Deep surgical site infection following thoracolumbar instrumented spinal surgery. Ten years of experience. / Infección quirúrgica profunda en cirugía instrumentada de raquis toracolumbar. Diez años de experiencia.

OBJECTIVE: To describe the characteristics and evolution of deep surgical site infection following thoracolumbar instrumented spinal surgery (DSITIS) in our centre over a period of ten years. MATERIAL AND METHOD: Descriptive retrospective study. Patient data (epidemiological/health status), surgical data, infection characteristics/presentation, isolated microorganisms, required surgical debridements, implant removal and major complications linked to infection were evaluated. RESULTS: We included 110 patients (80 females). Median follow-up after infection diagnosis was 3.6years. Adolescent idiopathic scoliosis, adult deformity and degenerative lumbar stenosis were the most frequent aetiologies. Sixty-two percent of the patients had at least one clinical feature that made them prone to infection. Infection presentation was early (0-3months from first surgery) in 60.4% of the cases, delayed (3-24months) in 11.7%, and late (more than 24months) in 27%. All patients were treated by surgical debridement. Twenty-five percent needed more than one surgical debridement. Implants were removed in 46% of the patients (71% in the first surgical debridement). The most frequent isolated microorganisms were coagulasa-negative Staphylococcus, Propionibacterium acnes and Enterococcus. Major complications appeared in 15% of the patients, and 88% of them required major surgeries. CONCLUSIONS: Late DSITIS is more frequent than previously reported. Skin microorganisms predominate among the DSITIS culprits. DSIITS produce a high rate of major complications that usually require major surgery for treatment.

[Sacral chordoma, a rare tumor]. / Le chordome sacré, tumeur rare.

One case of chordoma is described. A review of literature shows that this condition is rare. This malignant tumor grows slowly. The symptoms owing to the surrounding structures compression appear insidiously. Standard radiography, tomography, echography and computed tomography are an aid to diagnosis confirmed by biopsy. Surgical removal of the tumor is the primary modality of treatment. Surgical resection is carried out using a combined abdominal and trans-sacral approach. Complete tumoral resection is limited by preservation of sacral stability and urinary and fecal continence. Many patients are referred for radiation therapy after subtotal resection. Local recurrence is frequent. Metastasis is rare. 90 per cent of patients are dead in ten years.

[Volvulus of the gallbladder. Apropos of 2 new cases]. / Volvulus de la vésicule biliaire. A propos de deux nouveaux cas.

Acute torsion or volvulus of the gallbladder is a rare entity, which is seldom diagnosed before operation. Cholecystectomy, which must be performed without delay, is generally easy. Detorsion of the involved organ before cholecystectomy is recommended. The process occurs primarily in the aged. An increased incidence is noted in keeping with more enhanced longevity. Two new cases are reported. The literature is reviewed.

[Treatment of juvenile scoliosis: Increasing the lengthening interval with the growing rod technique should not necessarily compromise thoracic growth]. / Tratamiento de la escoliosis juvenil: aumentar el tiempo entre alargamientos con la técnica de barras de crecimiento no debe comprometer necesariamente el crecimiento torácico.

OBJECTIVE: Serial lengthening with growing rods is recommended every six months for the treatment of early onset scoliosis. The objective of this study was to evaluate the longitudinal growth of the thorax and control of the deformity in a series of patients with juvenile scoliosis when time intervals were increased between lengthenings. MATERIAL AND METHODS: Retrospective study of eight patients. The following variables were measured: the Cobb angle, the apical vertebral translation, the coronal balance, thoracic T1-L1 length, thoracic T5-T12 kyphosis, the proximal junctional kyphosis (PJK) angle, and the lumbar lordosis. Complications were recorded. RESULTS: Five idiopathic and three syndromic scoliosis cases (mean age 9.4 ± 1.5 years) were evaluated. The initial surgery was followed by with an average of two distractions per patient. The mean time between distractions was 15.7 months. The final coronal main curve correction was 58%. Apical translation and coronal balance were improved and maintained after the surgeries. The thoracic (T1-L1) preoperative length was 20.8 cm, the postoperative length was 24.4 cm, and the final length was 26 cm. At the end of follow-up, the average growth of the thorax was 5.2 cm. The preoperative (T5-T12) kyphosis was 33.5°, and final 32.1°. The change in the PJK angle was 2.5° at the end of follow-up. Most complications were related to instrumentation. Two superficial wound infections were encountered. CONCLUSION: For less severe juvenile scoliosis patients treated with growing rods, spacing out lengthenings over more than a year can decrease the number of surgeries, while still controlling the deformity and allowing longitudinal thoracic growth.

[Prognostic factors of the crankshaft phenomenon in patients with scoliosis and open triradiate cartilage. Is the double approach the solution?]. / Factores pronósticos del fenómeno de crankshaft en los pacientes con escoliosis y cartílago trirradiado abierto. ¿Es el doble abordaje la solución?

OBJECTIVE: To study young patients after scoliosis surgery in order to determine risk and prevention factors for developing a crankshaft phenomenon (CP). MATERIAL AND METHODS: Retrospective study of a cohort of 26 skeletally immature patients. Six were excluded due to progression of various conditions. Crankshaft was defined as an increase in the Cobb angle >10°, or an increase in the Mehta angle (DAVC) >10°, or any decrease in the apex-rib thoracic distance, or increase in the apical vertebral translation (AVT). Patients with and without CP development were compared in order to analyse preoperative, surgical and postoperative risk factors, as well as the influence of different surgical techniques. RESULTS: The mean follow-up was 83.9 months. Nine patients (45%) developed the crankshaft phenomenon. Only immaturity parameters were associated with development of CP. No preoperative or postoperative radiographic parameters appeared to influence its development. The amount of correction may be a protective factor (41.4 vs. 61.4%; P=.06). The double approach was able to prevent the development of CP (0%) compared with single posterior instrumentation (44%), P=.02. DISCUSSION: None of these preoperative factors seemed to predispose to CP: gender or aetiology, T5-T12 kyphosis or apical hypokyphosis, coronal Cobb, vertebral rotation, or DAVC. The residual postoperative Cobb, achieved kyphosis, or wired instrumentation versus hooks, also seemed to have no influence. CONCLUSION: In patients with open triradiate cartilage under 11 years of age, it seems advisable to correct by double approach to avoid the appearance of the crankshaft phenomenon.

[Is local bone graft sufficient to maintain the surgical correction in adolescent idiopathic scoliosis curves?]. / ¿Es el autoinjerto del campo quirúrgico suficiente para la obtención de una buena artrodesis en paciente con escoliosis idiopática del adolescente?

OBJECTIVE: The purpose of this study was to compare postoperative clinical and radiological results in adolescent idiopathic scoliosis curves treated by posterior arthrodesis using autogenous bone graft from iliac crest (CI) versus only local autograft bone (HL). PATIENTS AND METHODS: A retrospective matched cohort study was conducted on 73 patients (CI n=37 and HL n=36) diagnosed with adolescent idiopathic scoliosis and treated surgically by posterior arthrodesis. The mean post-operative follow-up was 126 months in the CI group vs. 66 months in the HL group. The radiographic data collected consisted of preoperative, postoperative, and final follow-up antero-posterior and lateral full-length radiographs. Loss of correction and quality of arthrodesis were evaluated by comparing the scores obtained from the Spanish version of the SRS-22 questionnaire. RESULTS: There were significant differences in the post-operative results as regards the correction of the Cobb angle of the main curve (HL 61 ± 15% vs. CI 51 ± 14%, P<.004), however a greater loss of correction was found in the local bone group (CI 4.5 ± 7.3° vs. HL 8.5 ± 6.3°, P=.02). There were no significant differences as regards the correction of the Cobb angle of the main curve at the end of follow-up. There were no clinical differences between the two groups in the SRS-22 scores. CONCLUSION: At 5 years of follow-up, there was a statistically significant greater loss of radiographic correction at the end of final follow-up in the local bone graft group. However clinical differences were not observed as regards the SRS-22 scores.

[Relationship between clinical results and sagittal profile in adult scoliosis. Value of the spinal-sacral angle and the spinal inclination angle]. / Correlación de resultados clínicos y perfil sagital en escoliosis del adulto. Valor del ángulo espinosacro y del ángulo de inclinación del raquis.

OBJECTIVES: To assess the clinical validity of two new recently described parameters (spinal-sacral angle (SSA) and spinal inclination angle (SIA) in adult scoliosis (AS) for evaluating the spinal-pelvic sagittal profile, as well as their still undefined role in AS. MATERIAL AND METHOD: A non-concurrent prospective radiographic and clinical study was conducted on 59 primary surgeries of AS (Cobb>40°), with a minimum of 2 years follow-up. The available X-rays and health questionnaires of 49 patients were used in the study. The changes in X-ray parameters after surgery were evaluated (Wilcoxon test), as well as the correlations as regards the clinical-radiography-age parameters (Spearman test and multiple linear regression). RESULTS: The median post-surgical follow-up was 8.5 years, and the median age of the patients was 49.5 years. There was a statistically significant change with the surgery in the SSA and SIA (less than 5° in both), thoracic kyphosis, lumbar lordosis (LL), pelvic rotation, sagittal balance (SB) and frontal Cobb. There was no correlation between pain and SSA-ST. There was a significant relationship between activity and SSA, ST, LL, SB, and age. After the multivariate analysis only age (not SSA or SIA) remained as a possible predictor of lower activity. DISCUSSION: When frontal deformity predominates, the sagittal radiographic parameters, including the newest angles, although they have an influence patient activity when analysed individually, they lose this influence when they are analysed together and with other clinical parameters. CONCLUSIONS: The SSA and SIA hardly change with surgery. They only correlate with activity, but cannot be considered predictors of this. Thus they do seem to be useful measurements in AS.

Use of liposomal amphotericin B in critically ill patients: a retrospective, multicenter, clinical study.

The clinical use of liposomal amphotericin B in 179 patients admitted to 30 medical-surgical intensive Care Units (ICUs) treated with this agent in 2006 was analyzed. Invasive fungal infections were proven, probable and possible in 44%, 16%, and 25% of cases, respectively. Fungi isolated were Candida albicans (38%), non-albicans Candida spp. (15%) and Aspergillus spp. (7%). The mean duration of treatment was 15 days (mean dose 3.7 mg/kg/day). The drug was used as rescue treatment after fluconazole or caspofungin in 47% of patients and as first line in 52% with a satisfactory clinical response in 54% of cases (72.6% with proven infection). Microbiological eradication was achieved in 68% of cases. Adverse events occurred in 51 patients but were severe in only 4. The use of liposomal amphotericin B both as first line and rescue treatment and mainly for proven invasive fungal infection was associated with a high rate of satisfactory clinical response.

[Laryngotracheoesophageal cleft]. / Hendidura laringotraqueoesofágica.

Laryngotracheoesophageal cleft is a rare congenital anomaly that should be considered in the differential diagnosis of any neonatal respiratory distress aggravated by feeding. Diagnosis is difficult, but can be made by roentgenographic and endoscopic techniques. Roentgenographic evidence of abnormal positioning of nasogastric tubes should arouse suspicion. Repeated bronchoscopy may be necessary to identify the defect. Immediate surgical repair is indicated. Incorporation of part of the esophageal wall into the repair may enhance success. Tracheostomy has been required in all survivors. The embryologic pathogenesis of the anomaly is discussed and it is concluded that the defect is found more often than is reported. We present the fifty-fourth case, the first associated to hypospadias in the world, and the first case in the Mexican literature. This child presented severe respiratory distress. Death occurred on the tenth neonatal day.

Hendidura laringotraqueoesofagica. / Laryngotracheoesophageal cleft

La hendidura laringotraqueoesofagica es una malformacion congenita rara que debe ser considerada en el diagnostico diferencial de cualquier sindrome de dificultad respiratoria neonatal que se agrave con la alimentacion.El diagnostico es dificil, pero puede lograrse con la ayuda de procedimientos radiograficos y endoscopicos. En el estudio radiografico, la posicion anormal de la sonda nasogastrica debe despertar la sospecha. Pueden ser necesarias broncoscopias repetidas para la identificacion del defecto.La reparacion inmediata es mandatoria. La incorporacion de una parte de la pared esofagica en la linea de sutura puede aumentar las posibilidades de exito. La traqueotomia ha sido una maniobra necesaria en todos los pacientes que han sobrevivido. Se discute la embriologia del defecto y ser mas comun de lo referido en la literatura. Presentamos el caso numero 54, el primero asociado reportado en Mexico. Este paciente presento signos graves de insuficiencia respiratoria y la muerte ocurrio al decimo dia de vida