Surgical timing prevails as the main factor over morphologic characteristics in the reduction by ligamentotaxis of thoracolumbar burst fractures.

BACKGROUND: thoracolumbar burst fractures are associated with spinal canal occupation. The indirect decompression of the spinal canal and reduction of the fragment can be achieved with the distraction of the middle column and ligamentotaxis. Nevertheless, the factors that influence the effectiveness of this procedure and its temporality are controversial. METHODS: The aim of this observational, cross-sectional study was to evaluate the effectiveness of indirect reduction by ligamentotaxis in thoracolumbar burst fractures according to the fracture's radiologic characteristics and the procedure's temporality. Patients diagnosed with a thoracolumbar burst fracture between 2010 and 2021 were submitted to indirect reduction by distraction and ligamentotaxis. A retrospective analysis of radiologic characteristics and temporality of the procedure was performed with an independent sample t-test or Pearson's correlation coefficient, as required. RESULTS: A total of 58 patients were included in the analysis. Postoperatively, ligamentotaxis significantly improved all radiologic parameters (canal occupation, endplates distance, and vertebra height). Still, none of the radiological characteristics of the fracture (width, height, position, sagittal angle) were associated with the postoperative change in canal occupation. The endplates distance and the temporality of ligamentotaxis significantly predicted the reduction of the fracture. CONCLUSION: Fragment reduction effectiveness is more significant when performed as early as possible and adequate distraction is achieved using the internal fixator system. The radiologic characteristics of the fractured fragment do not determine its reduction capacity.

An independent inter- and intra-observer agreement assessment of the AOSpine upper cervical injury classification system.

BACKGROUND CONTEXT: The complex anatomy of the upper cervical spine resulted in numerous separate classification systems of upper cervical spine trauma. The AOSpine upper cervical classification system (UCCS) was recently described; however, an independent agreement assessment has not been performed. PURPOSE: To perform an independent evaluation of the AOSpine UCCS. STUDY DESIGN: Agreement study. PATIENT SAMPLE: Eighty-four patients with upper cervical spine injuries. OUTCOME MEASURES: Inter-observer agreement; intra-observer agreement. METHODS: Complete imaging studies of 84 patients with upper cervical spine injuries, including all morphological types of injuries defined by the AOSpine UCCS were selected and classified by six evaluators (from three different countries). The 84 cases were presented to the same raters randomly after a 4-week interval for repeat evaluation. The Kappa coefficient (κ) was used to determine inter- and intra-observer agreement. RESULTS: The interobserver agreement was almost perfect when considering the fracture site (I, II or III), with κ=0.82 (0.78-0.83), but the agreement according to the site and type level was moderate, κ=0.57 (0.55-0.65). The intra-observer agreement was almost perfect considering the injury, with κ=0.83 (0.78-0.86), while according to site and type was substantial, κ=0.69 (0.67-0.71). CONCLUSIONS: We observed only a moderate inter-observer agreement using this classification. We believe our results can be explained because this classification attempted to organize many different injury types into a single scheme.

[Degenerative cervical myelopathy]. / Mielopatía cervical degenerativa: una patología cada vez más frecuente y que requiere diagnóstico y manejo precoz.

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Its prevalence is increasing as a result of population aging. The diagnosis of DCM is often delayed or overlooked, resulting in secondary neurologic morbidity. The natural course of DCM typically presents as a gradual neurological deterioration, with symptoms ranging from muscle weakness to complete paralysis, with variable degrees of sensory deficits and sphincter dysfunction. Magnetic resonance imaging (MRI) and electrophysiological studies allow the assessment of spinal cord function and its structural damage to determine treatment and clinical outcomes. All patients with signs and symptoms consistent with DCM should be referred to a spine surgeon for assessment and tailored treatment. Those patients with mild DCM can be managed non-operatively but require close monitoring and education about potentially alarming signs and symptoms. Surgery is not currently recommended for asymptomatic patients with evidence of spinal cord compression or cervical spinal stenosis on MRI, but they require a structured follow-up. Patients with moderate or severe DCM require surgical decompression to avoid further progression. The objective of this review is to raise awareness of degenerative cervical myelopathy and its increasing prevalence as well as to aid non-surgical healthcare workers for a timely diagnosis and management of this disabling condition.

Granuloma eosinofílico cervical en el adolescente: reporte de un caso y revisión de la literatura / Cervical eosinophilic granuloma in adolescents: case report and literature review

INTRODUCCIÓN El granuloma eosinofílico (GE) es una patología infrecuente, sobre todo en adultos, que puede afectar la columna cervical. A pesar de la vasta literatura, esta enfermedad afecta principalmente a la población infantil, y no hay un consenso sobre el manejo en adultos. Con el objetivo de aportar conocimiento respecto a esta patología poco frecuente, se presenta un caso clínico de GE cervical en un paciente de 16 años, a quien se trató de manera conservadora, con buenos resultados y retorno completo a sus actividades. CASO CLÍNICO Un hombre de 16 años, seleccionado de rugby, consultó por dolor cervical axial persistente y nocturno de 6 semanas de evolución, sin trauma evidente. Al examen, destacó dolor a la compresión axial sin compromiso neurológico asociado. Los exámenes de tomografía computarizada (TC) y resonancia magnética (RM) revelaron lesión lítica en el cuerpo de C3 de características agresivas, de presentación monostótica en tomografía por emisión de positrones-tomografía computada (TEP-TC) compatible con tumor primario vertebral. Se decidió realizar biopsia percutánea bajo TC, para definir el diagnóstico y manejo adecuado, la cual fue compatible con células de Langerhans. Al no presentar clínica ni imagenología de inestabilidad ósea evidente o compromiso neurológico, se manejó con tratamiento conservador, inmovilización cervical, analgesia oral, y seguimiento estrecho. A los cuatro meses de evolución, se presentó con una TC con cambios reparativos del cuerpo vertebral y sin dolor, y logró retomar sus actividad habituales. CONCLUSIONES El diagnóstico de GE es infrecuente a esta edad, y se debe plantear entre diagnósticos diferenciales de lesiones líticas agresivas primarias vertebrales. Es necesario el uso de imágenes, y la biopsia vertebral es fundamental para confirmar el diagnóstico. Su manejo va a depender de la sintomatología, del compromiso de estructuras vecinas, y de la estabilidad de la vértebra afectada. El manejo conservador con seguimiento clínico e imagenológico es una opción viable.

INTRODUCTION Eosinophilic granuloma (EG) is a rare, tumor-like lesion, infrequently affecting the cervical spine, particularly in adults. Although vastly described in literature, this pathology mainly affects children, and there is still no consensus on its treatment in older patients. With the goal of contributing to increase the knowledge regarding this infrequent pathology, we present a case of a C3 eosinophilic granuloma in a 16-year-old patient, who was treated conservatively, with good results, including complete return to his previous activities. CLINICAL CASE a 16-year-old male, elite rugby player, presented with a history of persistent neck pain, mainly at night, with no previous trauma. Upon physical examination, he reported neck pain with axial compression of the head, without neurological impairment. Both computed tomography (CT) and magnetic resonance imaging (MRI) scan revealed an aggressive lytic lesion in the C3 vertebral body, a with monostotic presentation on positron emission tomography-computed tomography (PET-CT) compatible with a primary spine tumor. A CT-guided percutaneous biopsy was obtained to establish the diagnosis and provide the proper management. The results were compatible with Langerhans cells. As he presented no symptoms or imaging findings of evident bone instability, as well as no neurological impairment, the patient was treated conservatively, with a cervical brace, oral pain medication and close followup. A CT obtained after four months of treatment showed reparative changes of the C3 vertebral body; at this point, the patient reported no neck pain, so he was able to return to his previous activities. CONCLUSIONS Although an EG is rare at this age, it should be considered in the differential diagnosis of primary vertebral aggressive lytic lesions. Imaging and a vertebral biopsy are paramount to confirm the diagnosis. The treatment modality depends on the symptoms, the involvement of adjacent structures, and the stability of the affected vertebra. Conservative management including clinical and imaging followup is a viable option.

Traumatic cervical spine injury due to pole dance accident: A potentially catastrophic unreported injury with a happy ending. Case report and literature review.

Background: Pole dancing is a sport that has become very popular. However, there is scarce literature on injuries associated with this sport. Here, we present a 23-year-old female who sustained a traumatic C4-C5 vertex cervical spine injury caused by a fall of 1 m while practicing pole dancing in an inverted position, requiring a 360 decompression/fusion. Case Description: A 23-year-old female sustained a 1 m fall in an inverted position while pole dancing resulting in a direct axial impact to the head. She developed the rapid onset of quadriparesis that was attributed to the emergent CT/MR-documented cervical flexodisruptive luxofracture (AOSpine C4-C5 fracture: C, F4 unilateral, N3, M2). Four hours post injury, she underwent a C4-C5 anterior cervical discectomy and fusion. Four days later, a posterior fusion was performed to add to the stabilization. Six years later, the patient remains neurologically intact. Conclusion: Pole dance is an emerging sport which carries a risk of cervical spine injury.

Mielopatía cervical degenerativa: una patología cada vez más frecuente y que requiere diagnóstico y manejo precoz

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Its prevalence is increasing as a result of population aging. The diagnosis of DCM is often delayed or overlooked, resulting in secondary neurologic morbidity. The natural course of DCM typically presents as a gradual neurological deterioration, with symptoms ranging from muscle weakness to complete paralysis, with variable degrees of sensory deficits and sphincter dysfunction. Magnetic resonance imaging (MRI) and electrophysiological studies allow the assessment of spinal cord function and its structural damage to determine treatment and clinical outcomes. All patients with signs and symptoms consistent with DCM should be referred to a spine surgeon for assessment and tailored treatment. Those patients with mild DCM can be managed non-operatively but require close monitoring and education about potentially alarming signs and symptoms. Surgery is not currently recommended for asymptomatic patients with evidence of spinal cord compression or cervical spinal stenosis on MRI, but they require a structured follow-up. Patients with moderate or severe DCM require surgical decompression to avoid further progression. The objective of this review is to raise awareness of degenerative cervical myelopathy and its increasing prevalence as well as to aid non-surgical healthcare workers for a timely diagnosis and management of this disabling condition.

Management of lumbar disc herniation with radiculopathy: Results of an Iberian-Latin American survey.

BACKGROUND: Lumbar disc herniation (LDH)/radiculopathy is the most frequent cause of lost workdays in people under 50 years of age. Although there is consensus about how to assess these patients, the optimal management strategy is still debated. METHODS: An online survey was sent to spine surgeons who are members of the Iberian-Latin American Spine Society to assess how they treat LDH with radiculopathy. RESULTS: There were 718 surgeons who answered the survey; 66% reported that 76-100% of their monthly clinic work was due to spine issues. The most frequently used conservative treatment modalities included non-opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) (90.5%), followed by physical therapy (55.2%) and pregabalin (41.4%). Notably, 40% of surgeons in the public sector believed that conservative treatment failed if symptoms persisted beyond 6-12 weeks, while 39% of private surgeons deemed conservative management insufficient if it had failed to provide symptomatic relief with 3-6 weeks. Of interest, 78% utilized epidural steroid injections (ESI); 51.7% preferred the transforaminal, 27.2% the interlaminar, and 7.5% the caudal approaches. The most frequent indications for surgery included: cauda equina syndrome, progressive neurological deficits, and intractable pain. Traditional microdiscectomy was the most common technique (68.5%) utilized, followed by 7.5% advocating endoscopic disc resection, and just 6.4% favoring the tubular discectomy. CONCLUSION: There is considerable heterogeneity among Iberian and Latin American spine surgeons in the treatment of LDH/radiculopathy. Although most begin with the utilization of NSAIDs and non-opioid analgesics, followed by ESI (88%), surgery was recommended for persistent symptoms/signs for those failing between 3 and 6 weeks (private sector) versus 6-12 weeks (public sector) of conservative therapy.

Treatment strategies for managing cervical spine injuries in rugby players.

BACKGROUND: Cervical spine fractures are potentially catastrophic injuries in rugby players. Here, we reviewed seven patients who sustained rugby-related cervical spine fractures. Notably, three of seven fractures were missed on initial X-rays, but were ultimately documented on CT studies obtained an average of 10 days later. METHODS: Seven patients sustained cervical spine fracture attributed to rugby (2009-2016) and were followed an average of 52 posttrauma months. Most injuries occurred at the C6-C7 level, and six of seven patients required surgery. Further, only two of seven patients exhibited resultant neurological deficits (e.g., one myelopathy and one radiculopathy). RESULTS: Although the rugby injury was sufficiently documented on initial X-rays in four patients, three initial X-rays missed fractures, which were documented on the CT studies obtained an average of 10 days later. CONCLUSION: Rugby-related cervical fractures must be considered where players continue to complain of pain following trauma. Notably, routine X-rays may miss fractures in 3 of 7 cases (43%), thus warranting supplemental CT examinations to definitively rule out fractures.

Treatment of severe pediatric spinal deformities.

The management of severe pediatric spinal deformities continues to evolve as advances in spinal instrumentation, surgical techniques, and neuromonitoring occur. The techniques of spinal osteotomies have been refined to allow surgeons to perform better corrections with less operative time, more safely, and through a posterior approach alone, making multiple patient positioning changes during surgery a less common occurrence. With these techniques comes a learning curve for the entire surgical team, wherein communication and planning can help minimize major complications and morbidity. This overview will review various techniques used in the correction of severe spinal deformities. Topics reviewed include the role of anterior release, traction, posterior releases, and osteotomies. Indications, techniques, and pitfalls will be reviewed. A clear understanding of the patient's deformity, normal sagittal parameters, spinal anatomy, and the principles of neuromonitoring will help improve surgical planning and patient outcome.

Resultados del tratamiento quirúrgico de las fracturas toracolumbares tipo C de la AO / Results of the surgical treatment of type C AO thoracolumbar fractures

AO Type C Thoracolumbar fractures are the most complex and unstable spine injuries, with a high frecuency of neurological impairment. The goal of this study is to describe the clinical characteristics, management and outcome in worker’s compensation patients with type C AO thoracolumbar fractures that were surgically treated in our hospital between January 1994 and December 2004. We collected 88 patients, 68 of them had work related accidents. Four patients were discarded because of insufficient data. The median follow up was 58 months. Of the 64 patients evaluated (mean age 35.7 years), 94 percent were men. The most common mechanism of injury was height fall (41 percent). Associated injuries occurred in 80 percent of the patients (23 percent had another spine fracture). Neurological impairment was present in 64 percent, 22 percent had incomplete, while 42 percent had complete impairment. The majority of the patients presented a C3 AO thoracolumbar fracture (50 percent). The average preoperative time was 6 days (range 0-64). The mean time of surgery was 224 minutes (range 80-640). Only 9.3 percent of the patients required a complementary anterior approach. The median hospitalization time was 61 days (6-275) and the mean postoperative rest was 9.8 months (1.4-34). We had 11 acute complications and 6 delayed complications. Return to work occurred in 64 percent of the patients, while 59 percent was compensated. Among the patients presenting partial neurological impairment, 50 percent improved at least one degree in the Frankel scale.

Las fracturas tóracolumbares tipo C de la AO corresponden a las lesiones espinales más complejas e inestables, con una alta incidencia de compromiso neurológico. El objetivo del presente estudio es describir las características clínicas, manejo y evolución de los pacientes accidentados del trabajo, con fracturas tóracolumbares tipo C de la AO, operados en nuestro hospital. Revisamos en forma retrospectiva los casos entre enero de 1994 y diciembre de 2004. Recolectamos 88 pacientes, 68 de los cuales correspondían a accidentados del trabajo. Cuatro casos fueron eliminados por información incompleta. La mediana de seguimiento fue de 58 meses. De los 64 pacientes evaluados (edad promedio 35,7 años),el 94 por ciento eran hombres. El mecanismo de lesión más común fue caída de altura (41 por ciento). Un 80 por ciento de los pacientes presentaron lesiones asociadas (23 por ciento con fractura de columna a otro nivel). Un 64 por ciento ingresó con compromiso neurológico, de los cuales, el 22 por ciento fue parcial y 42 por ciento completo. La mayoría de las fracturas fueron tipo C3 de la clasificación AO (50 por ciento). El tiempo promedio preoperatorio fue de 6 días (0-64). La duración promedio de la cirugía fue de 224 minutos (80-640). Un 9,3 por ciento de los pacientes requirió de una vía anterior complementaria. La mediana de hospitalización fue de 61 días (6-275) y el tiempo promedio de reposo post operatorio fue de 9,8 meses (1,4-34 meses). Hubo 11 complicaciones precoces y 6 tardías. Un 64 por ciento retornó al trabajo y un 59 por ciento fue indemnizado. De los pacientes con compromiso neurológico parcial, un 50 por ciento recuperó al menos un grado en la escala de Frankel.