Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 7.569
Filtrar
1.
BMC Surg ; 24(1): 142, 2024 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-38724895

RESUMO

PURPOSE: The aim of this study was to develop and validate a machine learning (ML) model for predicting the risk of new osteoporotic vertebral compression fracture (OVCF) in patients who underwent percutaneous vertebroplasty (PVP) and to create a user-friendly web-based calculator for clinical use. METHODS: A retrospective analysis of patients undergoing percutaneous vertebroplasty: A retrospective analysis of patients treated with PVP between June 2016 and June 2018 at Liuzhou People's Hospital was performed. The independent variables of the model were screened using Boruta and modelled using 9 algorithms. Model performance was assessed using the area under the receiver operating characteristic curve (ROC_AUC), and clinical utility was assessed by clinical decision curve analysis (DCA). The best models were analysed for interpretability using SHapley Additive exPlanations (SHAP) and the models were deployed visually using a web calculator. RESULTS: Training and test groups were split using time. The SVM model performed best in both the training group tenfold cross-validation (CV) and validation group AUC, with an AUC of 0.77. DCA showed that the model was beneficial to patients in both the training and test sets. A network calculator developed based on the SHAP-based SVM model can be used for clinical risk assessment ( https://nicolazhang.shinyapps.io/refracture_shap/ ). CONCLUSIONS: The SVM-based ML model was effective in predicting the risk of new-onset OVCF after PVP, and the network calculator provides a practical tool for clinical decision-making. This study contributes to personalised care in spinal surgery.


Assuntos
Aprendizado de Máquina , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Vertebroplastia , Humanos , Estudos Retrospectivos , Fraturas por Osteoporose/cirurgia , Fraturas por Osteoporose/etiologia , Fraturas por Osteoporose/diagnóstico , Feminino , Idoso , Masculino , Fraturas da Coluna Vertebral/cirurgia , Fraturas da Coluna Vertebral/etiologia , Fraturas da Coluna Vertebral/diagnóstico , Medição de Risco , Vertebroplastia/métodos , Pessoa de Meia-Idade , Internet , Fraturas por Compressão/cirurgia , Fraturas por Compressão/etiologia , Idoso de 80 Anos ou mais
2.
BMC Musculoskelet Disord ; 25(1): 343, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38693479

RESUMO

PURPOSE: To explore whether it is necessary to put drain tubes after posterior pedicle screw fixation of thoracolumbar fractures. METHODS: From April 2020 to January 2023, a total of 291 patients with recent thoracolumbar fractures (AO type-A or type-B) who received the pedicle screw fixation operation were enrolled retrospectively. In 77 patients, drain tubes were used in the pedicle screw fixation surgery, while no drain tubes were placed in the other group. After gleaning demographic information and results of lab examination and imageology examination, all data were put into a database. Independent-sample t-tests, Pearson Chi-Square tests, Linear regression analysis, and correlation analysis were then performed. RESULTS: Compared to the control group, the drainage group had significantly lower postoperative CRP levels (P = 0.047), less use of antipyretics (P = 0.035), higher ADL scores (P = 0.001), and lower NRS scores (P < 0.001) on the 6th day after surgery. Other investigation items, such as demographic information, operation time, intraoperative blood loss, body temperature, and other preoperative and postoperative lab results, showed no significant differences. CONCLUSIONS: The use of a drain tube in the pedicle screw fixation of thoracolumbar fractures is correlated with the improvement of patients' living and activity ability and the reduction of inflammation, postoperative fever and pain.


Assuntos
Drenagem , Fixação Interna de Fraturas , Vértebras Lombares , Parafusos Pediculares , Fraturas da Coluna Vertebral , Vértebras Torácicas , Humanos , Masculino , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Fraturas da Coluna Vertebral/cirurgia , Fraturas da Coluna Vertebral/diagnóstico por imagem , Vértebras Lombares/cirurgia , Vértebras Lombares/lesões , Feminino , Estudos Retrospectivos , Adulto , Pessoa de Meia-Idade , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/efeitos adversos , Drenagem/instrumentação , Drenagem/métodos , Resultado do Tratamento , Idoso
3.
Medicine (Baltimore) ; 103(18): e37931, 2024 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-38701286

RESUMO

BACKGROUND: This study evaluates the efficacy of dexmedetomidine (DEX) in reducing postoperative delirium (POD) and modulating pro-inflammatory cytokines in elderly patients undergoing thoracolumbar compression fracture surgery. METHODS: In this randomized, double-blind, placebo-controlled trial conducted from October 2022 to January 2023 at Anting Hospital in Shanghai, 218 elderly patients were randomized into DEX (n = 110) and normal saline (NS, n = 108) groups. The DEX group received 0.5 µg/kg/h DEX, and delirium incidence was assessed using the Confusion Assessment Method (CAM) on days 1 to 3 post-surgery. Levels of interleukins IL-1ß, IL-6, and tumor necrosis factor-α (TNF-α) were measured pre-operation (T0) and on postoperative days 1 (T1) and 3 (T3). Preoperative (T0) and postoperative day 1 (T1) cerebrospinal fluid (CSF) samples were treated with varying concentrations of olanzapine or DEX to observe their regulatory effects on the expression of Phospho-ERK1/2 and Phospho-JNK. RESULTS: Dexmedetomidine significantly lowered the incidence of POD to 18.2%, compared to 30.6% in the NS group (P = .033). While all patients showed an initial increase in cytokine levels after surgery, by T3, IL-6 and TNF-α levels notably decreased in the DEX group, with no significant change in IL-1ß levels across groups. The adverse events rate was similar between groups, demonstrating the safety of DEX in this population. In postoperative CSF samples, treatment with 0.5 mM DEX significantly downregulated Phospho-JNK and upregulated Phospho-ERK1/2 expression, demonstrating a dose-dependent modulation of inflammatory responses. CONCLUSION: Dexmedetomidine is effective in reducing early POD in elderly patients post-thoracolumbar compression fracture surgery. It also decreases IL-6 and TNF-α levels, indicating its potential in managing postoperative inflammatory responses. Treatment with 0.5 mM DEX significantly modulated Phospho-ERK1/2 and Phospho-JNK expressions in postoperative CSF samples, indicating a dose-dependent effect on reducing inflammation. This study contributes to understanding DEX's role in improving postoperative outcomes in elderly patients.


Assuntos
Citocinas , Dexmedetomidina , Fraturas por Compressão , Complicações Pós-Operatórias , Vértebras Torácicas , Humanos , Dexmedetomidina/uso terapêutico , Dexmedetomidina/administração & dosagem , Feminino , Masculino , Método Duplo-Cego , Idoso , Citocinas/líquido cefalorraquidiano , Citocinas/metabolismo , Fraturas por Compressão/cirurgia , Estudos Prospectivos , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/líquido cefalorraquidiano , Vértebras Lombares/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Delírio/prevenção & controle , Delírio/líquido cefalorraquidiano , Delírio/etiologia , Delírio/tratamento farmacológico , Cuidados Intraoperatórios/métodos , Pessoa de Meia-Idade
4.
J Med Invest ; 71(1.2): 179-183, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38735718

RESUMO

Osteoporotic vertebral fracture (OVF) is common in the elderly population. In this report, we describe a case with radiculopathy due to foraminal stenosis caused by OVF in a very elderly patient that was treated successfully by full-endoscopic foraminotomy under local anesthesia. The patient was an 89-year-old woman who presented with a chief complaint of left leg pain for 5 years. She visited a couple of hospitals and finally consulted us to determine the exact cause of the pain. Computed tomography scans were obtained and selective nerve root block at L3 was performed. The diagnosis was radiculopathy at L3 due to foraminal stenosis following OVF. The patient had severe heart disease, so we decided to avoid surgery under general anesthesia and planned full-endoscopic spine surgery under local anesthesia. We performed transforaminal full-endoscopic lumbar foraminotomy at L3-L4 to decompress the L3 nerve root. The leg pain disappeared completely immediately after surgery. Postoperative computed tomography confirmed appropriate bone resection. The leg pain did not recur during a year of postoperative follow-up. OVF may cause lumbar radiculopathy as a result of foraminal stenosis, and transforaminal full-endoscopic lumbar foraminotomy under local anesthesia would be the best option in an elderly patient with poor general condition. J. Med. Invest. 71 : 179-183, February, 2024.


Assuntos
Anestesia Local , Descompressão Cirúrgica , Endoscopia , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Estenose Espinal , Humanos , Feminino , Idoso de 80 Anos ou mais , Fraturas da Coluna Vertebral/cirurgia , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/etiologia , Estenose Espinal/cirurgia , Estenose Espinal/diagnóstico por imagem , Descompressão Cirúrgica/métodos , Endoscopia/métodos , Fraturas por Osteoporose/cirurgia , Fraturas por Osteoporose/diagnóstico por imagem , Vértebras Lombares/cirurgia , Vértebras Lombares/diagnóstico por imagem , Radiculopatia/cirurgia , Radiculopatia/etiologia
5.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi ; 38(4): 466-473, 2024 Apr 15.
Artigo em Chinês | MEDLINE | ID: mdl-38632068

RESUMO

Objective: To investigate the effectiveness of injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion for thoracolumbar fracture dislocation with disc injury. Methods: Between January 2017 and June 2022, 28 patients with thoracolumbar fracture dislocation with disc injury were underwent posterior depression, the injured vertebra fixation with inclined-long pedicle screws, and interbody fusion. There were 22 males and 6 females, with a mean age of 41.4 years (range, 22-58 years). The causes of injury included falling from height in 18 cases, traffic accident in 5 cases, and bruise in 5 cases. Fracture segment included 1 case of T 11, 7 cases of T 12, 9 cases of L 1, and 11 cases of L 2. According to the American Spinal Injury Association (ASIA) scale, the spinal injuries were graded as grade A in 4 cases, grade B in 2 cases, grade C in 11 cases, and grade D in 11 cases. Preoperative spinal canal encroachment ratio was 17.7%-75.3% (mean, 44.0%); the thoracolumbar injury classification and severity score (TLICS) ranged from 9 to 10 (mean, 9.9). Seventeen patients were associated with other injuries. The time from injury to operation ranged from 1 to 4 days (mean, 2.3 days). The perioperative indicators (operation time, intraoperative blood loss, and the occurrence of complications), clinical evaluation indicators [visual analogue scale (VAS) score and Oswestry Disability Index (ODI)], radiologic evaluation indicators [anterior vertebral height ratio (AVHR), kyphosis Cobb angle (KCA), intervertebral space height (ISH), vertebral wedge angle (VWA), displacement angle (DA), and percent fracture dislocation displacement (PFDD)], neurological function, and interbody fusion were recorded. Results: The operation time was 110-159 minutes (mean, 130.2 minutes). The intraoperative blood loss was 200-510 mL (mean, 354.3 mL). All incisions healed by first intention, and no surgical complications such as wound infection or hematoma occurred. All patients were followed up 12-15 months (mean, 12.7 months). The chest and lumbar pain significantly relieved, VAS scores and ODI after operation were significantly lower than those before operation, and further decreased with the extension of postoperative time, with significant differences ( P<0.05). At last follow-up, the ASIA classification of neurological function of the patients was grade A in 3 cases, grade B in 1 case, grade C in 1 case, grade D in 10 cases, and grade E in 13 cases, which was significantly different from preoperative one ( Z=-4.772, P<0.001). Imaging review showed that AVHR, KCA, ISH, VWA, DA, and PFDD significantly improved at 1 week, 3 months and last follow-up ( P<0.05). There was no significant difference between different time points after operation ( P>0.05). At last follow-up, according to the modified Brantigan score, all patients achieved good intervertebral bone fusion, including 22 complete fusion and 6 good intervertebral fusion with a few clear lines. No complications such as internal fixation failure or kyphosis occurred during follow-up. Conclusion: The injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion is an effective treatment for thoracolumbar fracture dislocation with disc injury, which can correct the fracture dislocation, release the nerve compression, restore the injured vertebral height, and reconstruct spinal stabilization.


Assuntos
Fratura-Luxação , Fraturas Ósseas , Cifose , Parafusos Pediculares , Fraturas da Coluna Vertebral , Masculino , Feminino , Humanos , Adulto , Perda Sanguínea Cirúrgica , Vértebras Lombares/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Fixação Interna de Fraturas/métodos , Resultado do Tratamento , Estudos Retrospectivos
6.
Zhongguo Gu Shang ; 37(4): 358-62, 2024 Apr 25.
Artigo em Chinês | MEDLINE | ID: mdl-38664205

RESUMO

OBJECTIVE: To investigate the clinical efficacy of body-surface guide plates for lateral segmental positioning in the thoracolumbar spine. METHODS: From March 2018 to March 2021, 768 gerontal patientss underwent percutaneous vertebroplasty with balloon dilatation due to thoracolumbar compression fracturess, 356 males and 412 females. aged from 64 to 92 years old with an average of (77.9±13.5) years old. All patients were treated in hospital within 1 week after injury. All patients underwent preoperative localization, and were divided into localization plate group and locator group according to different localization methods. There were 390 patients in the localization plate group, 180 males and 210 females, aged from 64 to 92 years old, with an average age of (78.4±14.3) years old. There were 378 patients in the locator group, 176 males and 202 females, aged from 64 to 90 years old, with an average age of (77.5±13.4) years old. After preliminary positioning with the above two methods, skin markers were made, cloth was routinely disinfected, and the spinal lateral position was fluoroscopically examined after the fine needle was inserted into the marked point and the vertical body at the near tail end. The accuracy of the original positioning method was evaluated. The number of times, time and accuracy of positioning of the two groups of patients were compared and analyzed. RESULTS: The specific data of patient positioning in the two groups were collected for statistical analysis. The number of times of fluoroscopy in the positioning plate group and the locator group was(3.3±0.5) times and (5.0±1.2) times, and the positioning time was (60.4±9.4) s and (105.0±30.9) s, respectively. The accuracy of fluoroscopy was 97.5% (380/390) and 85.7% (324/378), respectively, with statistical significance (P<0.05). CONCLUSION: The lateral segmental positioning plate of the body surface spine has the advantages of simple operation, accurate positioning, and reducing X-ray radiation for patients, which is worthy of clinical application.


Assuntos
Vértebras Lombares , Humanos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Vértebras Lombares/cirurgia , Placas Ósseas , Vértebras Torácicas/cirurgia , Vertebroplastia/métodos , Fraturas da Coluna Vertebral/cirurgia , Posicionamento do Paciente/métodos , Fraturas por Compressão/cirurgia
7.
Medicine (Baltimore) ; 103(16): e37885, 2024 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-38640290

RESUMO

RATIONALE: Aggressive vertebral hemangiomas (AVHs) destroy continuous vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare. The very aggressive behavior was attributable to its significant vascular component and contained no adipose tissue. PATIENT CONCERNS: We report a case of thoracic spine kyphosis of AVHs with multiple vertebral bodies and intervertebral disc destruction in a 45-year-old woman. DIAGNOSES: Based on the imaging studies, the patient underwent surgical removal of this lesion and spinal reconstruction. Histopathology consistent with vertebral hemangioma and contained no adipose. INTERVENTIONS: The patient underwent surgical removal of the lesion and spinal reconstruction. After subperiosteal dissection of the paraspinal muscles and exposure of the laminae, the laminae of the T5-7 vertebrae were removed and exposing the lesion. The lesion was soft and showed cystic changes, completely curetted and autogenous bone was implanted. Vertebroplasty was performed through T3-T9 pedicles bilaterally. Pedicle screw fixation was performed for segmental fixation and fusion. OUTCOMES: After 9 days of operation, the incision healed cleanly and free of pain. She was discharged in good general condition. The patient remained asymptomatic after follow-up 6 months of postoperative. LESSONS: AVHs destroy multiple vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare.


Assuntos
Hemangioma , Cifose , Parafusos Pediculares , Fraturas da Coluna Vertebral , Feminino , Humanos , Pessoa de Meia-Idade , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Cifose/etiologia , Cifose/cirurgia , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Hemangioma/complicações , Hemangioma/cirurgia , Hemangioma/patologia , Resultado do Tratamento , Fraturas da Coluna Vertebral/cirurgia
8.
Med Sci Monit ; 30: e943797, 2024 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-38641870

RESUMO

BACKGROUND Reconstruction surgery using titanium vertebral body replacements aids in spinal stability after damage. Functional evaluation includes Nurick and ASIA grading systems. This study compares outcomes of single and double-level corpectomy in patients treated with thoracolumbar reconstruction. MATERIAL AND METHODS Records of 16 patients who underwent vertebral reconstruction with expandable cages after single (n=9) and double (n=8) corpectomy were analyzed retrospectively. Thoracal and lumbar cases were approached posteriorly (n=14). Clinical evaluation was performed by neurological examination, Nurick Scale, American Spinal Injury Association (ASIA) Neurological Scores, and Visual Analog Scale (VAS). Preoperative and postoperative 3-month scores were recorded. Radiological evaluation was performed by calculation of regional angulation and postoperative recovery of vertebral body height. RESULTS Preoperatively, 2 patients had no motor or functional sensory deficits (ASIA grade E) and 6 patients were ASIA grade D. Immediately after surgery, 4 of the ASIA grade D patients improved to ASIA grade E, while 2 patients remained ASIA grade D during follow-up. Four patients were ASIA grade A; their conditions showed no improvement postoperatively. Preoperative and postoperative 3-month Nurick grade was statistically significant (P=0.022). Postoperative Cobb angle improved by a mean of 5.4° (P=0.001). Improvement by at least 1 grade in neurological recovery was observed in 6 (38%) of the cases. Pain scores analyzed using the VAS changed from a mean of 7 to a mean of 2.63 (P<0.001). CONCLUSIONS In our experience, expandable cages are useful in the restoration of different pathologies of the thoracolumbar trunk with low complication and revision rates. With expandable cages it is possible to achieve restoration of the Cobb angle, improvement in Nurick Grade and effective pain palliation.


Assuntos
Fraturas da Coluna Vertebral , Coluna Vertebral , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Coluna Vertebral/cirurgia , Radiografia , Dor , Vértebras Lombares/cirurgia , Vértebras Torácicas/cirurgia , Fraturas da Coluna Vertebral/cirurgia
9.
Medicine (Baltimore) ; 103(17): e37912, 2024 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-38669425

RESUMO

The purpose of the present study was to mechanically verify after vertebral augmentation (AVA) scores using a finite element method (FEM) with accurate material constants of balloon kyphoplasty (BKP) cement. Representative cases with AVA scores of 1 (case 1), 3 (case 2), and 5 (case 3) among patients with vertebral body fractures who underwent BKP were analyzed. A FEM model consisting of 5 vertebral bodies was created, including the injured vertebral body in each case. The amount of displacement for each load (up to 4000 N) between the upper and lower vertebral bodies of each model was measured. Young modulus of the BKP cement was calculated from actual measurements using the EZ-Test EZ-S (Shimadzu Corporation, Kyoto, Japan). In all cases, the number of shell elements (209,296-299,876), solid elements (1913,029-2417,671), and nodes (387,848-487,756) were similar, indicating that FEM modeling was comparable among the cases. Young modulus of BKP cement, calculated using EZ-Test EZ-S, was 572 MPa. Fractures were detected by compressive forces of 3300 N (upper) and 3300 N (lower), 3000 N (upper) and 3100 N (lower), and 1200 N (upper) and 1200 N (lower) in cases 1, 2, and 3, respectively. The AVA scoring system was mechanically verified using the accurate material constants of BKP cement. A multicenter survey and external validation are therefore required for the clinical implementation of the AVA score.


Assuntos
Análise de Elementos Finitos , Cifoplastia , Vértebras Lombares , Fraturas da Coluna Vertebral , Vértebras Torácicas , Humanos , Cifoplastia/métodos , Fraturas da Coluna Vertebral/cirurgia , Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Cimentos Ósseos , Feminino , Idoso , Masculino
10.
J Orthop Surg Res ; 19(1): 240, 2024 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-38622736

RESUMO

OBJECTIVE: To assess the radiographic outcomes, clinical outcomes and complications of percutaneous kyphoplasty (PKP) with and without posterior pedicle screw fixation (PPSF) in the treatment of severe osteoporotic vertebral compression fractures (sOVCF) with nonunion. METHODS: This study involved 51 patients with sOVCF with nonunion who underwent PKP or PPSF + KP. The operation time, intraoperative blood loss, volume of injected bone cement, operation costs and hospital stays were all recorded. In addition, the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were assessed separately for each patient before and after surgery. RESULTS: Compared with the PPSF + KP group, the PKP group had shorter operation time, less intraoperative blood loss, shorter hospital stays and fewer operation costs. However, cobb's angle improvement (13.4 ± 4.3° vs. 21.4 ± 5.3°), VWR improvement ratio (30.4 ± 11.5% vs. 52.8 ± 12.7%), HA (34.9 ± 9.0% vs. 63.7 ± 7.6%) and HM (28.4 ± 11.2% vs. 49.6 ± 7.7%) improvement ratio were all higher in PPSF + KP group than that in PKP group. In addition, the ODI index and VAS score in both groups were significantly decreased at the postoperative and final follow-up. PKP group's postoperative VAS score was significantly lower than that in PPSF + KP group, but there was no statistically significant difference in VAS score at the last follow-up. CONCLUSION: PKP and PPSF + KP can both effectively relieve the pain associated with sOVCF with nonunion. PPSF + KP can achieve more satisfactory vertebral reduction effects compared to PKP. However, PKP was less invasive and it has more advantages in shortening operation time and hospital stay, as well as decreasing intraoperative blood loss and operation costs.


Assuntos
Fraturas por Compressão , Cifoplastia , Fraturas por Osteoporose , Parafusos Pediculares , Fraturas da Coluna Vertebral , Humanos , Fraturas por Compressão/diagnóstico por imagem , Fraturas por Compressão/cirurgia , Fraturas por Compressão/tratamento farmacológico , Perda Sanguínea Cirúrgica , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Fraturas da Coluna Vertebral/tratamento farmacológico , Resultado do Tratamento , Fraturas por Osteoporose/diagnóstico por imagem , Fraturas por Osteoporose/cirurgia , Fraturas por Osteoporose/tratamento farmacológico , Cimentos Ósseos/uso terapêutico , Estudos Retrospectivos
11.
BMC Musculoskelet Disord ; 25(1): 294, 2024 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-38627655

RESUMO

PURPOSE: To assess the clinical safety, accuracy, and efficacy of percutaneous kyphoplasty (PKP) surgery using an enhanced method of unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fractures (P-OVCF) with scoliosis. METHODS: Clinical and radiographic data of P-OVCF patients with scoliosis who underwent PKP via unilateral puncture on the convex side from January 2018 to December 2021 were retrospectively analyzed. This technique's detailed surgical steps and tips were described. The local kyphosis angle (LKA), scoliosis Cobb angle (SCA), and local scoliosis Cobb angle (LSCA) were measured using X-ray and compared at pre-operation, post-operation, and the last follow-up. The width of pedicle (POW), inner inclination angle (IIA), lateral distance (LD), and puncture course length (PCL) were measured on the axial computed tomography image and compared between two sides. Postoperative computed tomography was employed to evaluate the condition of cement distribution and puncture. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back pain (BP). RESULTS: Thirty-six patients, 23 women and 13 men, with an average age of 76.31 ± 6.28 years were monitored for 17.69 ± 4.70 months. The median surgical duration of single vertebrae was 35 min. The volume of bone cement for single vertebrae was 3.81 ± 0.87 ml and the proportion of sufficient cement distribution of the patients was 97.22. LKA was considerably improved from pre-operation to post-operation and sustained at the last follow-up. SCA and LSCA were not significantly modified between these three-time points. IIA, PCL, and LD were lower on the convex side than on the concave side. POW was considerably wider on the convex side. The ODI and VAS-BP scores were significantly improved after surgery and sustained during the follow-up. CONCLUSIONS: Combining with the proper assessment of the pre-injured life status of patients, PKP surgery using unilateral puncture on the convex side for the treatment of P-OVCF with scoliosis can achieve safe, excellent clinical, and radiographic outcomes.


Assuntos
Fraturas por Compressão , Cifoplastia , Cifose , Fraturas por Osteoporose , Escoliose , Fraturas da Coluna Vertebral , Masculino , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Cifoplastia/métodos , Fraturas por Compressão/diagnóstico por imagem , Fraturas por Compressão/etiologia , Fraturas por Compressão/cirurgia , Escoliose/complicações , Escoliose/diagnóstico por imagem , Estudos Retrospectivos , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Resultado do Tratamento , Coluna Vertebral , Cimentos Ósseos/uso terapêutico , Punções , Cifose/diagnóstico por imagem , Cifose/etiologia , Cifose/cirurgia , Fraturas por Osteoporose/complicações , Fraturas por Osteoporose/diagnóstico por imagem , Fraturas por Osteoporose/cirurgia
12.
Beijing Da Xue Xue Bao Yi Xue Ban ; 56(2): 371-374, 2024 Apr 18.
Artigo em Chinês | MEDLINE | ID: mdl-38595261

RESUMO

With the development of modern medical standards, autoimmune diseases and their associated successive osteoporosis have received increasing attention in recent years. Patients with autoimmune diseases, due to the characteristics of the disease and the prolonged use of glucocorticoid hormone therapy, may affect the bone formation and bone absorption of the patient, followed by severe successive osteoporosis, thereby increasing the risk of osteoporotic vertebral fractures. Vertebral compression fractures of the spine are common fracture types in patients with osteoporotic fractures. Osteoporosis is a common complication after glucocorticoid therapy in patients with autoimmune diseases. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are minimally invasive operation and are commonly used surgical methods for the treatment of osteoporotic vertebral compression fractures. However, due to the operation of spinal puncture during the operation, there are serious surgical risks such as bone cement leakage, spinal epidural hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage in both PVP and PKP. As a result, it is necessary to evaluate the patient' s body before surgery carefully, especially in the case of blood coagulation. This article reports a case of autoimmune disease patient admitted to Peking University People' s Hospital due to lumbar 4 vertebral compression fracture combined with Sjögren' s syndrome. The patient' s preoperative examination showed that the activated partial thromboplastin time (APTT) was significantly prolonged. After completing the APTT extended screening experiment and lupus anticoagulant factor testing, the multi-disciplinary team (MDT) of Peking University People' s Hospital jointly discussed the conclusion that the patient' s test results were caused by an abnormal self-immunity anti-copulant lupus (LAC). Based on the results of the laboratory examination, the patient was considered to be diagnosed with combined antiphospholipid syndrome (APS). For such patients, compared with the patient' s tendency to bleed, we should pay more attention to the risk of high blood clotting in the lower limbs of the patient, pulmonary clots and so on. With timely anti-coagulation treatment, the patient safely passed the peripheral period and was successfully discharged from the hospital. Therefore, for patients with autoimmune diseases with prolonged APTT in the perioperative period, doctors need to carefully identify the actual cause and carry out targeted treatment in order to minimize the risk of surgical and perioperative complications and bring satisfactory treatment results to the patients.


Assuntos
Doenças Autoimunes , Fraturas por Compressão , Cifoplastia , Osteoporose , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Vertebroplastia , Humanos , Fraturas da Coluna Vertebral/cirurgia , Fraturas da Coluna Vertebral/etiologia , Fraturas por Compressão/cirurgia , Vertebroplastia/efeitos adversos , Vertebroplastia/métodos , Tempo de Tromboplastina Parcial , Glucocorticoides , Tempo de Protrombina , Cifoplastia/efeitos adversos , Cifoplastia/métodos , Osteoporose/complicações , Fraturas por Osteoporose/cirurgia , Fraturas por Osteoporose/etiologia , Cimentos Ósseos , Resultado do Tratamento , Estudos Retrospectivos
13.
J Orthop Surg Res ; 19(1): 211, 2024 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-38561767

RESUMO

BACKGROUND: Although short-segment posterior spinal fixation (SSPSF) has shown promising clinical outcomes in thoracolumbar burst fractures, the treatment may be prone to a relatively high failure rate. This study aimed to assess the effectiveness of machine learning models (MLMs) in predicting factors associated with treatment failure in thoracolumbar burst fractures treated with SSPSF. METHODS: A retrospective review of 332 consecutive patients with traumatic thoracolumbar burst fractures who underwent SSPSF at our institution between May 2016 and May 2023 was conducted. Patients were categorized into two groups based on treatment outcome (failure or non-failure). Potential risk factors for treatment failure were compared between the groups. Four MLMs, including random forest (RF), logistic regression (LR), support vector machine (SVM), and k-nearest neighborhood (k-NN), were employed to predict treatment failure. Additionally, LR and RF models were used to assess factors associated with treatment failure. RESULTS: Of the 332 included patients, 61.4% were male (n = 204), and treatment failure was observed in 44 patients (13.3%). Logistic regression analysis identified Load Sharing Classification (LSC) score, lack of index level instrumentation, and interpedicular distance (IPD) as factors associated with treatment failure (P < 0.05). All models demonstrated satisfactory performance. RF exhibited the highest accuracy in predicting treatment failure (accuracy = 0.948), followed by SVM (0.933), k-NN (0.927), and LR (0.917). Moreover, the RF model outperformed other models in terms of sensitivity and specificity (sensitivity = 0.863, specificity = 0.959). The area under the curve (AUC) for RF, LR, SVM, and k-NN was 0.911, 0.823, 0.844, and 0.877, respectively. CONCLUSIONS: This study demonstrated the utility of machine learning models in predicting treatment failure in thoracolumbar burst fractures treated with SSPSF. The findings support the potential of MLMs to predict treatment failure in this patient population, offering valuable prognostic information for early intervention and cost savings.


Assuntos
Fraturas por Compressão , Fraturas da Coluna Vertebral , Humanos , Masculino , Feminino , Fixação Interna de Fraturas , Vértebras Lombares/cirurgia , Vértebras Lombares/lesões , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Fraturas da Coluna Vertebral/cirurgia , Fraturas da Coluna Vertebral/etiologia , Falha de Tratamento , Estudos Retrospectivos , Fraturas por Compressão/etiologia
14.
Medicina (Kaunas) ; 60(4)2024 Mar 22.
Artigo em Inglês | MEDLINE | ID: mdl-38674165

RESUMO

Objectives: To investigate the outcomes of early balloon kyphoplasty (BKP) intervention compared with late intervention for osteoporotic vertebral fracture (OVF). Background: Osteoporotic vertebral fracture can lead to kyphotic deformity, severe back pain, depression, and disturbances in activities of daily living (ADL). Balloon kyphoplasty has been widely utilized to treat symptomatic OVFs and has proven to be a very effective surgical option for this condition. Furthermore, BKP is relatively a safe and effective method due to its reduced acrylic cement leakage and greater kyphosis correction. Materials and Methods: A retrospective cohort study was conducted at our hospital for patients who underwent BKP for osteoporotic vertebral fractures in the time frame between January 2020 and December 2022. Ninety-nine patients were included in this study, and they were classified into two groups: in total, 36 patients underwent early BKP intervention (EI) at <4 weeks, and 63 patients underwent late BKP intervention (LI) at ≥4 weeks. We performed a clinical, radiological and statistical comparative evaluation for the both groups with a mean follow-up of one year. Results: Adjacent segmental fractures were more frequently observed in the LI group compared to the EI group (33.3% vs. 13.9%, p = 0.034). There was a significant improvement in postoperative vertebral angles in both groups (p = 0.036). The cement volume injected was 7.42 mL in the EI, compared with 6.3 mL in the LI (p = 0.007). The mean surgery time was shorter in the EI, at 30.2 min, compared with 37.1 min for the LI, presenting a significant difference (p = 0.0004). There was no statistical difference in the pain visual analog scale (VAS) between the two groups (p = 0.711), and there was no statistical difference in cement leakage (p = 0.192). Conclusions/Level of Evidence: Early BKP for OVF treatment may achieve better outcomes and fewer adjacent segmental fractures than delayed intervention.


Assuntos
Cifoplastia , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Humanos , Cifoplastia/métodos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Fraturas por Osteoporose/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Idoso de 80 Anos ou mais , Resultado do Tratamento , Pessoa de Meia-Idade , Estudos de Coortes , Fatores de Tempo
15.
Clin Spine Surg ; 37(4): 178-181, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38637927

RESUMO

STUDY DESIGN: Retrospective Review. OBJECTIVE: The purpose of this study is to evaluate the efficacy of postoperative cervical orthoses to prevent fixation failure and loss of reduction after operative treatment of cervical spine fractures. SUMMARY OF BACKGROUND DATA: While cervical orthoses are most times tolerated in trauma patients, it is not clear that postoperative bracing is effective at reducing the rate of fixation failure or nonunion in this patient population. Cervical collars may delay rehabilitation, increase the risk of dysphagia and aspiration, and can contribute to skin breakdown. METHODS: All patients who underwent operative stabilization for cervical spine injuries at a single institution between January 2015 and August 2019 were identified through the institutional Research Electronic Data Capture (REDcap) database. Patient data, including cervical spine injury, surgery, post-operative orthosis use, and secondary surgeries for loss of reduction or infection, were recorded for all patients meeting the inclusion criteria. The primary outcome was the loss of reduction or failure of fixation, requiring revision surgery. Statistical analysis was performed using Jamovi (Version 1.1) statistical software. RESULTS: In all, 201 patients meeting inclusion and exclusion criteria were identified within the study period. Overall, 133 (66.2%) patients were treated with a cervical orthosis postoperatively and 68 (33.8%) patients were allowed to mobilize as tolerated without a cervical orthosis. Fixation failure and loss of reduction occurred in 4 (1.99%) patients. Of these 4, three patients were treated with a cervical orthosis postoperatively. There was no significant difference in the risk of instrumentation failure between patients in the postoperative orthosis and no orthosis groups ( P =0.706). CONCLUSION: The use of cervical orthoses after operative stabilization of cervical spine injuries remains controversial. There was no statistically significant difference in hardware failure or loss of fixation between patients treated in cervical orthoses postoperatively and those who were not.


Assuntos
Vértebras Cervicais , Aparelhos Ortopédicos , Humanos , Vértebras Cervicais/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Estudos Retrospectivos , Fraturas da Coluna Vertebral/cirurgia , Idoso , Traumatismos da Coluna Vertebral/cirurgia
16.
Turk Neurosurg ; 34(3): 407-414, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38650553

RESUMO

AIM: To evaluate and compare clinical outcomes between the posterior short-segment pedicle fixation with injured vertebra fixation (PSPFI) and fixation without injured vertebra fixation (PSPF) for thoracolumbar burst fracture (TLBF). MATERIAL AND METHODS: In this retrospective study, a total of 78 patients with TLBF were included and assigned to PSPFI (n=46) and PSPF (n=32) groups. The operative time, blood loss, perioperative complications, Oswestry disability index (ODI), and visual analog pain score (VAS) were examined immediately after surgery, 1 month, 3 months, and 1 year after surgery. Moreover, the postoperative vertebral height correction rate and postoperative Cobb angle correction rate were examined immediately and 1 year after surgery, as well as the corrected vertebral height loss rate and Cobb angle correction loss rate. RESULTS: No significant difference was identified in terms of operative time, blood loss, perioperative complications, ODI, and VAS after surgery (p > 0.05) between the PSPFI and PSPF groups. Moreover, the postoperative vertebral height correction rate and postoperative Cobb angle correction rate showed no difference between the groups as well. However, the PSPFI group had a significantly lower loss rate in terms of corrected vertebral height loss rate and Cobb angle correction loss rate than the PSPF group 1 year after surgery (p < 0.05). CONCLUSION: PSPFI and PSPF achieve similar clinical outcomes. However, posterior short-segment pedicle fixation with injured vertebra significantly maintains vertebral height correction rate and Cobb angle correction rate, which serve as a better choice for the treatment of TLBF.


Assuntos
Fixação Interna de Fraturas , Vértebras Lombares , Fraturas da Coluna Vertebral , Vértebras Torácicas , Humanos , Estudos Retrospectivos , Masculino , Fraturas da Coluna Vertebral/cirurgia , Feminino , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Vértebras Lombares/cirurgia , Vértebras Lombares/lesões , Adulto , Resultado do Tratamento , Pessoa de Meia-Idade , Fixação Interna de Fraturas/métodos , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Adulto Jovem , Fusão Vertebral/métodos
17.
Turk Neurosurg ; 34(3): 461-467, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38650561

RESUMO

AIM: To compare the efficacy and feasibility of target area cement-enhanced percutaneous vertebroplasty (PVP) and conventional PVP in osteoporotic thoracolumbar non-total vertebral fractures. MATERIAL AND METHODS: Retrospective analysis of one hundred and two patients treated in our hospital from March 2020 to May 2021 and divided into groups A (targeted) and B (conventional PVP). The Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height ratio, intraoperative bleeding, operative time, bone cement volume, complications, and refracture of the injured vertebra were evaluated in both groups. RESULTS: The 2 days and 1-year post-operative VAS and ODI scores improved significantly in both groups (p < 0.05). The 2 days post-operative VAS and ODI scores were better in group A (p < 0.05), and there was no significant difference in the scores between the groups at the last follow-up (p > 0.05). The anterior vertebral height ratios were significantly higher in both groups 2 days postoperatively (p < 0.05); however, there was no significant difference in the 2 days and 1-year post-operative ratios in group A (p > 0.05). The anterior vertebral height ratio reduced in group B after 1 year compared to the 2 days post-operative value (p < 0.05). There was no statistical difference in intraoperative bleeding and the operative time between the groups (p > 0.05), and the bone cement volume was lesser in group A (p < 0.05). Six patients in group A and four patients in group B demonstrated cement leakage, the difference was not statistically significant (p > 0.05). Three patients in group A and 11 patients in group B demonstrated refracture, the difference was statistically significant (p < 0.05). CONCLUSION: Target area cement-enhanced PVP can effectively relieve short-term pain and functional disability and reduce the long-term possibility of secondary collapse. Therefore, it is a technically feasible and efficacious method for the treatment of osteoporotic thoracolumbar non-total vertebral fractures.


Assuntos
Cimentos Ósseos , Vértebras Lombares , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Vértebras Torácicas , Vertebroplastia , Humanos , Vertebroplastia/métodos , Feminino , Masculino , Fraturas da Coluna Vertebral/cirurgia , Fraturas por Osteoporose/cirurgia , Idoso , Estudos Retrospectivos , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Vértebras Lombares/cirurgia , Vértebras Lombares/lesões , Resultado do Tratamento , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais
18.
Acta Orthop Traumatol Turc ; 58(1): 20-26, 2024 01.
Artigo em Inglês | MEDLINE | ID: mdl-38525506

RESUMO

OBJECTIVE: It was aimed at evaluating the effect of the size of the pedicle screw placed on the fractured vertebra on the long-term radiological and clinical results of short-segment posterior instrumentation applied in the surgical treatment of thoracolumbar vertebral fractures. METHODS: This retrospective study included 36 patients who underwent short-segment posterior instrumentation surgery for a single-level thoracolumbar (T11-L2) fracture between January 2015 and March 2021. The patients included in the study were divided into 2 groups according to the size of the pedicle screw placed in the fractured vertebra (group A: intermediate screw 4.5 mm, ≤35 mm+less than 50% of the vertebral corpus length, m/f: 13/4, n: 17, age: 36.5; group B: intermediate screw 5.5 mm, ≥40 mm+more than 70% of the vertebral corpus length, m/f: 11/8, n: 19, age: 42.6). All patients were periodically evaluated clinically and radiologically. Vertebral compression angle (VCA), anterior and posterior vertebral body height (ABH-PBH), intraoperative parameters (instrumentation time and intraoperative fluoroscopy number), and complications were compared between the 2 groups. RESULTS: Both groups were comparable with respect to age, sex, level of injury, AO classification, mechanism of injury, and American Spinal Cord Injury Association impairment scale. Restoration of VCA and vertebral corpus heights was achieved sufficiently in both groups after operation (P < .0001). There was no significant difference between the 2 groups in terms of early postoperative VCA, VCA measured at final follow-up, or loss of correction in VCA. At the last follow-up, PBH was statistically significantly better preserved in group B (P=.0424). There was no difference between the 2 groups in terms of operation time and the number of intraoperative fluoroscopies. Implant failure was observed in 1 patient in group A. CONCLUSION: This study has revealed that using a long, thick pedicle screw placed in the fractured vertebra can better preserve the PBH at the final follow-up. No correlation was found between the size of the intermediate screw and the preservation of the correction in the postoperative vertebral heights and VCA during the follow-up. LEVEL OF EVIDENCE: Level III, Therapeutic Study.


Assuntos
Fraturas por Compressão , Parafusos Pediculares , Fraturas da Coluna Vertebral , Humanos , Adulto , Estudos Retrospectivos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Vértebras Lombares/lesões , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Fixação Interna de Fraturas/métodos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Resultado do Tratamento
19.
BMC Musculoskelet Disord ; 25(1): 216, 2024 Mar 14.
Artigo em Inglês | MEDLINE | ID: mdl-38481188

RESUMO

BACKGROUND: To achieve good bone fusion in anterior column reconstruction for vertebral fractures, not only bone mineral density (BMD) and bone metabolism markers but also lever arms due to bone bridging between vertebral bodies should be evaluated. However, until now, no lever arm index has been devised. Therefore, we believe that the maximum number of vertebral bodies that are bony and cross-linked with the contiguous adjacent vertebrae (maxVB) can be used as a measure for lever arms. The purpose of this study is to investigate the surgical outcomes of anterior column reconstruction for spinal fractures and to determine the effect of bone bridging between vertebral bodies on the rate of bone fusion using the maxVB as an indicator of the length of the lever arm. METHODS: The clinical data of 81 patients who underwent anterior column reconstruction for spinal fracture between 2014 and 2022 were evaluated. The bone fusion rate, back pain score, between the maxVB = 0 and the maxVB ≥ 2 patients were adjusted for confounding factors (age, smoking history, diabetes mellitus history, BMD, osteoporosis drugs, surgical technique, number of fixed vertebrae, materials used for the anterior props, etc.) and analysed with multivariate or multiple regression analyses. The bone healing rate and incidence of postoperative back pain were compared among the three groups (maxVB = 0, 2≦maxVB≦8, maxVB ≧ 9) and divided by the maxVB after adjusting for confounding factors. RESULTS: Patients with a maxVB ≥ 2 had a significantly higher bone fusion rate (p < 0.01) and postoperative back pain score (p < 0.01) than those with a maxVB = 0. Among the three groups, the bone fusion rate and back pain score were significantly higher in the 2≦maxVB≦8 group (p = 0.01, p < 0.01). CONCLUSIONS: Examination of the maxVB as an indicator of the use of a lever arm is beneficial for anterior column reconstruction for vertebral fractures. Patients with no intervertebral bone bridging or a high number of bone bridges are in more need of measures to promote bone fusion than patients with a moderate number of bone bridges are.


Assuntos
Osteoporose , Fraturas da Coluna Vertebral , Fusão Vertebral , Humanos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/etiologia , Fraturas da Coluna Vertebral/cirurgia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Osteoporose/complicações , Resultado do Tratamento , Dor nas Costas/complicações , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Vértebras Lombares/lesões , Estudos Retrospectivos , Vértebras Torácicas/cirurgia
20.
Pol Merkur Lekarski ; 52(1): 104-111, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38518241

RESUMO

OBJECTIVE: Aim: To evaluate the influence of the degree of detail of the nature of the pathomorphological changes in the osteoligamentous structures on the tactics of treating the patients with the traumatic damage to the thoracolumbar junction. PATIENTS AND METHODS: Materials and Methods: A retrospective analysis of the treatment tactics was carried out in 96 patients with a traumatic injury of the thoracolumbar junction, both those who underwent a surgical treatment and those who underwent a conservative therapy. The lesions were classified using F. Magerl and AOSpine classifications; the neurological status was assessed according to the ASIA scale, the nature of the damage was specified using the McCormack criteria. The statistical data processing was performed using the Random Forest machine learning algorithm. RESULTS: Results: The nature of the injury makes it possible to unambiguously determine the optimal method of therapy when using the F. Magerl classification with a probability of 58.33%, while in relation to the AOSpine classification this figure is 55.21%. When building the models that include the nature of the damage, the level of the neurological disorders and the McCormack criteria, it was found that the use of the F. Magerl classification demonstrates an error in unambiguously determining the most effective treatment method at the level of 26.04%, while the use of AOSpine this figure was 21.88%. CONCLUSION: Conclusions: The application of the AOSpine classification is more promising for the development of a multifactorial algorithm for the treatment of the traumatic injuries of the thoracolumbar junction.


Assuntos
Fraturas da Coluna Vertebral , Humanos , Fraturas da Coluna Vertebral/cirurgia , Estudos Retrospectivos , Vértebras Lombares/cirurgia , Vértebras Torácicas/cirurgia , Vértebras Torácicas/lesões , Tratamento Conservador
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...