Independent inter and intra-observer agreement of the Schizas's classification of degenerative lumbar stenosis: Comparison among three levels of surgical training. / [Artículo traducido] Acuerdo inter- e intraobservador independiente de la clasificación de Schizas de estenosis lumbar degenerativa. Comparación entre tres niveles de entrenamiento quirúrgico.

INTRODUCTION AND OBJECTIVES: Lumbar spinal stenosis is a common age-related condition that affects the quality of life. Multiple classifications have been developed to quantify the severity of stenosis affecting comparison between studies and homogenous communication among surgeons and researchers. Even though this classification has not shown a direct clinical correlation, Schizas's classification appears to be a simple method to assess stenosis. Our objective was to evaluate the inter and intraobserver independent agreement of the Schizas's classification to assess stenosis severity. Additionally, we aimed to compare agreement among three levels of training in spine surgery. MATERIALS AND METHODS: An independent inter and intra observer agreement was conducted among junior, senior orthopedic residents and attending spine surgeons. Ninety lumbar levels from 30 patients were evaluated by 16 observers. Weighted kappa agreement was used. RESULTS: Overall interobserver and intraobserver agreement was of 0.57 (95% CI=0.52-0.63) and 0.69 (0.55-0.79), respectively. Interobserver agreement according to level of training yielded values of 0.53 (0.46-0.60) for junior residents, 0.61 (0.54-0.67) for senior residents and 0.67 (0.59-0.74) for attendings. Intraobserver agreement was of 0.54 (0.48-0.60) for junior, 0.60 (0.55-0.66) for senior and 0.66 (0.60-0.72) for attendings. CONCLUSION: The Schizas's classification showed moderate interobserver and substantial intraobserver agreement. Among attending surgeons, substantial inter and intraobserver agreement was observed. The classification allowed acceptable communication among trained spine surgeons.

Independent inter and intra-observer agreement of the Schizas's classification of degenerative lumbar stenosis: Comparison among three levels of surgical training.

INTRODUCTION AND OBJECTIVES: Lumbar spinal stenosis is a common age-related condition that affects the quality of life. Multiple classifications have been developed to quantify the severity of stenosis affecting comparison between studies and homogenous communication among surgeons and researchers. Even though this classification has not shown a direct clinical correlation, Schizas's classification appears to be a simple method to assess stenosis. Our objective was to evaluate the inter and intraobserver independent agreement of the Schizas's classification to assess stenosis severity. Additionally, we aimed to compare agreement among three levels of training in spine surgery. MATERIALS AND METHODS: An independent inter and intra observer agreement was conducted among junior, senior orthopedic residents and attending spine surgeons. Ninety lumbar levels from 30 patients were evaluated by 16 observers. Weighted kappa agreement was used. RESULTS: Overall interobserver and intraobserver agreement was of 0.57 (95% CI=0.52-0.63) and 0.69 (0.55-0.79), respectively. Interobserver agreement according to level of training yielded values of 0.53 (0.46-0.60) for junior residents, 0.61 (0.54-0.67) for senior residents and 0.67 (0.59-0.74) for attendings. Intraobserver agreement was of 0.54 (0.48-0.60) for junior, 0.60 (0.55-0.66) for senior and 0.66 (0.60-0.72) for attendings. CONCLUSION: The Schizas's classification showed moderate interobserver and substantial intraobserver agreement. Among attending surgeons, substantial inter and intraobserver agreement was observed. The classification allowed acceptable communication among trained spine surgeons.

Frequency of vitamin d deficiency in patients with lumbar spinal stenosis and its relationship with obesity, depression, and pain intensity: a cross-sectional study / Frequência da deficiência de vitamina D em pacientes com estenose espinhal lombar e sua relação com obesidade, depressão e intensidade da dor: um estudo transversal

ABSTRACT Objective This study was conducted to determine the frequency of vitamin D deficiency in patients with lumbar spinal stenosis and to define the relationship between vitamin D levels and obesity, depression, and pain intensity. Methods This study was conducted with 69 patients (Male = 32, Female = 37) diagnosed with lumbar spinal stenosis. The participants' 25(OH)D levels were measured by radioimmunoassay. In addition, bone metabolic status, including bone mineral density and bone turnover markers, was also evaluated. The Beck Depression Inventory was used to determine the depression statuses of the patients, while the McGill Melzack Pain Questionnaire was administered to measure pain intensity. The results were evaluated at a significance level of p<0.05. Results Vitamin D deficiency (<20 ng/mL) was found in 76.8% of the patients. Binary logistic regression analysis showed a significantly higher frequency of vitamin D deficiency in patients who: 1) had higher body mass indexes (OR 3.197, 95% CI 1.549-6.599); 2) fared higher in Beck's depression score (OR 1.817, 95% CI 1.027-3.217); and 3) were female rather than male (OR 1.700, 95% CI 0.931-3.224) (p<0.05). Conclusion In this study, vitamin D deficiency was prevalent in lumbar spinal stenosis patients. In addition, obese, depressed, and female individuals have higher risks of vitamin D deficiency.

RESUMO Objetivo Este estudo foi realizado para determinar a frequência de deficiência de vitamina D em pacientes com estenose espinhal lombar e para definir a relação entre os níveis de vitamina D e obesidade, depressão e intensidade da dor. Métodos Este estudo foi realizado com 69 pacientes (homens = 32, mulheres = 37) diagnosticados com estenose espinhal lombar. Os níveis de 25(OH)D dos participantes foram medidos por radioimunoensaio. Além disso, o estado metabólico ósseo, incluindo densidade mineral óssea e marcadores de remodelação óssea, também foi avaliado. O Inventário de Depressão de Beck foi usado para determinar os estados de depressão dos pacientes, enquanto o Questionário de Dor McGill Melzack foi aplicado para medir a intensidade da dor. Os resultados foram avaliados a um nível de significância de p<0,05. Resultados A deficiência de vitamina D (<20 ng/mL) foi encontrada em 76,8% dos pacientes. A análise de regressão logística binária mostrou uma frequência significativamente maior de deficiência de vitamina D nos seguintes pacientes: 1) com maior índice de massa corporal (OR 3,197, 95% IC 1,549-6,599); 2) com maior pontuação na escala de depressão de Beck (OR 1,817, 95% IC 1,027-3,217) e 3) do sexo feminino em vez de masculino (OR 1,700, 95% IC 0,931-3,224) (p<0,05). Conclusão Neste estudo, a deficiência de vitamina D foi prevalente em pacientes com estenose espinhal lombar. Além disso, pessoas obesas, deprimidas e mulheres correm maior risco de deficiência de vitamina D.

Influence of age, sex, height and lumber stenosis on the position of the conus medullaris in adults / Influencia de la edad, sexo, altura y estenosis lumbar en la posición del cono medular en adultos

Anatomical orientation of the termination level of Conus Medullaris (CM) has imperative role clinically for anesthetists and neurosurgeons which is considered as an objective guide to perform spinal anesthesia and spinal punctures circumspectly with less chance to have serious injuries. The current retrospective study was carried on to determine the location of the CM and how its termination level can be influenced by age, sex, height and lumber stenosis spine disease. The study included 462 participants that consisted of 199 men and 263 women range from 21 to 80 years of age and height range between 150-190 cm. Also, it included 150 lumber stenosis patients. The location of the CM was imaged using a series of magnetic resonance images (MRI) for the lumbosacral spine at different levels including, T12, T12-L1, L1, L1-L2, and L2. The measurements revealed inconsiderable differences in the CM termination level in relation to age, sex and height in a healthy study population. Moreover, the results showed insignificant differences in the CM termination level between men and women whether they are healthy or having lumbar spinal stenosis. In conclusion, the most common level of CM termination is at L1 followed by L1-L2. It is safe to perform a lumbar neuraxial procedures at the level of L3-L4.

La orientación anatómica del nivel de terminación del Conus medullaris (CM) tiene un importante papel clínico para los anestesistas y neurocirujanos, que se considera una guía objetiva para realizar la anestesia espinal y las punciones de la columna circunspectivamente con menos posibilidades de provocar lesiones graves. Se llevó a cabo un estudio retrospectivo para determinar la ubicación del CM y cómo su nivel de terminación puede verse afectado por la edad, el sexo, la altura y una patología de la columna vertebral, la estenosis lumbar. El estudio incluyó 462 participantes que consistían en 199 hombres y 263 mujeres de 21 a 80 años de edad y una altura de entre 150-190 cm. Además, se incluyeron 150 pacientes con estenosis lumbar. La ubicación del CM se determinó mediante una serie de imágenes de resonancia magnética (RM) de la columna lumbosacra a diferentes niveles, incluidos T12, T12-L1, L1, L1-L2 y L2. Las mediciones revelaron diferencias considerables en el nivel de terminación de CM en relación con la edad, el sexo o la altura en una población de estudio saludable. Además, los resultados mostraron diferencias poco significativas en el nivel de terminación de CM entre hombres y mujeres, sanos o con estenosis espinal lumbar. En conclusión, se encontró que el nivel más común de terminación del CM es L1 seguido de L1-L2, considerándose seguro realizar procedimientos neuroaxiales lumbares a nivel de L3-L4.

Estenosis de canal lumbar: comorbilidades y análisis morfométrico / Lumbar canal stenosis: comorbidities and morphometric analysis

Introducción: La Estenosis de Canal Lumbar (ECL) refiere al estrechamiento central del canal raquídeo, recesos laterales o agujeros de conjunción. Comúnmente, causa lumbalgia crónica en quienes la padecen afectando gravemente su calidad de vida. Sin embargo, su pronóstico, incidencia sigue siendo incierta en nuestra región. Objetivo: El presente trabajo tiene como propósito, determinar la frecuencia local de la ECL y su relación con distintos parámetros morfométricos, comorbilidades y el cuestionario CSI. Material y Método: Se realizó un estudio prospectivo, analítico, asociativo y de corte transversal de las consultas atendidas por el servicio de Neurocirugía del Hospital Enrique Vera Barros de la ciudad de La Rioja Capital, Argentina durante el período agosto-diciembre 2018. Se aplicó el cuestionario "Central Sensitization Inventory" (CSI). Resultados: La ECL fue diagnosticada en 42.9% de hombres que consultaron por lumbalgia y en el 33.3% en el caso de las mujeres. La media de la edad de los pacientes con ECL fue 57 años. El 100% de pacientes presentaron comorbilidades, siendo la más prevalente la artrosis. La dorsopatía más asociada fue la Hernia de Disco Lumbar (27.3%). La intensidad del dolor y los diámetros antero-posterior (DAP) y laterales (DL), fueron inversamente significativos (DAP= -,813 p=0,09; DL= -,967 p=0,007). El puntaje en el CSI fue significativamente mayor en pacientes con ECL (37 vs. 24,62 pts.) (p=,028). Finalmente, la correlación entre los DAP y DL con el puntaje del CSI mostró una correlación inversa (DAP= -,733 p>0,05; DL= -,639 p>0,05). Conclusión: En nuestro estudio encontramos que la prevalencia de ECL es más alta en hombres de edad media y que presentan comorbilidades asociadas, además el análisis morfométrico del canal raquídeo se asocia con la intensidad del dolor y el puntaje en el CSI. Por lo cual estas variables podrían ser utilidad clínica al momento de decidir el manejo adecuado para pacientes con ECL.

Introduction: Lumbar Spinal Stenosis (LSS) anatomically can involve the central canal, lateral recess, neural foramen or any combination of these locations. Although, LSS has been consider a common cause of chronic low back pain. Only few studies had explored the prevalence, incidence and associated variables in non-Caucasian populations. Therefore, the aim of this study is to determine the local frequency of LSS and its relationship with different morphometric parameters, comorbidities and the Central Sensitization Inventory (CSI). Methods: A prospective, analytical, associative and cross-sectional study of patients With LSS by single academic center was carried out. Diagnoses were done by clinical and MRI assessment. Results: LSS was diagnosed in 42.9% of males and 33.3% of females who consulted for low back pain. The average age of the patients with LSS was 57 years. 100% of LSS patients presented comorbidities, the most prevalent being osteoarthritis. Lumbar Disc Hernia was associated in 27.3% of patients with LSS. Pain intensity was inversely correlated (AP= -,813 p=0,09; L= -,967 p=0,007) with anteroposterior (AP), and lateral (L) diameters. The score in the CSI was significantly higher in patients with LSS (37 vs. 24,62 pts.) (p=,028). Finally, the correlation between the AP and L diameters with the CSI score was inverse (AP= -,733 58 p>0,05; L= -,639 p>0,05). Conclusions: In our study, we found that the prevalence of LSS is higher in middle-aged men with associated comorbidities. In addition, morphometric analysis of the spinal canal is associated with pain intensity and CSI scores. Therefore, these variables could be clinical applicable when deciding the appropriate management for patients with LSS.

Atrofia paraespinal postoperatoria. ¿El abordaje importa? / Postoperative paraspinal atrophy. Does boarding matter?

Objetivo: Comparar la magnitud de la atrofia muscular postoperatoria que producen tres abordajes en fusiones lumbares segmentarias para patología degenerativa (línea media vs. Wiltse vs. MIS TLIF). Material y métodos: Se realizó un estudio observacional, transversal, multicéntrico, descriptivo y retrospectivo, de una serie de pacientes operados por patología degenerativa lumbar. Analizamos 45 pacientes (24 mujeres), con una edad media de 58.7 años, operados en 5 centros quirúrgicos entre 2015 y 2018. Se realizó una fusión instrumentada de un nivel, desde L3 hasta S1 (7 casos L3-L4, 25 casos L4-L5 y 13 casos L5-S1). Quince casos fueron realizados por abordajes por línea media, 15 por abordaje de Wiltse y 15 MIS TLIF. Todos fueron estudiados con Resonancia Magnética preoperatoria y con un mínimo de 6 meses luego de la cirugía (media de 14.6 meses). Estas fueron analizadas por 3 observadores especialistas en cirugía de columna. Se tomaron 2 variables para comparar el grado de atrofia entre pre y postoperatorio: área de sección transversal (AST) de músculo multifidus (MM) y erectores espinales (EE) y grado de infiltración grasa (IG) mediante la clasificación visual de Kjaer. Los análisis realizados fueron ejecutados utilizando el programa estadístico RStudio (versión 1.1.383) y se compararon valores de p obtenidos mediante la suma de rangos de Wilcoxon. Resultados: No se encontraron diferencias significativas entre los distintos abordajes en relación a la atrofia del MM. La comparación de p para AST de los EE mostró diferencias entre MIS TLIF vs línea media (p 0.018) y de línea media vs Wiltse (p 0.027). Conclusión: Los abordajes mínimamente invasivos utilizados para descompresión y artrodesis monosegmentaria lumbar, tuvieron más impacto sobre la atrofia muscular en los EE que en MM. Estudios randomizados y controlados serían de utilidad para validar los resultados de este trabajo.

Aim: To compare the level of post-operative muscle atrophy associated with three different approaches to achieve segmental lumbar fusion in patients with degenerative back disease: (1) the standard midline approach; (2) Wiltse's minimally-invasive surgery (MIS-W) approach; and (3) minimal-invasive surgery (MIS) with transforaminal lumbar interbody fusion (MIS-TLIF). Methods and Materials: A multi-center, observational, cross-sectional, retrospective study was performed on a series of patients who had undergone surgery for degenerative lumbar disease. All patients were studied preoperatively and for at least six months post-operatively (mean follow-up: 14.6 months) by magnetic resonance imaging (MRI), all images analyzed by three spine-imaging specialists. Three variables were used to compare the level of atrophy before and after surgery: (1) the cross sectional area (CSA) of the multifidus muscle (MM); (2) the CSA of the spinal erector muscles (SEM); and (3) fat infiltration level, as rated per the Kjaer visual classification system. Inter-group differences in these three outcomes were assessed using Wilcoxon rank sum tests. Results: Forty-five patients (24 females), of mean age 58.7 years, underwent surgery at five participating surgical centers between 2015 and 2018. One-level instrumented fusion, from L3 to S1, was performed: at the L3-L4 level in seven patients, L4-L5 in 25, and L5-S1 in 13. Surgical access was split evenly between the three approaches, each performed in 15 patients. No significant differences were detected between the approaches, in terms of MM atrophy or fat infiltration level. Less CSA-SEM atrophy was detected with the MIS-TLIF than midline (p = 0.018), and with the MIS-W than midline (p = 0.027) approach. Conclusions: Relative to the standard midline approach, two minimally-invasive surgery approaches used for decompression and lumbar mono-segmental arthrodesis reduced atrophy in the spinal erector muscles, but not the multifidus muscle. Randomized controlled trials might be useful to validate the results of this investigation.

Descompresión mínimamente invasiva para estenosis del canal lumbar: técnica y resultados clínicos tempranos / Minimally invasive decompression for lumbar canal stenosis: technique and early clinical results

Introducción: La estenosis de canal lumbar (ECL) representa la patología espinal de mayor indicación quirúrgica en la población adulta, resultando en dolor lumbar, así como dolor en miembros inferiores y claudicación de la marcha. La descompresión quirúrgica es el tratamiento de elección cuando el tratamiento conservador ha fallado. Aunque la descompresión tradicional o abierta es un procedimiento efectivo, la descompresión tubular mínimamente invasiva a través de un retractor tubular y microscopio ha demostrado ser una alternativa válida con excelentes resultados. Objetivos: Describir la técnica de descompresión tubular mínimamente invasiva y analizar los resultados clínicos tempranos. Material y Métodos: Treinta y un pacientes con ECL sintomático, sin respuesta al tratamiento conservador, fueron sometidos a descompresión tubular mínimamente invasiva durante el año 2017. Información demográfica e intraoperatoria fue analizada. El resultado clínico fue evaluado usando la escala de Oswestry Disability Index (ODI) y la Escala Visual Analógica (VAS). El seguimiento mínimo fue de 3 meses. Resultados: Treinta y un niveles fueron quirúrgicamente descomprimidos. El tiempo promedio de cirugía fue de 90 minutos. La pérdida de sangre fue de 30 ml promedio. Veintinueve pacientes fueron dados de alta dentro de las 24 hs y 2 dentro de las 48 hs. Se observó una mejora de 22 puntos en el ODI y 5 puntos en el VAS. No se registraron fístulas ni infecciones. Conclusión: La descompresión tubular mínimamente invasiva es una alternativa segura y efectiva para el tratamiento quirúrgico de la ECL con mínima pérdida sanguínea, corta estadía hospitalaria y baja tasa de complicaciones, conservando la estabilidad espinal.

Introduction: Lumbar Spinal Stenosis (LSS) is the most frequently surgically treated spinal in adults, which consists in low back pain, radiculopathy and neurogenic claudication. Surgical decompression is the best choice when medical treatment was not enough. Although traditional or open surgical decompression is effective, minimally invasive decompression through tubular retractors and microscope has demonstrate to be a good choice with excellent results. Aim: To describe minimally invasive tubular decompression surgical technique and analyze early clinical results. Materials and Method: In 31 patients with sintomatic LSS, without response to medical treatment, has been performed minimal invasive tubular decompression during 2017. Demographics and perioperative data has been analyzed. Clinical results were evaluated using Oswestry Disability Index (ODI) and Visual Analogic Scale (VAS). Follow-up was at least three months. Results: Thirty-one levels were surgically decompressed. Mean surgery time was 90 minutes. Blood loss was about 30 ml. nineteen patients were discharged home in less than 24 hours, meanwhile 2 were discharged at 48 hours after surgery. Patients got better in about 22 points in ODI and 5 points in VAS. No cerebrospinal fluid leaks and infections were recorded. Conclusion: Minimal invasive tubular decompression is a safe and effective alternative for surgical treatment of LSS, with a minimum blood loss, short hospital stay, low rate of complications, and preserving spinal stability.

Uso da inteligência articial como armamento no diagnóstico e condução clínica da estenose de canal lombar / Use of Articial Intelligence in Diagnosis and Clinical Conduct of Lumbar Spinal Stenosis

A estenose do canal vertebral lombar (ECL) é uma patologia complexa, com alta incidência entre pessoas acima de 65 anos de idade. No entanto, o diagnóstico correto é, por vezes, difícil de ser confirmado. O uso de modelos de Inteligência Articial (IA) na medicina é, em geral, desconhecida para a maioria da comunidade médica, mas tem sido usada há décadas na assistência em UTI, os métodos de imagem e dispositivos de diagnóstico eletrônico (ECG). Através de uma revisão sistemática da literatura, com foco nos achados clínicos e radiológicos, juntamente com todas as modalidades de tratamento, foi possível identicar o ambiente completo de pacientes LSS, para responder a quatro questões: (a) "Com base no quadro clínico, o paciente tem um, cenário moderado ou grave?"; (b) "Com base nos dados radiológicos, o paciente pode ser classicado com um cenário leve,moderada ou grave?"; (c) "Qual é a probabilidade, com base na anamnese, do paciente ter ECL?"; (d) "Qual é o melhor tratamento a ser oferecido?".þ. Como auxílio de um software usando Sistema Especialista (Expert Sinta), uma linguagem de IA, alocamos todas as variáveis e seus valores para orientar o software responder às quatro perguntas. Foi possível identicar 657 artigos cientícos, no entanto apenas 63 poderia mencionar não apenas as variáveis, mas a sua probabilidade de ocorrência ou teve disponibilidade texto completo. Foi possível classicar a intensidade do quadro clínico e radiológico, criar um índice de probabilidade para LSS e oferecer o melhor tratamento. Recomendamos o uso, sob supervisão médica, em de Neurocirurgia ou clínicas ortopédicas como um conselheiro para os pacientes com ELA.

The lumbar spinal stenosis (LSS) is a complex pathology with high incidence among people above 65 years old. However, the correct diagnose is sometimes difcult to perform. The use of Articial Intelligence (AI) models in medicine is, in general, unfamiliar for the majority of medical community, but has been used for decades in assistance in ICUs, image methods and electronic diagnostic devices (EKG). Through a systematic literature review focused in the clinical and radiological ndings, in addition to all treatmentmodalities, we identied the complete environment of LSS patients, to answer four questions. (a) "Based on the clinical presentation, the patient has a mild, moderate or severe scenario?", (b) "Based on the radiological data, the patient can be classied having a mild, moderate or severe scenario?", (c) "What is the probability, based on the anamneses, the patient has LSS?", and (d) "What is the best treatment to be offered?".With the aid of a software using Expert System (Expert Sinta), a language of AI, we allocate all the variables and their values to orient the software to answer the four questions. It was possible to identify 657 scientic articles, however only 63 could mention not only the variables, but their occurrence probability or had full text availability. It was possible to classify the intensity the clinical and radiological scenario, create a probability index for LSS and offer the best treatment. We recommend the use, under medical supervision, in neurosurgery or orthopedic clinics as an adviser for patients with LSS.

Rescate de la vía aérea en posición prona con máscara laríngea en casos de estenosis de la columna lumbar y descompresión percutánea posterior por medio de un espaciador interespinoso / Airway rescue in the prone position with laryngeal mask airway in a case of lumbar spinal stenosis undergoing percutaneous posterior decompression using an inter-spinous spacer device

Se programa a un paciente afectado por dolor lumbar para la inserción percutánea electiva de un espaciador interespinoso bajo anestesia local en posición prona. A la mitad de la cirugía el paciente presentó dolor severo que le impidió mantenerse quieto, con lo cual fue necesario utilizar anestesia general para terminar la operación. Pudimos insertar con éxito una vía aérea con máscara laríngea clásica en posición prona y la cirugía se llevó a buen término sin problemas.

A patient suffering from low backache was electively posted under local anaesthesia by the surgeon for insertion of percutaneous inter-spinous spacer in lumbar spine in prone position. In the middle of surgery, the patient developed severe pain and was unable to keep still requiring general anaesthesia to complete the operation. We successfully inserted classic laryngeal mask airway in the prone position and the operation was completed uneventfully.