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1.
World Neurosurg ; 133: e76-e83, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31521757

RESUMO

OBJECTIVE: Spine fractures, including associated spinal cord injury, account for 3%-6% of all skeletal fractures annually in the United States. Patients who undergo interhospital transfer after injury may have a greater likelihood of nonroutine disposition, longer hospital stay, and higher cost. We evaluated the effects of patient transfer on functional outcomes after spine trauma. METHODS: Patients were treated after acute traumatic spine injury at a rehabilitation hospital in 2011-2017. Compared patients were those directly admitted to the tertiary hospital or transferred from a community hospital. RESULTS: A total of 188 patients (mean age 46.1 ± 18.6 years, 77.1% men) were evaluated, including 130 (69.1%) directly admitted and 58 (30.9%) transferred patients. The most common levels of injury were at C5 (19.1%) and C6 (12.2%), and most injuries were American Spinal Injury Association injury severity score grade D (33.2%) or grade A (32.1%). No statistical difference in age, injury pattern, timing from injury to surgery, or rehabilitation length of stay was seen between admitted and transferred patients. A significant improvement in ambulation distances was seen at discharge for directly admitted compared with transferred patients (447.7 ± 724.9 vs. 159.9 ± 359.5 feet; P = 0.005). However, no significant difference primary outcomes, namely American Spinal Injury Association injury severity score distribution (P = 0.2) or Functional Independence Measures (Δ30.9 ± 15.9 vs. 30.1 ± 17.1; P = 0.7), were seen between admitted and transferred patients at time of rehabilitation discharge. CONCLUSIONS: Interhospital transfer status did not diminish time to rehabilitation after injury or reduce functional recovery, suggesting early surgical treatment in community settings may have merit prior to transfer.


Assuntos
Transferência de Pacientes , Traumatismos da Coluna Vertebral/reabilitação , Atividades Cotidianas , Adulto , Idoso , Continuidade da Assistência ao Paciente , Feminino , Hospitais Comunitários , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Recuperação de Função Fisiológica , Traumatismos da Medula Espinal/etiologia , Traumatismos da Medula Espinal/reabilitação , Traumatismos da Medula Espinal/cirurgia , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/cirurgia , Centros de Atenção Terciária , Centros de Traumatologia , Índices de Gravidade do Trauma , Resultado do Tratamento , Adulto Jovem
2.
Artigo em Inglês | MEDLINE | ID: mdl-31768546

RESUMO

BACKGROUND: Occipitocervical instability may result from transcondylar resection of the occipital condyle. Initially, patients may be able to maintain a neutral alignment but severe occipitoatlantal subluxation may subsequently occur, with cranial settling, spinal cord kinking, and neurological injury. OBJECTIVE: To evaluate the ability of posterior fixation constructs to prevent progression to severe deformity after radical unilateral condylectomy. METHODS: Eight human cadaveric specimens (Oc-C2) underwent biomechanical testing to compare stiffness under physiological loads (1.5 N m). A complete unilateral condylectomy was performed to destabilize one Oc-C1 joint, and the contralateral joint was left intact. Unilateral Oc-C1 or Oc-C2 constructs on the resected side and bilateral Oc-C1 or Oc-C2 constructs were tested. RESULTS: The bilateral Oc-C2 construct provided the greatest stiffness, but the difference was only statistically significant in certain planes of motion. The unilateral constructs had similar stiffness in lateral bending, but the unilateral Oc-C1 construct was less stiff in axial rotation and flexion-extension than the unilateral Oc-C2 construct. The bilateral Oc-C2 construct was stiffer than the unilateral Oc-C2 construct in axial rotation and lateral bending, but there was no difference between these constructs in flexion-extension. CONCLUSION: Patients who undergo a complete unilateral condylectomy require close surveillance for occipitocervical instability. A bilateral Oc-C2 construct provides suitable biomechanical strength, which is superior to other constructs. A unilateral construct decreases abnormal motion but lacks the stiffness of a bilateral construct. However, given that most patients undergo a partial condylectomy and only a small proportion of patients develop instability, there may be scenarios in which a unilateral construct may be appropriate, such as for temporary internal stabilization.

4.
J Neurosurg Spine ; : 1-10, 2019 03 29.
Artigo em Inglês | MEDLINE | ID: mdl-30925480

RESUMO

OBJECTIVE The objective of this study was to investigate the effect of hospital type and patient transfer during the treatment of patients with vertebral fracture and/or spinal cord injury (SCI). METHODS The National Inpatient Sample (NIS) database was queried to identify patients treated in Utah from 2001 to 2011 for vertebral column fracture and/or SCI (ICD-9-CM codes 805, 806, and 952). Variables related to patient transfer into and out of the index hospital were evaluated in relation to patient disposition, hospital length of stay, mortality, and cost. RESULTS A total of 53,644 patients were seen (mean [± SEM] age 55.3 ± 0.1 years, 46.0% females, 90.2% white), of which 10,620 patients were transferred from another institution rather than directly admitted. Directly admitted (vs transferred) patients showed a greater likelihood of routine disposition (54.4% vs 26.0%) and a lower likelihood of skilled nursing facility disposition (28.2% vs 49.2%) (p < 0.0001). Directly admitted patients also had a significantly shorter length of stay (5.6 ± 6.7 vs 7.8 ± 9.5 days, p < 0.0001) and lower total charges ($26,882 ± $37,348 vs $42,965 ± $52,118, p < 0.0001). A multivariable analysis showed that major operative procedures (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.4­2.0, p < 0.0001) and SCI (HR 2.1, 95% CI 1.6­2.8, p < 0.0001) were associated with reduced survival whereas patient transfer was associated with better survival rates (HR 0.4, 95% CI 0.3­0.5, p < 0.0001). A multivariable analysis of cost showed that disposition (ß = 0.1), length of stay (ß = 0.6), and major operative procedure (ß = 0.3) (p < 0.0001) affected cost the most. CONCLUSIONS Overall, transferred patients had lower mortality but greater likelihood for poor outcomes, longer length of stay, and higher cost compared with directly admitted patients. These results suggest some significant benefits to transferring patients with acute injury to facilities capable of providing appropriate treatment, but also support the need to further improve coordinated care of transferred patients, including surgical treatment and rehabilitation.

5.
J Neurosurg Spine ; : 1-9, 2019 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-30771758

RESUMO

OBJECTIVEThere is contradictory evidence regarding the relative contribution of the key stabilizing ligaments of the occipitoatlantal (OA) joint. Cadaveric studies are limited by the nature and the number of injury scenarios that can be tested to identify OA stabilizing ligaments. Finite element (FE) analysis can overcome these limitations and provide valuable data in this area. The authors completed an FE analysis of 5 subject-specific craniocervical junction (CCJ) models to investigate the biomechanics of the OA joint and identify the ligamentous structures essential for stability.METHODSIsolated and combined injury scenarios were simulated under physiological loads for 5 validated CCJ FE models to assess the relative role of key ligamentous structures on OA joint stability. Each model was tested in flexion-extension, axial rotation, and lateral bending in various injury scenarios. Isolated ligamentous injury scenarios consisted of either decreasing the stiffness of the OA capsular ligaments (OACLs) or completely removing the transverse ligament (TL), tectorial membrane (TM), or alar ligaments (ALs). Combination scenarios were also evaluated.RESULTSAn isolated OACL injury resulted in the largest percentage increase in all ranges of motion (ROMs) at the OA joint compared with the other isolated injuries. Flexion, extension, lateral bending, and axial rotation significantly increased by 12.4% ± 7.4%, 11.1% ± 10.3%, 83.6% ± 14.4%, and 81.9% ± 9.4%, respectively (p ≤ 0.05 for all). Among combination injuries, OACL+TM+TL injury resulted in the most consistent significant increases in ROM for both the OA joint and the CCJ during all loading scenarios. OACL+AL injury caused the most significant percentage increase for OA joint axial rotation.CONCLUSIONSThese results demonstrate that the OACLs are the key stabilizing ligamentous structures of the OA joint. Injury of these primary stabilizing ligaments is necessary to cause OA instability. Isolated injuries of TL, TM, or AL are unlikely to result in appreciable instability at the OA joint.

6.
Spine J ; 19(2): 206-211, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29960110

RESUMO

BACKGROUND CONTEXT: Lumbar pedicle screw placement can be technically challenging. Malpositioned screws occur in up to 15% of patients and could result in radiculopathy or instrumentation failure. PURPOSE: To compare intraoperative electromyography (EMG) and image guidance using an O-arm for identifying pedicle breach during elective lumbar fusion. STUDY DESIGN: Prospective observational study. PATIENT SAMPLE: All adult patients undergoing elective lumbar spinal fusion operations for degenerative spine disorders (including adjacent segment degeneration, degenerative scoliosis, and symptomatic spondylosis and spondylolisthesis) at a single institution from July 1, 2014, to December 1, 2015, were prospectively tracked. OUTCOME MEASURES: Pedicle breach. METHODS: Pedicle screws from L2-S1 were placed using C-arm assisted freehand technique. All screws were stimulated with EMG and evaluated using the O-arm intraoperative imaging system. Electromyography data were compared with intraoperative images to assess the accuracy of identifying pedicle breaches. No funding was received for this work. RESULTS: One thousand six lumbar pedicles screws were placed from L2 to S1 in 164 consecutive cases. The mean patient age was 59.2 years. Thirty-five breaches (15 lateral and 20 medial) were visualized with O-arm imaging and confirmed by palpation (3.5% of screws placed). Of the breaches, 14 screws stimulated below the 12-mA threshold, nine screws stimulated between 12 and 20 mA, and 12 screws did not generate an EMG response. Forty screws stimulated below a 12-mA threshold but showed no breach on imaging. Using the 12-mA threshold, the sensitivity of EMG was 40%, specificity was 96%, positive predictive value was 26%, and negative predictive value was 98%. All 35 breached screws were corrected during surgery. There were no postoperative symptoms caused by breached screws and no patients required reoperation. CONCLUSIONS: Our findings indicate that EMG may not be a highly reliable tool in determining an anatomical breach during placement of lumbar pedicle screws. O-arm may be better for detecting either medial or lateral breaches than EMG stimulation if there are concerns about screw placement or for confirmation of placement before leaving the operating room.


Assuntos
Eletromiografia/métodos , Parafusos Pediculares/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Fusão Vertebral/métodos , Cirurgia Assistida por Computador/métodos , Adulto , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Escoliose/cirurgia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/instrumentação , Espondilolistese/cirurgia , Cirurgia Assistida por Computador/efeitos adversos , Cirurgia Assistida por Computador/instrumentação , Tomografia Computadorizada por Raios X/métodos
7.
Neurosurgery ; 84(1): E53-E55, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202868

RESUMO

QUESTION: Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient and conflicting evidence regarding the effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient It is suggested that "early" surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined "early" surgery inconsistently, ranging from <8 h to <72 h after injury. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_10.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Planejamento de Assistência ao Paciente , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/cirurgia
8.
Neurosurgery ; 84(1): E24-E27, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202904

RESUMO

QUESTION 1: Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1: A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B. QUESTION 2: In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes? RECOMMENDATION 2: There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.


Assuntos
Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/classificação , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Neurocirurgiões , Fraturas da Coluna Vertebral/cirurgia , Resultado do Tratamento
9.
Neurosurgery ; 84(1): E43-E45, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202931

RESUMO

QUESTION: Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_6.


Assuntos
Hemodinâmica , Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/cirurgia , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia , Traumatismos da Coluna Vertebral/fisiopatologia
10.
Neurosurgery ; 84(1): E36-E38, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202962

RESUMO

QUESTION: Does the administration of a specific pharmacologic agent (eg, methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury? RECOMMENDATION: There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, that the complication profile should be carefully considered when deciding on the administration of methylprednisolone. Strength of recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_5.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/tratamento farmacológico , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Metilprednisolona/uso terapêutico , Fraturas da Coluna Vertebral/tratamento farmacológico , Fraturas da Coluna Vertebral/cirurgia
11.
Neurosurgery ; 84(1): 2-6, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202985

RESUMO

BACKGROUND: The thoracic and lumbar ("thoracolumbar") spine are the most commonly injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is frequently associated with spinal cord injury and other visceral and bony injuries. Prolonged pain and disability after thoracolumbar trauma present a significant burden on patients and society. OBJECTIVE: To formulate evidence-based clinical practice recommendations for the care of patients with injuries to the thoracolumbar spine. METHODS: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar spinal injuries based on specific clinically oriented questions. Relevant publications were selected for review. RESULTS: For all of the questions posed, the literature search yielded a total of 6561 abstracts. The task force selected 804 articles for full text review, and 78 were selected for inclusion in this overall systematic review. CONCLUSION: The available evidence for the evaluation and treatment of patients with thoracolumbar spine injuries demonstrates considerable heterogeneity and highly variable degrees of quality. However, the workgroup was able to formulate a number of key recommendations to guide clinical practice. Further research is needed to counter the relative paucity of evidence that specifically pertains to patients with only thoracolumbar spine injuries. The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/normas , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/diagnóstico , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Humanos
12.
Neurosurgery ; 84(1): E28-E31, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202989

RESUMO

BACKGROUND: Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI). OBJECTIVE: To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes. METHODS: A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review. RESULTS: Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries. CONCLUSION: This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries. QUESTION 1: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention? RECOMMENDATION 1: Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery. Strength of Recommendation: Grade B. QUESTION 2: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2: Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.


Assuntos
Vértebras Lombares/diagnóstico por imagem , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Processamento de Imagem Assistida por Computador , Vértebras Lombares/cirurgia , Imagem por Ressonância Magnética , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Tomografia Computadorizada por Raios X
13.
Neurosurgery ; 84(1): E50-E52, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203034

RESUMO

QUESTION 1: Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 1: There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient. QUESTION 2: Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 2: There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia
14.
Neurosurgery ; 84(1): E39-E42, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203078

RESUMO

QUESTION 1: Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures? RECOMMENDATION 1: There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 2: For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)? RECOMMENDATION 2: There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 3: Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures? RECOMMENDATION 3: There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. RECOMMENDATION 4: Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Tromboembolia/etiologia , Tromboembolia/terapia , Anticoagulantes/uso terapêutico , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/complicações , Fraturas da Coluna Vertebral/complicações
15.
Neurosurgery ; 84(1): E32-E35, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203084

RESUMO

QUESTION 1: Which neurological assessment tools have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1: Numerous neurologic assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale and Frankel Scale for Spinal Cord Injury) have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specifically studied in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade C. QUESTION 2: Are there any clinical findings (eg, presenting neurological grade/function) in patients with thoracic and lumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2: Entry American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function can be used to predict neurological function and outcome in patients with thoracic and lumbar fractures (Table I https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4_table1). Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4.


Assuntos
Vértebras Lombares/lesões , Exame Neurológico , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/diagnóstico , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/cirurgia , Traumatismos da Coluna Vertebral/fisiopatologia , Traumatismos da Coluna Vertebral/cirurgia
16.
Neurosurgery ; 84(1): E46-E49, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203096

RESUMO

BACKGROUND: Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries. OBJECTIVE: To determine if the use of external bracing improves outcomes compared to no brace for neurologically intact patients with thoracic or lumbar burst fractures. METHODS: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically comparing external bracing to no brace for neurologically intact patients with thoracic or lumbar burst fractures were selected for review. RESULTS: Three studies out of 1137 met inclusion criteria for review. One randomized controlled trial (level I) and an additional randomized controlled pilot study (level II) provided evidence that both external bracing and no brace equally improve pain and disability in neurologically intact patients with burst fractures. There was no difference in final clinical and radiographic outcomes between patients treated with an external brace vs no brace. One additional level IV retrospective study demonstrated equivalent clinical outcomes for external bracing vs no brace. CONCLUSION: This evidence-based guideline provides a grade B recommendation that management either with or without an external brace is an option given equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures. The decision to use an external brace is at the discretion of the treating physician, as bracing is not associated with increased adverse events compared to no brace. QUESTION: Does the use of external bracing improve outcomes in the nonoperative treatment of neurologically intact patients with thoracic and lumbar burst fractures? RECOMMENDATION: The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_8.


Assuntos
Braquetes , Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia
17.
Neurosurgery ; 84(1): E56-E58, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203100

RESUMO

QUESTION: Does the choice of surgical approach (anterior, posterior, or combined anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS: In the surgical treatment of patients with thoracolumbar burst fractures, physicians may use an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. Strength of Recommendation: Grade B With regard to radiologic outcomes in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may use an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_11.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Planejamento de Assistência ao Paciente , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Fixação Interna de Fraturas , Guias como Assunto , Humanos , Vértebras Lombares/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Resultado do Tratamento
18.
World Neurosurg ; 121: e786-e791, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30312812

RESUMO

BACKGROUND: Prescription opioid medications negatively affect postoperative outcomes after lumbar spine surgery. Furthermore, opioid-related overdose death rates in the United States increased by 200% between 2000 and 2014. Thus, alternatives are imperative. Mindfulness-based stress reduction (MBSR), a mind-body therapy, has been associated with improved activity and mood in opioid-using patients with chronic pain. This study assessed whether preoperative MBSR is an effective adjunct to standard postoperative care in adult patients undergoing lumbar spine surgery for degenerative disease. METHODS: The intervention group underwent a preoperative online MBSR course. The comparison group was matched retrospectively in a 1:1 ratio by age, sex, type of surgery, and preoperative opioid use. Prescription opioid use during hospital admission and at 30 days postoperatively were compared with preoperative use. Thirty-day postoperative patient-reported outcomes for pain, disability, and quality of life were compared with preoperative patient-reported outcomes. Dose-response effect of mindfulness courses was assessed using Mindful Attention Awareness Scale scores. RESULTS: In this pilot study, 24 participants were included in each group. Most intervention patients (70.83%) completed 1 session, and the mean Mindful Attention Awareness Scale score was 4.28 ± 0.71 during hospital admission. At 30 days, mean visual analog scale back pain score was lower in the intervention group (P = 0.004) but other patient-reported outcomes did not differ. CONCLUSIONS: During hospital admission, no significant dose-response effect of mindfulness techniques was found. At 30 days postoperatively, MBSR use was associated with less back pain. Further research is needed to assess the effectiveness of preoperative MBSR on postoperative outcomes in lumbar spine surgery for degenerative disease.


Assuntos
Analgésicos Opioides/uso terapêutico , Degeneração do Disco Intervertebral , Atenção Plena/métodos , Dor Pós-Operatória , Período Pré-Operatório , Qualidade de Vida/psicologia , Estresse Psicológico , Idoso , Analgésicos/uso terapêutico , Avaliação da Deficiência , Pessoas com Deficiência , Feminino , Humanos , Degeneração do Disco Intervertebral/psicologia , Degeneração do Disco Intervertebral/cirurgia , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/psicologia , Projetos Piloto , Estudos Retrospectivos , Estresse Psicológico/etiologia , Estresse Psicológico/psicologia , Estresse Psicológico/reabilitação , Resultado do Tratamento
19.
Neurosurgery ; 84(1): E59-E62, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30299485

RESUMO

BACKGROUND: Treatment of thoracolumbar burst fractures has traditionally involved spinal instrumentation with fusion performed with standard open surgical techniques. Novel surgical strategies, including instrumentation without fusion and percutaneous instrumentation alone, have been considered less invasive and more efficient treatments. OBJECTIVE: To review the current literature and determine the role of fusion in instrumented fixation, as well as the role of percutaneous instrumentation, in the treatment of patients with thoracolumbar burst fractures. METHODS: The task force members identified search terms/parameters and a medical librarian implemented the literature search, consistent with the literature search protocol (see Appendix I), using the National Library of Medicine PubMed database and the Cochrane Library for the period from January 1, 1946 to March 31, 2015. RESULTS: A total of 906 articles were identified and 38 were selected for full-text review. Of these articles, 12 articles met criteria for inclusion in this systematic review. CONCLUSION: There is grade A evidence for the omission of fusion in instrumented fixation for thoracolumbar burst fractures. There is grade B evidence that percutaneous instrumentation is as effective as open instrumentation for thoracolumbar burst fractures. QUESTION: Does the addition of arthrodesis to instrumented fixation improve outcomes in patients with thoracic and lumbar burst fractures? RECOMMENDATION: It is recommended that in the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiological outcomes, and adds to increased blood loss and operative time. Strength of Recommendation: Grade A. QUESTION: How does the use of minimally invasive techniques (including percutaneous instrumentation) affect outcomes in patients undergoing surgery for thoracic and lumbar fractures compared to conventional open techniques? RECOMMENDATION: Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures as the evidence suggests equivalent clinical outcomes. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_12.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/normas , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Artrodese , Medicina Baseada em Evidências , Fixação Interna de Fraturas , Humanos , Parafusos Pediculares , Resultado do Tratamento
20.
J Neurosurg Sci ; 63(1): 36-41, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27588820

RESUMO

BACKGROUND: Patients undergoing elective spinal fusion have an alarming rate of vitamin D deficiency, but its impact on bone fusion and patient outcomes is unclear. We investigated the association of perioperative vitamin D levels, fusion rates, and patient-reported outcome in patients undergoing spinal fusion for cervical spondylotic myelopathy. METHODS: In this one-year, prospective, single-center observational study, serum 25-OH vitamin D levels were measured perioperatively in adult patients. Serum vitamin D levels <30 ng/mL were considered abnormal. The primary outcome measures were postoperative patient-reported outcomes (Neck Disability Index, Visual Analog Scale, EuroQol EQ-5D-3L, EQ-VAS). Secondary outcome measures were the presence of and time to solid bony fusion, controlling for Body Mass Index (BMI), age, and number of motion segments. RESULTS: Forty-one of 58 patients (71%) had laboratory-confirmed abnormal vitamin D levels. Patients with low vitamin D were younger (P<0.05) and had a higher BMI (P<0.05) than patients with adequate vitamin D, but the groups were otherwise similar. There were no differences in mean time to fusion between the two groups, but patients with low vitamin D reported more postoperative disability (P<0.05). Multivariate model analysis demonstrated an independent, significant association between normal vitamin D and lower postoperative neck disability index (P=0.05) and EQ-5D-3L (P=0.03). CONCLUSIONS: Vitamin D deficiency (<30 ng/mL) is highly prevalent in patients undergoing elective spinal fusion for cervical myelopathy. Low vitamin D levels were associated with worse patient-reported outcomes and were an independent predictor of greater disability, which suggests vitamin D supplementation may offer some benefit in these patients.


Assuntos
Hidroxicolecalciferóis/sangue , Complicações Pós-Operatórias , Doenças da Medula Espinal/sangue , Doenças da Medula Espinal/cirurgia , Fusão Vertebral/métodos , Espondilose/sangue , Espondilose/cirurgia , Deficiência de Vitamina D/sangue , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/fisiopatologia
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