Questions involved demographic features, familiarity with management of tSCI, and timing of surgery in various tSCI scenarios. The participants were also asked if they would like to operate earlier on patients with tSCI, indicating potential obstacles to early surgery. RESULTS: A total of 307 surgeons answered the questionnaire. Early surgery (<24 h) is performed by 66.8% for ASIA A, 76.9% for ASIA B, and 76.9% for ASIA C/D injuries. For traumatic cauda equina syndrome (tCES), 85.2% performed surgery within 24 h. For traumatic central cord syndrome (tCCS) without osteoligamentous instability, only 31.5% performed surgery within 24 h and 41.2% follow-up on these patients, indicating surgery if no symptom improvement. Early surgery was performed always or in most cases by 50.4% and 41.8% of surgeons for incomplete and complete tSCI, respectively. The majority (85.4%) would like to operate earlier on patients with tSCI than they actually do. The most frequently perceived barriers to early surgery were difficulty of access to surgical implants (70.9%) and delay in patient transport to reference hospital for surgery (57.8%). CONCLUSION: Latin American spine surgeons tend to operate earlier on patients with tCES and incomplete tSCI, then on those with complete tSCI and tCCS. The most reported obstacles for early surgery involved healthcare resources.

Epidemiology and Management of Spinal Trauma in Children and Adolescents <18 Years Old.

OBJECTIVE: This retrospective study reports the epidemiology, clinical aspects, and management of spinal trauma in children and adolescents. METHODS: Multicenter study of 215 cases of spinal trauma in individuals <18 years of age. All patients were submitted to preoperative and postoperative radiologic and clinical evaluation. The fractures were classified according to the AOSpine fracture classification. Neurological evaluation was performed using the Frankel scale at admission to hospital and at the last follow-up. RESULTS: Mean age was 14.7 (± 2.5) years and most of the patients were male (72.6%). Falls were responsible for 52.6% of the spinal trauma. Compression fracture was the most common type of fracture, observed in 48.4% of the cases. Most spinal fractures were located at the thoracic level (58.7%). Associated injuries were observed in 37.2% of the cases. The complication rates were 15.8%. Normal neurological examination was observed in 160 cases (74.4%) at the final follow-up. Neurological impairment was mostly observed due to shallow water diving, dislocation fractures types, and fractures located between the lower cervical spine and the thoracic spine. Surgical treatment was performed in 73.8% of the cases. Better neurological outcome was observed in fractures due to falls, fractures located in the upper cervical (C1-C2) and lower lumbar spine injuries (L3-L5). CONCLUSIONS: Surgical treatment is often necessary in children and adolescents after spinal trauma. Higher incidence of spinal cord injury was observed after shallow water diving, fractures located in the lower cervical spine and thoracic spine, and type B and C fractures.

Effectiveness of Operative and Nonoperative Care for Adult Spinal Deformity: Systematic Review of the Literature.

STUDY DESIGN: Systematic review. OBJECTIVE: There is a need for synthesizing data on effectiveness of treatments for patients with adult spinal deformity (ASD) due to its increasing prevalence and health care costs for these patients. The objective of this review was to estimate the effectiveness of surgery versus nonoperative care in patients with ASD. METHODS: A systematic review of articles in published in English using PubMed between 2005 and 2015. Surgical and nonsurgical series that reported baseline and follow-up health-related quality of life measures of patients with ASD with a minimum 2 years of follow-up were selected. Independent extraction of articles by 2 authors using predefined data fields, including risk of bias assessment. RESULTS: Surgery significantly reduces disability, pain, and improves patients' quality of life. The average postoperative improvement in Oswestry Disability Index was -19.1 (±9.0), Numerical Rating Scale back pain -4.14 (±1.38), Numerical Rating Scale leg pain -3.36 (±1.33), Short-Form Health Survey 36-SF36-Physical Component score 11.2 (±5.07), and Short-Form Health Survey 36-Mental Component score 9.93 (±4.96). The complication rate ranged from 9.52% to 81.52% (mean = 39.62%), and the need for revision surgery ranged from 1.72% to 40.0% (mean = 15.71%). The best existing evidence about nonoperative care of ASD is provided from observational studies with very high risk of bias. Quantitative analyses of nonsurgical cohorts did not demonstrate significant changes in quality of life of patients after 2 years of observation. CONCLUSIONS: This data may assist clinicians to counsel patients, as well as to inform health care providers and policymakers about what to expect from the treatment for ASD.

Management of Type II Odontoid Fractures: Experience from Latin American Spine Centers.

OBJECTIVE: To analyze characteristics of type II odontoid fracture (TII-OF), including clinical and radiographic factors, that influence surgical planning in 8 Latin American centers. METHODS: Retrospective chart review was performed of 88 patients with TII-OF between 2004 and 2015 from 8 Latin American centers. Parameters studied included 1) demographic data and causes of TII-OF, 2) clinical and neurologic presentation, 3) characteristics of fracture (degree of odontoid displacement, displacement of odontoid relative to C2 body, anatomy of fracture line, distance between fragments, presence of comminution, contact area between odontoid and C2 body), 4) type of treatment, and 5) clinical and radiographic outcome. Bone fusion was assessed using computed tomography. RESULTS: Mean patient age was 45.33 years ± 23.54; 78.4% of patients were male. Surgery was the primary treatment in 65 patients (73.8%), with an anterior approach in 64.6%. Surgery was usually preferred in patients with posterior or horizontal oblique fracture lines, local pain, and a smaller bone contact surface between the odontoid and the body of C2. A posterior approach was chosen when distance between the fractured bone fragments was >2 mm or after failed conservative or anterior odontoid screw treatment in a symptomatic patient. CONCLUSION: The treatment of choice for TII-OF in 8 Latin American trauma centers was surgery through an anterior approach using screw fixation. Posterior segmental C1-C2 fixation was indicated when distance between bone fragments was >2 mm and in symptomatic patients with nonunion.

Perspective of Value-Based Management of Spinal Disorders in Brazil.

INTRODUCTION: The state of value-based management of spinal disorders and ongoing Brazilian strategies toward its implementation are highlighted in this article. METHODS: The health care system, economic impact of spine surgery, use of patient-reported outcomes, ongoing studies about health economics, and current strategies toward implementation of quality assessment of spine care in Brazil are reviewed. RESULTS: During the past 20 years, there has been an increase of 226% in the number and 540% in the total cost of spine surgeries in the public health system. Examples of economic regulatory mechanisms involve the process of health technology assessment and the auditing processes imposed by health insurance companies. Some barriers to implementing clinical registries were identified from a large Latin American survey. Strategies based on education and technical support have been conducted to improve the quality of comparative-effectiveness research in spine care. Only 1 cost-utility study on spine care has been published until now. CONCLUSIONS: The paradigm of value-based management of spinal disorders is still incipient in Brazil. Some issues from our analysis must be emphasized: (1) Brazil presents many regional disparities and scarce resources for health care; it is crucial for the health system to allocate resources based on the value of interventions; (2) because of the high economic and social burden of developing new technologies for diagnosis and treatment, research in health economics of spine care in Brazil should be prioritized; (3) these efforts would help to provide a more accessible and effective health system for patients with spinal problems.

Economic value of treating lumbar disc herniation in Brazil.

OBJECT: Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil. METHODS: The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation). RESULTS: The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197-0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained. CONCLUSIONS: The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.

Controversies on vertebroplasty and kyphoplasty for vertebral compression fractures / Controvérsias em vertebroplastia e cifoplastia para fraturas vertebrais em compressão / Controversias en vertebroplastia y cifoplastia para fracturas de compresión vertebral

Vertebroplasty and kyphoplasty are widely used for osteoporotic and cancer-related vertebral compression fractures refractory to medical treatment. Many aspects of these procedures have been extensively discussed in the literature during the last few years. In this article, we perform a critical appraisal of current evidence on effectiveness and ongoing controversies regarding surgical technique, indications and contraindications, clinical outcomes and potential complications of these procedures.

A vertebroplastia e a cifoplastia têm sido amplamente utilizadas para fraturas por compressão osteoporóticas e relacionadas a tumor refratárias ao tratamento clinico. Nos últimos anos, vários aspectos relacionados a esses procedimentos têm sido amplamente discutidos na literatura. Neste artigo, realizamos uma análise crítica da evidência atual sobre a efetividade desses procedimentos e sobre as controvérsias referentes a técnica cirúrgica, indicações e contraindicações, resultados clínicos e possíveis complicações.

La vertebroplastia y la cifoplastia han sido ampliamente utilizadas en fracturas por compresión osteoporóticas y relacionadas con tumor refractarias al tratamiento clínico. En los últimos años, diversos aspectos relacionados con estos procedimientos han sido ampliamente discutidos en la literatura. En este artículo, presentamos un análisis crítico de la evidencia actual sobre la eficacia y las controversias relativas a la técnica quirúrgica, indicaciones y contraindicaciones, resultados clínicos y posibles complicaciones.

Management of wound infection after lumbar arthrodesis maintaining the instrumentation / Manejo da infecção de ferida operatória após artrodese lombar mantendo a instrumentação / Manejo de la infección operatoria después de artrodesis lumbar sin remover la instrumentación

To determinate whether a surgical protocol with immediate extensive debridement, closed irrigation system and antibiotic therapy would be effective to achieve healing of deep wound infection without removing the instrumentation.

Determinar se um protocolo cirúrgico de desbridamento extenso imediato, sistema de irrigação fechado e antibioticoterapia seria eficaz para alcançar a resolução da infecção profunda da ferida sem remover a instrumentação.

Determinar si un protocolo quirúrgico de desbridamiento extenso inmediato, sistema de irrigación cerrado y antibioticoterapia seria eficaz para alcanzar la resolución de la infección profunda de la herida sin remover la instrumentación.

Responsiveness of depression and its influence on surgical outcomes of lumbar degenerative diseases.

OBJECTIVE: To demonstrate the responsiveness of depression after surgery for lumbar degenerative disease and to verify the impact of this condition on surgical outcomes. PATIENT SAMPLE: A prospective cohort study with 91 patients with lumbar degenerative diseases who were evaluated preoperatively, at 30 days and 1 year postoperatively. OUTCOME MEASURES: Evolution of depression between the follow-ups and its correlation with satisfaction. METHODS: Depression was assessed with Beck Depression Inventory. According to depression responsiveness, patients were classified into four groups: NN = no depression; ND = normal during the preoperative period and depression within 1 year; DN = depression during the preoperative period and normal within 1 year; DD = depression during the preoperative period and within 1 year. RESULTS: Prevalence of preoperative depression was 28.6% and 17.6% within 1 year postoperatively. Most patients (65.4%) with depression in the preoperative period recovered postoperatively. Poor preoperative HRQoL measures were associated with higher rates of responsiveness of depression during the follow-up. Patients with depression at the 1-year postoperative follow-up had a worse functional outcome. Patients who improved from depression had similar outcome to those without depression. Dissatisfaction within 1 year postoperatively was greater in patients who become depressed after surgery and remain depressed at 1-year follow-up (NN = 8.8%; ND = 42.9%; DN = 17.6%; DD = 44.4%; P = 0.012). CONCLUSION: Most patients with depression in the preoperative recover within 1 year postoperatively. Responsiveness of depression is associated with surgical outcomes. The presence of depression after the surgical treatment, independent of when it starts, had a major negative impact on prognosis.

Preoperative motor deficit in lumbar disc herniation and its influence on quality of life / Déficit motor pré-operatório por hérnia de disco lombar e sua influência na qualidade de vida / Déficit motor preoperatorio por hernia de disco lumbar y su influencia en la calidad de vida

Objective: Evaluate the impact of motor deficit (MD) on pain, disability, depression and quality of life measures of patients with LDH prior to a specific treatment. Methods: A total of 254 consecutively enrolled patients with LDH associated to neurological impairment and sciatica who have not responded to conservative treatment were evaluated. After reviewing the exclusion criteria, 168 were included. Validated instruments were used in the preoperative period to evaluate: pain, disability, quality of life, anxiety and depression. Results: Normal motor strength was observed in 57 (33.9%) patients and MD was observed in 111 (66.1%) cases. No statistically significant differences were observed between patients with and without MD regarding gender, age, level of herniation, lateralization and workers&apos; compensation. Regarding quality of life, no difference was detected in the eight domains of SF36 and between the PCS and MCS groups. The only difference observed was a higher disability rate in the MD group, with the mean ODI difference being 7.84 (CI 95%: 1.82â€"13.87; p=0.011). Motor weakness was observed in 35.1% (n=39/111) of patients who had abnormal results at the motor evaluation, being related to severity (X²: 46.058; p<0.0001). Conclusion: In patients with LDH without prior specific treatment, the presence of MD did not modify the pain, disability, depression measures and self-reported quality of life. The MD has no discriminative ...

Objetivo: Avaliar o impacto do déficit motor (DM) sobre dor, incapacidade, depressão e medidas de qualidade de vida em pacientes com HDL antes de tratamento específico. Métodos: Avaliou-se consecutivamente um total de 254 pacientes inscritos com HDL associado à lesão neurológica e ciática que não responderam ao tratamento conservador. Depois de analisar os critérios de exclusão, 168 foram incluídos. Instrumentos validados foram utilizados no período pré-operatório para avaliar: dor, incapacidade, qualidade de vida, ansiedade e depressão. Resultados: Verificou-se força motora normal em 57 (33,9%) pacientes e o DM foi observado em 111 (66,1%) casos. Não foram observadas diferenças estatisticamente significativas entre pacientes com e sem DM com relação a sexo, idade, nível de hérnia, lateralização e compensação trabalhista. Com relação à qualidade de vida, não foi detectada diferença nos oito domínios do SF-36 e entre os grupos PCS e MCS. A única diferença observada foi taxa de deficiência superior no grupo DM, sendo a diferença média do ODI de 7,84 (IC 95%: 1,82-13,87, p = 0,011) A fraqueza motora foi observada em 35,1% (n=39/111) dos pacientes que tiveram resultado anormal na avaliação motora ...

Objetivo: Evaluar el impacto del déficit motor (DM) en el dolor, la discapacidad, la depresión y de la medida de calidad de vida en pacientes con HDL antes de un tratamiento específico. Métodos: Ha sido evaluado consecutivamente un total de 254 pacientes inscritos con HDL asociado a lesión neurológica y ciática que no han respondido al tratamiento conservador. Después de analizar los criterios de exclusión, se incluyeron 168 pacientes. Se utilizaron instrumentos validados en el preoperatorio para evaluar: dolor, discapacidad, calidad de vida, ansiedad y depresión. Resultados: La fuerza motora normal se observó en 57 (33,9%) pacientes y DM se observó en 111 (66,1%) casos. No se observaron diferencias estadísticamente significativas entre los pacientes con y sin DM con respecto a sexo, edad, nivel de la hernia, lateralización y compensación laboral En cuanto a la calidad de vida no se detectaron diferencias en los ocho dominios del SF-36 y entre los grupos PCS y MCS. La única diferencia observada fue una tasa de deficiencia superior en el grupo DM, con la diferencia promedio del ODI de 7,84 (IC 95%: 1,82-13,87, p = 0,011). La debilidad motora observada fue del 35,1% (n=39/111) de los pacientes con resultados anormales en la evaluación motora, que estaba relacionada con la gravedad (X²: 46,058, p<0,0001). Conclusión: ...

Surgical planning and neurological outcome after anterior approach to remove a disc herniation at the C7-T1 level in 19 patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to report the neurological presentation, outcome and surgical planning in a series of patients with a symptomatic single-level C7-T1 disc herniation who underwent anterior surgical discectomy and fusion. SUMMARY OF BACKGROUND DATA: Disc herniations at C7-T1 are uncommon, and there are few large series in the literature describing anterior treatment of such herniations. METHODS: We performed a retrospective study of patients who underwent surgery for a C7-T1 disc herniation and reviewed the medical records, operative reports, and imaging studies. The surgeons' view line was drawn and its relation to the manubrium and the great vessels was determined on T1 sagittal magnetic resonance imaging. The location of the herniated disc in the spinal canal was determined using a T2 axial magnetic resonance imaging and classified as central, foraminal, and central/foraminal. Loss of muscle strength was evaluated preoperatively and at the last follow-up according to the classification of the Medical Research Council. The disc space was approached anteriorly by a standard cervical supramanubrial Smith-Robinson approach. RESULTS: We identified 19 patients who had undergone C7-T1 discectomy and fusion. The mean age of the sample was 54.26 ± 8.65 years. There was a higher proportion of male patients (57.9%, 11/19). The clinical presentation was predominantly motor deficit in 15/19 cases (78.9%) in intrinsic hand muscles, and usually improved after surgery. The mean follow-up period was 27.05 ± 15.10 months. All the patients underwent an anterior cervical supramanubrial approach with microdiscectomy and fusion. Anterior cervical plate fixation was used in 9/19 cases (47.3%). In the rest of the cases, a stand-alone intervertebral device was placed. CONCLUSION: An anterior cervical supramanubrial approach was easily accomplished in all patients. Motor deficit was the most common surgical indication. LEVEL OF EVIDENCE: 4.

Is the lasègue sign a predictor of outcome in lumbar disc herniation surgery? / O sinal de lasègue é um preditor do resultado da cirurgia de hérnia de disco lombar? / ¿La señal de laségue es un predictor de resultado en la cirugía de hernia de disco lumbar?

OBJECTIVE: Evaluate the predictive value of the Lasègue sign on self-reported quality of life measures (HRQoL) in patients who undergo microdiscectomy. METHODS: 95 patients with clinical and radiological diagnosis of LDH who underwent microdiscectomy were included. The patients were assessed by a neurological examination and answered validated instruments to assess pain, disability, quality of life, and mood disorder in the preoperative period, and 1, 6 and 12 months after surgery. RESULTS: Preoperative Lasègue sign was identified in 56.8% (n=54/95) of the cases. There was no difference between the groups in the preoperative period regarding HRQoL. At one year follow-up no statistically significant difference in HRQoL was observed in the Lasègue group. The discrimination capacity of the preoperative Lasègue sign to determinate variations in HRQoL outcomes one year postoperatively was low. CONCLUSION: Lasègue sign is not a good predictor of outcome after microdiscectomy for LDH.

OBJETIVO: Avaliar o valor preditivo do Sinal de Lasègue em medidas de qualidade de vida (HRQoL) em pacientes submetidos a microdiscectomia. MÉTODOS: 95 pacientes com diagnóstico clínico e radiológico de HDL submetidos à microdiscectomia foram incluídos. Os pacientes foram avaliados por exame neurológico e responderam instrumentos validados para medir dor, incapacidade, qualidade de vida e transtornos do humor no período pré-operatório e 1, 6 e 12 meses após a cirurgia. RESULTADOS: O sinal de Lasègue no pré-operatório foi identificado em 56,8% (n = 54/95) dos casos. Não houve diferença entre os grupos no pré-operatório em relação à HRQoL. Em um ano de pós-operatório não foi observada diferença estatística com relação à HRQoL no grupo com Lasègue. A capacidade de discriminação do Sinal de Lasègue pré-operatório para determinar variações na HRQoL em um ano de pós-operatório foi baixa. CONCLUSÃO: O Sinal de Lasègue não é um bom preditor de prognóstico após microdiscectomia na HDL.

OBJETIVO: Evaluar el valor predictivo de la señal de Lasègue en medidas de calidad de vida (HRQoL) en pacientes sometidos a microdiscectomía. MÉTODOS: Se incluyeron 95 pacientes con diagnóstico clínico y radiológico de HDL que se sometieron a microdiscectomía. Los pacientes fueron evaluados por examen neurológico y respondieron a instrumentos para medir dolor, incapacidad, calidad de vida y disturbios del humor en el periodo preoperatorio y 1, 6 y 12 meses después de la cirugía. RESULTADOS: La señal de Lasègue en el preoperatorio se identificó en el 56,8% (n = 54/95) de los casos. No hubo diferencia entre los grupos en el preoperatorio en relación a la HRQoL. En un año de post operatorio no se observó diferencia estadística con relación a la HRQoL en el grupo con Lasègue. La capacidad de discriminación de la señal de Lasègue preoperatoria para determinar variaciones en la MCV en un año de postoperatorio fue baja. CONCLUSIÓN: La señal de Lasègue no es un buen predictor de pronóstico post microdiscectomía en la HDL.

Depression Subscale of the Hospital Anxiety and Depression Scale applied preoperatively in spinal surgery.

OBJECTIVE: To evaluate the accuracy of the Depression Subscale of Hospital Anxiety and Depression Scale (HADS-D) in spine surgery, comparing it to Beck Depression Inventory (BDI). METHODS: In a cross-sectional study, the HADS-D and the BDI were applied to patients undergoing spine surgery for lumbar (n=139) or cervical spondylosis (n=17). Spearman correlation tests for HADS-D and BDI were applied. The internal consistency of HADS-D was estimated by Cronbach's alpha coefficient. RESULTS: According to the BDI, the prevalence of depression was of 28.8% (n=45). The Spearman r coefficient between HADS-D and BDI was 0.714 (p<0.001). Cronbach's alpha for HADS-D was 0.795. The area of the ROC curve was 0.845. Using a cutoff for HADS-D >10, there was a sensitivity of 71.1%, specificity of 95.4%, and positive likelihood-ratio of 15.78. CONCLUSIONS: HADS-D showed a strong correlation with BDI and good reliability. HADS-D is a good alternative for screening depression and assessing its severity.

Depression Subscale of the Hospital Anxiety and Depression Scale applied preoperatively in spinal surgery / Subescala de Depressão da Escala Hospitalar de Depressão e Ansiedade no pré-operatório de coluna vertebral

OBJECTIVE: To evaluate the accuracy of the Depression Subscale of Hospital Anxiety and Depression Scale (HADS-D) in spine surgery, comparing it to Beck Depression Inventory (BDI). METHODS: In a cross-sectional study, the HADS-D and the BDI were applied to patients undergoing spine surgery for lumbar (n=139) or cervical spondylosis (n=17). Spearman correlation tests for HADS-D and BDI were applied. The internal consistency of HADS-D was estimated by Cronbach's alpha coefficient. RESULTS: According to the BDI, the prevalence of depression was of 28.8% (n=45). The Spearman r coefficient between HADS-D and BDI was 0.714 (p<0.001). Cronbach's alpha for HADS-D was 0.795. The area of the ROC curve was 0.845. Using a cutoff for HADS-D >10, there was a sensitivity of 71.1%, specificity of 95.4%, and positive likelihood-ratio of 15.78. CONCLUSIONS: HADS-D showed a strong correlation with BDI and good reliability. HADS-D is a good alternative for screening depression and assessing its severity.

OBJETIVO: Avaliar a acurácia da Subescala de Depressão da Escala Hospitalar de Depressão e Ansiedade (HADS-D) em cirurgia da coluna, comparando-a com o Inventário de Depressão de Beck (BDI). MÉTODOS: Estudo transversal, no qual a HADS-D e o BDI foram aplicados em pacientes submetidos à cirurgia da coluna vertebral por espondilose lombar (n=139) ou cervical (n=17). Teste de correlação de Spearman foi aplicado entre HADS-D e BDI. A consistência interna da HADS-D foi estimada pelo coeficiente alfa de Cronbach. RESULTADOS: De acordo com o BDI, a prevalência de depressão foi de 28,8% (n=45). O coeficiente r de Spearman entre HADS-D e BDI foi de 0,714 (p <0,001). Alpha de Cronbach para o HADS-D foi de 0,795. A área da curva ROC foi de 0,845. Usando um corte para HADS-D >10, houve sensibilidade de 71,1%, especificidade de 95,4% e razão de verossimilhança positiva de 15,78. CONCLUSÕES: HADS-D apresentou forte correlação com o BDI e boa confiabilidade. A HADS-D é uma boa alternativa para a triagem de depressão e verificação da gravidade dos sintomas.

Correlation between persistent neurological impairment and clinical outcome after microdiscectomy for treatment of lumbar disc herniation.

BACKGROUND: Outcome of lumbar disc herniation is often based on clinical scores and less frequently on the neurological examination. However, even when clinical outcome measures are favorable, patients may still experience motor or sensory impairment. OBJECTIVE: To evaluate the percentage of patients with persistent neurological deficits after lumbar disc surgery and whether these correlate with clinical outcome. METHODS: A total of 150 patients with sciatica and lumbar disc herniation with neurological impairment underwent microdiscectomy and were prospectively followed for 24 months. Patients were assessed pre- and postoperatively with neurological examination, the Oswestry Disability Index (ODI), and the visual analog scale (VAS) for pain. RESULTS: Twenty-four months after surgery, 25% of patients who presented with motor deficits, 40% of patients with sensory deficits, and 48% of patients with reflex abnormalities remained unchanged. The VAS and the ODI showed significant improvement in both patients with and without persistent neurological impairment immediately after surgical repair of the herniated disc with progressive improvement over the follow-up period. However, when calculating the area under the receiver operating characteristics curve, no statistically significant correlation could be established between the presence and persistence of neurological impairment and the 2 clinical scores. CONCLUSION: There seems to be no correlation between clinical results and neurological impairment when assessed by the VAS and ODI.

Effect of deep wound infection following lumbar arthrodesis for degenerative disc disease on long-term outcome: a prospective study: clinical article.

OBJECT: Deep wound infections are one of the most common and serious complications of spinal surgery. The impact of such infections on long-term outcomes is not well understood. The purpose of this study was to evaluate the functional status and satisfaction in patients who suffered a deep wound infection after undergoing lumbar arthrodesis for symptomatic degenerative disc disease. METHODS: The authors conducted a prospective study in 13 patients with a clinical and radiological diagnosis of symptomatic degenerative lumbar stenosis and instability; after undergoing decompression and instrumentation-augmented arthrodesis, the patients suffered a deep wound infection (infection group). A 3:1 (39-patient) matched cohort was selected for comparison (control group). All surgeries were performed during the same period and by a single surgeon. The postoperative infections were all treated in a similar manner and the instrumentation was not removed. Both groups were followed up and assessed with validated outcome instruments: Numerical Rating Scale of pain, Oswestry Disability Index, 36-Item Short Form Health Survey, Beck Depression Inventory, and Hospital Anxiety and Depression Scale. Patient satisfaction was also determined. RESULTS: The median follow-up duration was 22 months (range 6-108 months). The mean patient age was 62 ± 10 years, and 59.6% of the patients were female. There was no significant difference between the groups in pain, functional disability, quality of life, or depression and anxiety. However, 53.8% of the patients with infection were not satisfied with the procedure at the final evaluation, compared with 15.4% of the patients without a deep wound infection (p = 0.003). CONCLUSIONS: Patients with successfully treated postoperative deep wound infections do not have a difference in functional outcome compared with patients who underwent an identical operation but did not suffer a complicating infection. Patients who suffered an infection were more likely to be unsatisfied with the procedure than patients who did not.

Anterior approach to the cervicothoracic junction: proposed indication for manubriotomy based on preoperative computed tomography findings.

OBJECTIVE: The purpose of this study was to present straightforward preoperative methods to define the need for manubriotomy in the anterior surgical approach to the cervicothoracic junction. METHODS: Preoperative MR imaging and CT scanning studies were performed in all patients. The CT images with sagittal reconstructions including the manubrium were done to apply the so-called surgeons' view line. This line is parallel to the inferior plateau of the superior healthy vertebrae or the vertebrae above the herniated intervertebral disc, and the decision concerning the need for manubriotomy depends on the correlation between this line and the manubrium. RESULTS: Preoperative planning of the need for manubriotomy was correct in all cases. Manubriotomy was never performed in C-7 corpectomy or C7-T1 discectomy cases; nevertheless, manubriotomy was needed in half of the cases when the T-1 corpectomy was the lowest level to be resected (8 cases), and in 4 cases the lowest level to be approached was T-2. The mean surgical time, bleeding volume, postoperative pain intensity, and length of hospital stay were less in the cervicotomy than in the manubriotomy group. CONCLUSIONS: By using the surgeons' view line and its correlation with the manubrium, the need for manubriotomy can be predicted without compromising decompression and reconstruction. The statistical differences observed in the surgical variables between the manubriotomy and cervicotomy cases justified the use of preoperative evaluation of the need for manubriotomy as an aid to surgical planning and to give the patient and family realistic expectations about the surgery.

Spontaneous idiopathic spinal epidural hematoma: two different presentations of the same disease / Hematoma epidural espinhal espontâneo: duas diferentes apresentações da mesma doença / Hematoma epidural espinal espontáneo: dos diferentes presentaciones clínicas de la misma enfermedad

We report two cases of spontaneous spinal epidural hematoma with different clinical presentations without precipitating factors and a brief review of the literature. Our case first developed acute and had progressive cervical spinal cord signs that determined emergency decompressive laminectomy. On the other hand, the second patient, who was chronic, was operated almost five months after the initial symptoms and the radiological diagnosis was a large facet cyst. Early surgical intervention is the chosen treatment for spontaneous spinal epidural hematomas. Spinal surgeons should bear in mind that spontaneous spinal epidural hematomas may have different clinical presentations according to their location in order to perform a differential diagnosis.

Os autores relatam dois casos de hematoma epidural espinhal espontâneo com diferentes apresentações clínicas e sua revisão da literatura. O primeiro paciente apresentava sinais e sintomas de compressão medular cervical, necessitando de laminectomia de urgência, enquanto no segundo paciente, que era crônico, havia sintomatologia de lombociatalgia por compressão nervosa de evolução de cinco meses e com diagnóstico radiológico de cisto facetário. A intervenção cirúrgica precoce é o tratamento de escolha para os hematomas epidurais espinhais espontâneos. Os hematomas epidurais espinhais espontâneos, conforme a localização na coluna vertebral, diferem na apresentação clínica e no manejo. Na região lombar, o diagnóstico diferencial deve ser feito com patologias degenerativas.

Fueron relatados dos casos de hematoma epidural espinal espontáneo con diferentes presentaciones clínicas sin factores precipitantes, y fue hecha una breve revisión de la literatura. Nuestro caso 1 tuvo un desarrollo agudo y mostró señales progresivas en la columna cervical que determinaron una laminectomía descompresiva de emergencia. Por otro lado, el segundo paciente, crónico, fue operado casi cinco meses después de los síntomas iniciales y el diagnóstico radiológico fue de un gran quiste sinovial. La intervención quirúrgica temprana es el tratamiento de elección para hematomas espontáneos epidurales espinales. El tratamiento quirúrgico representa la forma más común de terapia para todos los tipos de presentaciones clínicas. Debemos considerar que el tratamiento conservador (o no) sea más común en casos de presentación leve, principalmente en pacientes con hematoma espinal crónico. Para realizar un diagnóstico diferencial, los cirujanos deben recordar que los hematomas epidurales espinales espontáneos pueden tener distintas presentaciones clínicas según su ubicación.