Glutathione effect on functional and histological recovery after spinal cord injury in rats

OBJECTIVE

The aim of this study was to evaluate the GSH effect on functional and histological recovery after experimental spinal cord injury in rats.

METHODS

Forty Wistar rats were subjected to spinal cord injury through the Multicenter Animal Spinal Cord Injury Study (MASCIS) Impactor system. The rats were sorted and divided into four groups, as follows: Group 1 ‒ Laminectomy and spinal cord injury; Group 2 ‒ Laminectomy, spinal cord injury and Saline Solution (SS) 0.9%; Group 3 ‒ Laminectomy, spinal cord injury, and GSH; and Group 4 ‒ lLaminectomy without spinal cord injury. GSH and SS were administered intraperitoneally. Groups 1 and 4 received no intervention.

RESULTS

The rats were evaluated for locomotor function recovery at seven different times by the Basso, Beattie, and Bresnahan (BBB) scale on days 2, 7, 14, 21, 28, 35, and 42 after the spinal cord injury. On day 42, the rats were sacrificed to analyze the histological findings of the injured spinal cord. In the group submitted to GSH, our experimental study revealed better functional scores on the BBB scale, horizontal ladder scale, and cranial and caudal axon count. The differences found were statistically significant in BBB scores and axonal count analysis.

CONCLUSION

This study demonstrated that using glutathione in experimental spinal trauma can lead to better functional recovery and improved axonal regeneration rate in Wistar rats submitted to experimental spinal cord injury.

Access to the Lumbosacral Spine: A Current View

The surgical approach to the lumbosacral spine has been the subject of experimental and scientific anatomical studies since the Hippocratic era. However, it was in the 20th century that, with the evolution of asepsis and antibiotic therapy, spine surgery began to evolve at breakneck speed, and the various possibilities of access roads became objects of development and discussion. As a result, pathologies of the lumbosacral spine can be accessed in different ways and positions, from the traditional posterior approach in the prone position to the anterior, oblique, lateral, and endoscopic approaches. The current article brings state-of-the-art access routes to the lumbosacral spine. This article objective is to elucidate the possibilities of accesses the lumbar spine for any purposes, as decompression, fusion, tumour resections, reconstruction or deformity correction, despites type of implants or implants positioning.

Health-Related Predictive Factors of Brazilian Children With Early Onset Scoliosis Using the EOSQ-24 and CHQ-PF50 Questionnaires

BACKGROUND

Assessing the quality of life (QOL) of children with early onset scoliosis (EOS) has been discussed recently. Therefore, the study aimed to apply and correlate the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) with the 50-item Childhood Health Questionnaire (CHQ-PF50) to find predictive factors impacting QOL.

METHODS

Cross-sectional study involving a population of caregivers of patients with EOS. The sample consisted of 72 patients. Two research assistants applied the Portuguese version of the EOSQ-24 and CHQ-PF50 in 3 treatment centers. The EOSQ-24 assesses the subjective response of children with EOS from the parent's point of view. The CHQ is a self-administered questionnaire or parental proxy assessment of the psychological and social status of children aged 5 to 18 years.

RESULTS

Of 72 patients, 41 (56.9%) were females, mean age of 11.9 ± 4.2 years. The most common scoliosis was of neuromuscular origin (32%). The CHQ-PF50 showed that family-related items had significant scores. The most affected subcategory was physical function (45.5), and the least affected was mental health (90.8). Thus, the CHQ-PF50 PhS summary index was 27, and the CHQ-PF50 PsS was 71.7. Moreover, the critical categories for the EOSQ-24 questionnaire were daily life and physical function (45.1 and 47.8, respectively), and the least affected categories were transfer and pulmonary function (70.8 and 68.9, respectively). Four subcategories showed a strong correlation between both questionnaires: general health (r = 0.749, P < 0.001), physical function (r = 0.645, P < 0.001), bodily pain (r = 0.714, P < 0.001), and mental health (r = 0.424, P < 0.001). Using CHQ-PF50 as a dependent variable in multiple regression analysis (P = 0.028), the only variable affecting the scores was syndromic scoliosis (P = 0.019; 95% CI -27.4 to -2.5).

CONCLUSION

A strong correlation between both questionnaires was seen for general health, physical function, bodily pain, and mental health. Syndromic scoliosis was a predictor of worse QOL according to the CHQ-PF50.

LEVEL OF EVIDENCE: 2

Evaluation of the effect of intrathecal GM1 in 24, 48, and 72 hours after acute spinal cord injury in rats

OBJECTIVE

The aim of this study was to evaluate the best timing and feasibility of intrathecal application of sodium monosialoganglioside (GM1) after spinal cord contusion in Wistar rats as an experimental model.

METHODS

Forty Wistar rats were submitted to contusion spinal cord injury after laminectomy. The animals were randomized and divided into four groups: Group 1 - Intrathecal application of GM1 24 hours after contusion; Group 2 - Intrathecal application of GM1 48 hours after contusion; Group 3 - intrathecal application of GM1 72 hours after contusion; Group 4 - Sham, with laminectomy and intrathecal application of 0.5 mL of 0.9% saline solution, without contusion. The recovery of locomotor function was evaluated at seven different moments by the Basso, Beattie, and Bresnahan (BBB) test. They were also assessed by the horizontal ladder, with sensory-motor behavioral assessment criteria, pre-and postoperatively.

RESULTS

This experimental study showed better functional scores in the group submitted to the application of GM1, with statistically significant results, showing a mean increase when evaluated on known motor tests like the horizontal ladder and BBB, at all times of evaluation (p < 0.05), especially in group 2 (48 hours after spinal cord injury). Also, fewer mistakes and slips over the horizontal ladder were observed, and many points were achieved at the BBB scale analysis.

CONCLUSION

The study demonstrated that the intrathecal application of GM1 after spinal cord contusion in Wistar rats is feasible. The application 48 hours after the injury presented the best functional results.

Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis

Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.

High dose image-guided, intensity modulated radiation therapy (IG-IMRT) for chordomas of the sacrum, mobile spine and skull base: preliminary outcomes

PURPOSE

To report preliminary outcomes of high dose image-guided intensity modulated radiotherapy (IG-IMRT) in the treatment of chordomas of the sacrum, mobile spine and skull base.

METHODS

Retrospective analysis of chordoma patients treated with surgery and/or radiotherapy (RT) in a single tertiary cancer center. Initial treatment was categorized as (A) Adjuvant or definitive high-dose RT (78 Gy/39fx or 24 Gy/1fx) vs (B) surgery-only or low dose RT. The primary endpoint was the cumulative incidence of local failure.

RESULTS

A total of 31 patients were treated from 2010 through 2020. Median age was 55 years, tumor location was 64% sacrum, 13% lumbar, 16% cervical and 6% clivus. Median tumor volume was 148 cc (8.3 cm in largest diameter), 42% of patients received curative-intent surgery and 65% received primary RT (adjuvant or definitive). 5-year cumulative incidence of local failure was 48% in group A vs 83% in group B (p = 0.041). Tumor size > 330 cc was associated with local failure (SHR 2.2, 95% CI 1.12 to 7.45; p = 0.028). Eight patients developed distant metastases, with a median metastases-free survival of 56.1 months. 5-year survival for patients that received high dose RT was 72% vs 76% in patients that received no or low dose RT (p = 0.63).

CONCLUSION

Our study suggests high-dose photon IG-IMRT improves local control in the initial management of chordomas. Health systems should promote reference centers with clinical expertise and technical capabilities to improve outcomes for this complex disease.

IMPACT OF THE COVID-19 PANDEMIC ON SPINE SURGERY IN A TERTIARY HEALTH CARE INSTITUTION

Objectives:

To assess postoperative complications, including COVID-19 infection, among patients undergoing surgeries at a tertiary institution during the pandemic, and to develop a local epidemiological profile of spine surgery patients.

Methods:

Retrospective descriptive study of all patients who underwent spine surgery between March 2020 and 14 January 2021 in a tertiary institution in Latin America. All patients who underwent spine surgery were included, without age restrictions. The main outcomes were postoperative complications, including COVID-19 infection.

Results:

74 patients were included in the study, 43 males and 31 females. The average age was 49.6 years. The mean duration of hospitalization was 11.5 days. Urgent surgeries were performed in 60.81% of cases. During hospitalization, only 5 of 74 patients were diagnosed with COVID-19, and only 1 patient had pulmonary involvement estimated to be greater than 50%. On average, 1.9 surgical debridements were required after postoperative surgical site infection.

Conclusions:

During the hospitalization period, only 6.7% of patients were diagnosed with COVID-19 infection. The COVID-19 infection death rate was 1 in 5 cases. The postoperative surgical site infection rate was 10.8%, similar to the level before the pandemic. Level of Evidence IV; Observational retrospective descriptive study .

Effects of ganglioside GM1 and erythropoietin on spinal cord injury in mice: Functional and immunohistochemical assessments

OBJECTIVES

To evaluate the functional and immunohistochemical effects of ganglioside GM1 and erythropoietin following experimental spinal cord injury.

METHODS

Thirty-two male BALB/c mice were subjected to experimental spinal cord injury using the NYU Impactor device and were randomly divided into the following groups: GM1 group, receiving standard ganglioside GM1 (30 mg/kg); erythropoietin group, receiving erythropoietin (1000 IU/kg); combination group, receiving both drugs; and control group, receiving saline (0.9%). Animals were evaluated according to the Basso Mouse Scale (BMS) and Hindlimb Mouse Function Score (MFS). After euthanasia, the immunohistochemistry of the medullary tissue of mice was analyzed. All animals received intraperitoneal treatment.

RESULTS

The GM1 group had higher BMS and MFS scores at the end of the experiment when compared to all other groups. The combination group had higher BMS and MFS scores than the erythropoietin and control groups. The erythropoietin group had higher BMS and MFS scores than the control group. Immunohistochemical tissue analysis showed a significant difference among groups. There was a significant increase in myelinated axons and in the myelinated axon length in the erythropoietin group when compared to the other intervention groups (p < 0.01).

CONCLUSIONS

Erythropoietin and GM1 have therapeutic effects on axonal regeneration in mice subjected to experimental spinal cord injury, and administration of GM1 alone had the highest scores on the BMS and MFS scales.

COMPARISON BETWEEN START BACK SCREENING TOOL AND DRAM FOR DETECTION OF PSYCHOSOCIAL FACTORS IN LOW BACK PAIN

ABSTRACT Objective: To correlate the results of the STarT Back Screening Tool and DRAM questionnaires, applied simultaneously, in a population with low back pain. Methods: Comparative cross-sectional study with 84 participants with low back pain assessed by both STarT Back Screening Tool (SBST) and DRAM questionnaires. The degree of correlation between the two questionnaires was analyzed through the evaluation of individualized data and using the Spearman correlation coefficient. Results: According to the DRAM, 19% of the patients were classified as “normal”, 32.1% as “at risk” and 48.8% as “distressed”. According to SBST, 59.5% of patients were classified as “low risk”, 31% as “medium risk” and 9.5% as “high risk”. Applying the Spearman's coefficient to evaluate the degree of correlation between the two questionnaires, a value of 0.4 was obtained. This shows that there is a positive, but weak, correlation (p <0.001) between the two questionnaires. Conclusion: There is a positive correlation between the two questionnaires, but the DRAM showed a greater tendency to classify patients with some degree of psychological distress when compared to the SBST. Both questionnaires are effective in identifying these factors, but the data suggest that the DRAM may be more effective as a screening tool in patients with low back pain, in view of the higher number of patients identified. Level of evidence III; Diagnostic test study.

EPIDEMIOLOGY OF VERTEBRAL SPINE FRACTURES IN A HOSPITAL IN SÃO PAULO IN THE TWO-YEAR PERIOD 2017-2018

ABSTRACT Objectives: To evaluate the epidemiological profile of patients with spinal fractures over a two-year period (2017 and 2018) in a quaternary hospital in the city of São Paulo. Methods: A cross-sectional study was carried out through the analysis of the electronic medical records of patients treated by the Spine group of the Department of Orthopedics and Traumatology at the Orthopedics and Traumatology Emergency Room of Hospital das Clínicas de São Paulo in the years 2017 and 2018. Results: A total of 185 patients were evaluated over two years. Males were the gender most frequently evaluated (69.19%), and the mean patient age was 43.95 years. The most common trauma mechanisms were falls from a height (45.95%) and traffic accidents (29.73%). The cervical spine, affected in 28.65%, was the most affected region, followed by the thoracolumbar region (26.56%). Most patients did not present deficits at the initial moment (71.89%) and 54.05% of patients underwent surgery for treatment. Conclusion: Most traumas involving the spine affect adults of working age (from 20 to 60 years old), with a predominance of males. Most injuries occurred in the cervical region, which is the region most commonly associated with severe trauma and neurological injuries. This study can help in planning prevention and precaution strategies for spinal trauma. Level of evidence III; Cross-sectional study.

Assessment of the Accuracy of the AO Spine-TL Classification for Thoracolumbar Spine Fractures Using the AO Surgery Reference Mobile App

STUDY DESIGN

Cohort study.

OBJECTIVES

This study aimed to evaluate the accuracy of the AO Surgery Reference mobile app in the diagnosis of thoracolumbar fractures of the spine according to the AO TL classification, and to discuss the usefulness of this app in the teaching and training of the resident physicians in orthopedics and traumatology area.

METHODS

The 24 residents of Orthopedic and Traumatology program assessed 20 cases of thoracolumbar fractures selected from the hospital database on 2 different occasions, with a 30-day interval, and they classified these cases with and without using the AO Surgery Reference app. A group of spine experts previously established the gold standard and the answers were statistically compared, with the inter- and intraobserver reliability evaluated by the kappa index.

RESULTS

The use of the AO Surgery Reference app increased the classification success rate of the fracture morphology (from 53.4% to 72.5%), of the comorbidity modifier (from 61.4% to 77.9%) and of the neurological status modifier (from 55.1% to 72.9%). In addition, the mobile app raised the classification agreement and accuracy. The kappa index increased from 0.30 to 0.53 regarding the morphological classification of fractures.

CONCLUSIONS

The residents improved their ability to recognize and classify thoracolumbar spine fractures, which reinforces the importance of this tool in medical education and clinical practice.

Risk Factors Associated with Postoperative Infection in Cancer Patients Undergoing Spine Surgery

OBJECTIVES

To determine the rate of and main risk factors for postoperative infection in cancer patients who underwent spine surgery in the last 5 years in order to determine whether there is an association between postoperative infection and increased mortality during hospitalization.

METHODS

All cancer patients who underwent surgical procedures between January 2015 and December 2019 at a single hospital specializing in spine cancer surgery were analyzed. The primary outcome of interest was postoperative infection. Bivariate logistic regression was used to estimate the odds ratio and 95% confidence interval for each variable in relation to the occurrence of infection.

RESULTS

We evaluated 324 patients, including 176 men (54.3%) and 148 women (45.7%) with a mean age of 56 years. The incidence of postoperative infection was 20.37%. Of the 324 patients, 39 died during hospitalization (12%).

CONCLUSIONS

Surgical time greater than 4 hours, surgical instrumented levels greater than 6, and an Eastern Cooperative Oncology Group of 3 or 4 were associated with an increased risk of postoperative infection, but these factors did not lead to an increase in mortality during hospitalization.

Clinical and Radiological Results After Minimally Invasive Transpsoas Lateral Access Surgery for Degenerative Lumbar Stenosis

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The lateral transpsoas access is a retroperitoneal approach for the lumbar spine to perform the lateral lumbar interbody fusion (LLIF), an intersomatic arthrodesis performed with a cage placed on the lateral borders of the epiphyseal ring. The procedure can be used to provide indirect decompression of the nervous structures through the discectomy and restoration of the disc height. The objective of the present study was to evaluate the indirect decompression following LLIF both with radiological and clinical parameters.

METHODS

Prospective clinical and radiological study in a single center with 20 patients diagnosed with 1- or 2-level degenerative lumbar stenosis. Radiological analysis on magnetic resonance imaging included foramen height, canal area, canal diameter, and disc height. Clinical outcomes included visual analogue scale (VAS) and Oswestry Disability Index (ODI) collected up to 12 months. Complications and reoperations were recorded.

RESULTS

In total, 25 levels were treated. No reoperation was required. Disc height was increased by an average of 25% (P < .001). The canal area increased from 109 to 149 mm² (P < .001) and from 9.3 to 12.2 mm (P < .001) in anteroposterior diameter. The foramen area demonstrated the effect of indirect decompression on both sides (P < .001). The height of the foramen showed significant average increase of 2.8 mm (P < .001). The results from VAS and ODI questionnaires confirmed the clinical effect of indirect decompression.

CONCLUSION

We observed that indirect decompression by the LLIF method is feasible both radiologically and clinically with a low rate of complications and reoperations.

Adult Degenerative Scoliosis

Populational aging increases the incidence of musculoskeletal degenerative processes, such as adult scoliosis (AS). Adult scoliosis is defined as a spinal deformity in the coronal plane with a Cobb angle > 10°. Adult scoliosis may be iatrogenic or result from a degenerative process (scoliosis de novo ) or a pre-existing scoliosis.

Adult scoliosis is a potentially limiting condition that affects a heterogeneous group of patients. Clinical treatment proved to be ineffective and surgery is often indicated. The present paper reviews AS pathophysiology, clinical presentation and diagnosis, in addition to surgical indications and the main techniques currently used.

Translation, Cross-cultural Adaptation and Reliability of Brazilian portuguese version of the DRAM Questionnaire for Psychometric Evaluation in Low Back Pain

Objective  Based on studies regarding pain physiology and its relation to emotional distress conditions, psychological evaluation became essential to determine the most favorable patient profiles to distinct therapeutic approaches. The Distress Risk Assessment Method (DRAM) has been developed as a screening instrument for patients with lumbar pain, classifying them in subgroups as normal, at risk, distressed somatic and distressed depressive, based on the two components of DRAM scores (Modified Somatic Perception Questionnaire [MSPQ] and Zung questionnaires). The objective of the present study is to translate and culturally adapt the DRAM to the Brazilian Portuguese language, and to determine the reliability of the final version.

Methods  As proposed by the International Quality of Life Assessment (IQOLA) method, a Brazilian Portuguese version of the DRAM has been applied to a sample of 85 individuals from 3 participant centers.

Results  The results confirmed the reliability and reproducibility of the DRAM in its Brazilian Portuguese final version: Cronbach alpha of 0.815 (MSPQ) and 0.794 (Zung) and intraclass correlation coefficient (ICC) of 0.688 (MSPQ) and 0.659 (Zung).

Conclusion  The presented DRAM version in Brazilian Portuguese is reliable and is available to clinical practice use.

Percutaneous Endoscopic Lumbar Discectomy Versus Microdiscectomy for the Treatment of Lumbar Disc Herniation: Pain, Disability, and Complication Rate-A Randomized Clinical Trial

Purpose

The objective was to compare the traditional microdiscectomy with percutaneous endoscopic lumbar discectomy for the treatment of disc herniations regarding pain, disability, and complications.

Methods

Randomized clinical trial with 47 patients with disc herniations treated with 2 different surgical techniques: traditional microdiscectomy or percutaneous endoscopic lumbar discectomy. Forty-seven patients were divided into 2 groups and monitored for 12 months. Irradiated and low back pain were evaluated with the visual analog scale. Surgery complications were recorded.

Results

After surgery, the sciatica and disability improved significantly but without significant differences between the groups. Improvements in back pain were significant until the third month. There were no statistical differences between groups regarding recurrence, infection, and the need for reoperation.

Conclusions

Endoscopic discectomy results are similar to those of conventional microdiscectomy regarding pain and disability improvement. Postoperative lumbar pain is less intense with endoscopic discectomy than conventional microdiscectomy only during the first 3 months. Endoscopic discectomy is a safe and efficient alternative to microdiscectomy.

Clinical Trials

Trial protocol registration number: RBR-5symrd (http://www.ensaiosclinicos.gov.br).

Comparative tomographic study of the iliac screw and the S2-alar-iliac screw in children

OBJECTIVES

The recent advancements in spine fixation aid in the treatment of complex spinal pathologies. Both the iliac screw (IS) and the S2-alar-iliac (S2AI) screw provide adequate stability in the fixation of complex lumbosacral spine pathologies, leading to a significant increased rate of using these techniques in the daily practice of the spine surgeons. This study aims to analyze, describe, and compare the insertion and positioning parameters of the S2AI screw and IS techniques in children without spinal deformities.

METHODS

An observational retrospective study was conducted at a university hospital in 2018, with 25 computed tomography (CT) images selected continuously. Mann-Whitney-Shapiro-Wilk tests were performed. The reliability of the data was assessed using the intraclass correlation. The data were stratified by age group only for Pearson's correlation analysis.

RESULTS

The mean age was 11.7 years (4.5 SD). The mean IS length was 106.63 mm (4.59 SD). The mean length of the S2AI screw was 104.13 mm (4.22 SD). The mean skin distance from the IS entry point was 28.13 mm (4.27 SD) and that for the S2AI screw was 39.96 mm (4.54 SD).

CONCLUSIONS

Through CT, the S2AI screw trajectory was observed to have a greater bone thickness and skin distance than the IS. There was a linear correlation between age and screw length for both techniques. A similar relationship was observed between skin distance and age for the S2AI screw technique. In children, the S2AI screw technique presents advantages such as greater cutaneous coverage and implant thickness than the IS technique.

VDAC1 is essential for neurite maintenance and the inhibition of its oligomerization protects spinal cord from demyelination and facilitates locomotor function recovery after spinal cord injury

During the progression of the neurodegenerative process, mitochondria participates in several intercellular signaling pathways. Voltage-dependent anion-selective channel 1 (VDAC1) is a mitochondrial porin involved in the cellular metabolism and apoptosis intrinsic pathway in many neuropathological processes. In spinal cord injury (SCI), after the primary cell death, a secondary response that comprises the release of pro-inflammatory molecules triggers apoptosis, inflammation, and demyelination, often leading to the loss of motor functions. Here, we investigated the functional role of VDAC1 in the neurodegeneration triggered by SCI. We first determined that in vitro targeted ablation of VDAC1 by specific morpholino antisense nucleotides (MOs) clearly promotes neurite retraction, whereas a pharmacological blocker of VDAC1 oligomerization (4, 4′-diisothiocyanatostilbene-2, 2′-disulfonic acid, DIDS), does not cause this effect. We next determined that, after SCI, VDAC1 undergoes conformational changes, including oligomerization and N-terminal exposition, which are important steps in the triggering of apoptotic signaling. Considering this, we investigated the effects of DIDS in vivo application after SCI. Interestingly, blockade of VDAC1 oligomerization decreases the number of apoptotic cells without interfering in the neuroinflammatory response. DIDS attenuates the massive oligodendrocyte cell death, subserving undisputable motor function recovery. Taken together, our results suggest that the prevention of VDAC1 oligomerization might be beneficial for the clinical treatment of SCI.

Evaluation of Alternative Halo Ring Positions in Children Using Tomography

OBJECTIVES

The halo ring can be applied in children, through skeletal traction or a halo vest device, to treat many cervical spine pathologies, including traumatic injuries and pathologies related to deformities. However, the procedure is associated with various complications, such as infection, pin loosening, and respiratory and neurological problems. Although widely studied in adults, the best pin insertion site in children and the correlations of pin insertion sites with outcomes and complications have not been completely elucidated. This study aimed to determine alternative pin placement sites based on a morphological analysis of the infant skull by computerized tomography (CT).

METHODS

An analytical-descriptive study was performed using 50 CT scans from children. The Wilcoxon and Friedman tests were used.

RESULTS

A linear and directly proportional relation was found between cranial thickness and patient age. The average thicknesses of the anterior points across all ages analyzed ranged from 4.16 mm to 4.98 mm. The thicknesses of the posterior points varied from 3.94 mm to 4.27 mm. Within each age range, points 1 cm above the standard insertion sites had thicknesses similar to those of the standard sites, and points 2 cm above the standard insertion sites had thicknesses greater than those of the standard sites.

CONCLUSIONS

The cranial thickness at all points increases linearly with age. Points 1 and 2 cm above the standard insertion sites are viable alternatives for the placement of halo pins. Preoperative CT can aid in choosing the best positioning sites for pins in the skull.

SPINE METASTASIS OF INTRACRANIAL HEMANGIOPERICYTOMA: CASE REPORT OF TWO TREATMENTS

Objective:

To report the use of two techniques (radiosurgery and en bloc vertebrectomy) on the same patient for the treatment of two metastases in different sites of the spine arising from intracranial hemangiopericytoma. Intracranial hemangiopericytomas are rare, comprising approximately 2.4% of meningeal tumors and <1% of all tumors of the central nervous system. Metastases to the spine are even rarer: The largest case series reported in the literature has 5 and 7 cases.

Methods:

A 37-year-old man diagnosed with intracranial hemangiopericytoma was referred for a metastatic lesion in T12 and underwent en bloc resection using the Tomita technique.

Results:

The disease evolved with a metastasis to T2 treated by radiosurgery with 1600 cGy. The patient died 1,706 days after the en bloc resection of T12 and 1324 days after the radiosurgery of T2, and no recurrence occurred in these locations due to progression of the systemic diseases (liver and central nervous system).

Conclusion:

This is the first case reported in the literature in which two different techniques were used to treat metastatic lesions in the spine from an intracranial hemangiopericytoma and is unique for its use of two treatments in the same patient. Level of evidence: V, case report

FOUR-LEVEL EN BLOC VERTEBRECTOMY: A NOVEL TECHNIQUE AND LITERATURE REVIEW

Objective:

To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction.

Methods:

A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital.

Results:

The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient.

Conclusion:

The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

COMPLICATED LUMBAR TUBERCULOUS SPONDYLODISCITIS IN DISSEMINATED TUBERCULOSIS, TREATED USING A NON-CONVENTIONAL ANTERIOR SUPPORT SYSTEM FOR HYDROSTATIC DISTRACTION: A CASE REPORT

Objective:

To describe a case of disseminated tuberculosis affecting the lumbar spine that was treated using a non-conventional anterior support system.

Background:

Tuberculous spondylodiscitis is the most common and most severe form of extrapulmonary tuberculosis. Although antibiotic therapy is the most frequently used treatment, surgery is necessary in cases of neurological deficit, spinal instability, significant deformity, severe sepsis, paravertebral and epidural abscesses or in cases wherein clinical treatment has failed. A surgical procedure is also indicated when a biopsy is required. With the development of new methods for reconstruction and fixation of the spine, complete debridement of the tuberculous foci has become an increasingly common approach, but there is a lack consensus on the best technique.

Methods and results:

The patient suffered from disseminated tuberculosis affecting the lumbar region of the spine, with an abscess in the psoas muscle. He underwent extensive debridement via both anterior and posterior approaches, using a non-conventional anterior support system that promotes hydrostatic distraction.

Conclusions:

Treatment using the hydrostatic distraction system was able to reestablish both the stability and anatomy of the lumbar curve. Level of evidence IV, Case report.

SURGICAL CORRECTION OF SEVERE AND FIXED CHIN-ON-CHEST DEFORMITY

Objective:

To describe a successful surgical treatment for the challenging severe and fixed chin-on-chest deformity due to isolated neck extensor myopathy (INEM).

Background data:

INEM is an idiopathic cause of dropped head syndrome (DHS) that results in severe cervicothoracic kyphosis, defined as chin-on-chest deformity. The existing literature on surgical management is limited, with outcomes ranging from poor to excellent. INEM may present to the spinal surgeon for consideration of surgical management.

Methods:

The authors present a technique that uses a staged posterior and anterior approach combined with osteotomies and corpectomy to correct the severe and fixed deformity. A state of the art anterior and posterior instrumentation system was used.

Results:

At the three-months follow-up, there was good deformity correction and the patient's satisfaction was high, with no neurological deterioration occurring.

Conclusions:

The technique illustrated in this study represents a successful option to treat this debilitating deformity. More evidence is needed to set up a definitive algorithm for the management of this condition. Level of evidence IV, Case Report.

Evaluation of the effects of erythropoietin and interleukin-6 in rats submitted to acute spinal cord injury

OBJECTIVE

To evaluate the effects of interleukin-6 (IL-6) and erythropoietin (EPO) in experimental acute spinal cord injury (SCI) in rats.

METHODS

Using standardized equipment, namely, a New York University (NYU) Impactor, a SCI was produced in 50 Wistar rats using a 10-g weight drop from a 12.5-mm height. The rats were divided into the following 5 groups of 10 animals each: "Group EPO", treated with erythropoietin only; "Group EPO + IL-6", treated with both substances; "Group IL-6", receiving IL-6 administration only; "Group Placebo", receiving a placebo solution; and "Group Sham", submitted to an incomplete procedure (only laminectomy, without SCI). All drugs and the placebo solution were administered intraperitoneally for three weeks. The animals were followed up for 42 days. Functional motor recovery was monitored by the Basso, Beattie, and Bresnahan (BBB) scale on days 2, 7, 14, 21, 28, 35 and 42. Motor-evoked potential tests were performed on the 42nd day. Histological analysis was performed after euthanasia.

RESULTS

The group receiving EPO exhibited superior functional motor results on the BBB scale. IL-6 administration alone was not superior to the placebo treatment, and the IL-6 combination with EPO yielded worse results than did EPO alone.

CONCLUSIONS

Using EPO after acute SCI in rats yielded benefits in functional recovery. The combination of EPO and IL-6 showed benefits, but with inferior results compared to those of isolated EPO; moreover, isolated use of IL-6 resulted in no benefit.

ROTATION ASSESSMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS WITH ROD DEROTATION

Objective:

Adolescent idiopathic scoliosis (AIS) is characterized by rotational and lateral deformity of the spine. The measurement of vertebral rotation is important for prognosis and treatment. Our objective was to evaluate whether the Nash-Moe method can be used to measure axial deformity correction with surgical treatment using the rod derotation maneuver at both the apex and extremities of the deformity in patients with AIS.

Methods:

Rotation was assessed using the Nash and Moe criteria, on preoperative and postoperative radiographs. We also evaluated the severity on the coronal plane using the Cobb method, ratio of correction achieved, screw density, and number of vertebrae involved in the instrumentation.

Results:

The Cobb method correction average was 54.8%. When we disregarded vertebrae that presented preoperative Nash-Moe grade 0, the average measurable correction was 54.5% in the first non-instrumented vertebra above, 69.2% in the first instrumented vertebra, 32.2% in the apical vertebra, 36.8% in the last instrumented vertebra, and 30% in the first non-instrumented vertebra below. In our study, 32.14% of the patients presented a measurable correction in the apical vertebra.

Conclusion:

On the axial plane, correction can be satisfactorily evaluated using the Nash-Moe method. Level of Evidence VI. Case Series.

RADIATION EXPOSURE DURING SPINE SURGERY USING C-ARM FLUOROSCOPY

OBJECTIVE

To evaluate the radiation dose received by staff in spine surgeries, including those who are not considered occupationally exposed workers.

METHODS

All spinal surgeries performed in the same department during a period of 12 months were evaluated with regard to the exposure of surgeons, scrub nurses, and auxiliary personnel working in the operating room to radiation from C-arm fluoroscopy. Radiation was measured by 15 film badge dosimeters placed on the professionals' lapels, gloves, and room standardized sites. The films were analyzed in the dosimetry laboratory by collections per period.

RESULTS

During the 12 months, 81 spinal surgeries were performed by the same team, with surgical times ranging from 1 to 6 hours. The total radiation dose ranged from 0.16 mSv to 2.29 mSv depending on the dosimetry site. The most exposed site was the wrist of the main surgeon.

CONCLUSION

The results showed that in the spinal surgeries in our setting, the radiation doses are low and within legal limits. Nevertheless, constant training of professionals is essential for radiation protection of medical staff and patients. Level of evidence I/b, exploratory cohort study.

TOMOGRAPHIC STUDY OF THE S2-ALAR-ILIAC SCREW TECHNIQUE IN BRAZILIAN WOMEN

ABSTRACT Objective: Lumbosacral fixation presents problems in its arthrodesis, mainly due to pseudoarthrosis. Iliac screws minimize this problem, however, they show problems in the operative wound. The S2-Alar-iliac (S2AI) screw presents a lower rate of these complications. The anatomical differences between the populations and the sexes analyzed in the literature justify the study of the S2AI screw technique in Brazilian women. Methods: A total of 14 adult female CT scans were analyzed by 4 evaluators. Results: The mean bone length was 131.8 mm, the largest bone diameter was 22.6 mm, and the smallest bone diameter was 22.6 mm. Conclusions: The data presented are compatible with the literature and may assist spine surgeons in choosing the best implant and surgical technique. Level of Evidence I; Diagnostic Studies — Investigating a Diagnostic Test (anatomical investigation).

Comparative tomographic study of the S2-alar-iliac screw versus the iliac screw

AIMS

Iliac screws and S2-alar-iliac screws provide adequate mechanical stability for the fixation of lumbosacral spine pathologies, which has led to a significant increase in the use of these techniques in the routine practice of spine surgeons. However, studies on the ideal technical positioning for both techniques are limited.

STUDY DESIGN

This is an observational, retrospective, analytical descriptive study.

OBJECTIVE

To analyze, describe and compare the insertion and positioning parameters of the S2-alar-iliac and iliac screw techniques in adult patients without spinal deformities.

METHODS

The present study comprises a retrospective analysis of lumbosacral computed tomography images selected continuously in 2016 from 25 patients at a university hospital. Mann-Whitney-Shapiro-Wilk tests were performed. Data reliability was assessed using intraclass correlation.

RESULTS

The mean length of the iliac screw was greater than that of the S2-alar-iliac screw, and the S2-alar-iliac screw sat 20.5 mm deeper than the iliac screw. The mean of the greatest bone thickness for the iliac screw was 20.72 mm; that of the S2-alar-iliac screw was 23.24 mm. The mean distance from the iliac screw entry point to the skin was 32.46 mm, and the mean distance from the S2-alar-iliac screw entry point to the skin was 52.87 mm.

CONCLUSION

The trajectory of the S2-alar-iliac screws studied via computed tomography was greater in terms of bone thickness and deeper relative to the skin compared with the iliac screws. The S2-alar-iliac technique may have desirable clinical advantages in terms of the diameter of the screws and reduced protrusion when used in adults. These slides can be retrieved from Electronic supplementary material.

SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS

Objective:

The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver.

Study design:

Report of a case series with description of a new surgical technique.

Methods:

The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used.

Results:

In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively).

Conclusion:

The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.

Standardization of a spinal cord lesion model and neurologic evaluation using mice

OBJECTIVE

To standardize a spinal cord lesion mouse model.

METHODS

Thirty BALB/c mice were divided into five groups: four experimental groups and one control group (sham). The experimental groups were subjected to spinal cord lesion by a weight drop from different heights after laminectomy whereas the sham group only underwent laminectomy. Mice were observed for six weeks, and functional behavior scales were applied. The mice were then euthanized, and histological investigations were performed to confirm and score spinal cord lesion. The findings were evaluated to prove whether the method of administering spinal cord lesion was effective and different among the groups. Additionally, we correlated the results of the functional scales with the results from the histology evaluations to identify which scale is more reliable.

RESULTS

One mouse presented autophagia, and six mice died during the experiment. Because four of the mice that died were in Group 5, Group 5 was excluded from the study. All the functional scales assessed proved to be significantly different from each other, and mice presented functional evolution during the experiment. Spinal cord lesion was confirmed by histology, and the results showed a high correlation between the Basso, Beattie, Bresnahan Locomotor Rating Scale and the Basso Mouse Scale. The mouse function scale showed a moderate to high correlation with the histological findings, and the horizontal ladder test had a high correlation with neurologic degeneration but no correlation with the other histological parameters evaluated.

CONCLUSION

This spinal cord lesion mouse model proved to be effective and reliable with exception of lesions caused by a 10-g drop from 50 mm, which resulted in unacceptable mortality. The Basso, Beattie, Bresnahan Locomotor Rating Scale and Basso Mouse Scale are the most reliable functional assessments, and but the horizontal ladder test is not recommended.

Granulocyte Colony-Stimulating Factor Combined with Methylprednisolone Improves Functional Outcomes in Rats with Experimental Acute Spinal Cord Injury

OBJECTIVES

To evaluate the effects of combined treatment with granulocyte colony-stimulating factor (G-CSF) and methylprednisolone in rats subjected to experimental spinal cord injury.

METHODS

Forty Wistar rats received a moderate spinal cord injury and were divided into four groups: control (no treatment); G-CSF (G-CSF at the time of injury and daily over the next five days); methylprednisolone (methylprednisolone for 24 h); and G-CSF/Methylprednisolone (methylprednisolone for 24 h and G-CSF at the time of injury and daily over the next five days). Functional evaluation was performed using the Basso, Beattie and Bresnahan score on days 2, 7, 14, 21, 28, 35 and 42 following injury. Motor-evoked potentials were evaluated. Histological examination of the spinal cord lesion was performed immediately after euthanasia on day 42.

RESULTS

Eight animals were excluded (2 from each group) due to infection, a normal Basso, Beattie and Bresnahan score at their first evaluation, or autophagy, and 32 were evaluated. The combination of methylprednisolone and G-CSF promoted greater functional improvement than methylprednisolone or G-CSF alone (p<0.001). This combination also exhibited a synergistic effect, with improvements in hyperemia and cellular infiltration at the injury site (p<0.001). The groups displayed no neurophysiological differences (latency p=0.85; amplitude p=0.75).

CONCLUSION

Methylprednisolone plus G-CSF promotes functional and histological improvements superior to those achieved by either of these drugs alone when treating spinal cord contusion injuries in rats. Combining the two drugs did have a synergistic effect.

Feasibility of anterior screw fixation in children: a tomographic study

PURPOSE

Morphology measures of the odontoid process in children under 12 years old were carried out to demonstrate the viability of anterior internal fixation in this population once their active profile may not be compatible with successful conservative treatment.

METHODS

During a 6-month period, 36 tomographic examinations of the cervical spine region that provided visualization of the odontoid process were selected. Group 1 included children between 6 and 9 years of age, and group 2 contained children from 9 to 12 years of age. There were 23 (63.8%) male patients and 13 (36.2%) female patients. Patients diagnosed with a tumor, an infection, fracture non-union, or congenital malformation were excluded. Exams were ordered as part of a protocol applied to non-specific neck pain and pediatric trauma entries. The following parameters were analyzed: (1) screw attack angle, (2) height of the odontoid process, and (3) minimal transverse diameter of the odontoid process.

RESULTS

In Groups 1 and 2, the average values of the screw attack angle were 55.9° ± 2.3° and 54.8° ± 4.5°, respectively; the average heights of the odontoid process were 26.58 ± 3.28 and 29.48 ± 3 mm, respectively, and the average minimal transverse diameter of the odontoid process were 6.57 ± 1.08 and 6.23 ± 0.88 mm, respectively. The minimal transverse diameter of the odontoid process was statistically higher in males than that in females, regardless of age (p = 0.007).

CONCLUSION

In both groups, the minimal transverse diameter of the odontoid process allowed for the use of one 3.5-4.5 mm screw for anterior internal fixation. These slides can be retrieved under Electronic Supplementary Material.

En bloc vertebrectomy for the treatment of spinal lesions. Five years of experience in a single institution: a case series

OBJECTIVES

The objective of this study is to describe the experience of a Brazilian public university hospital regarding the treatment of metastatic or benign spine lesions with en bloc vertebrectomy of the thoracic and lumbar spines.

METHODS

This study was a retrospective case series and included all medical records of patients with benign aggressive, primary malignant, or metastatic spine lesions who underwent en bloc vertebrectomy from 2010 to 2015.

RESULTS

A total of 17 patients were included in the analysis. Most of them (71%) were indicated for surgery based on an oncologic resection for localized disease cure. Overall, 10 of the 17 patients (59%) underwent vertebrectomy via an isolated posterior approach using the technique described by Roy-Camille et al. and Tomita et al., while 7 patients (41%) underwent double approach surgeries. Of the 17 patients who underwent the en bloc resection, 8 are still alive and in the outpatient follow-up (47%), and almost all patients with metastatic lesions (8/9) died. The average survival time following the surgical procedure was 23.8 months. Considering the cases of metastatic lesions and the cases of localized disease (malignant or benign aggressive disease) separately, we observed an average survival time of 15 months and 47.6 months respectively.

CONCLUSION

This study demonstrates and reinforces the reproducibility of the en bloc vertebrectomy technique described by Tomita et al.

Epidemiology of cauda equina syndrome. What changed until 2015

Objective

The primary objective of this study was to analyze the characteristics and outcomes of cases admitted to hospital with cauda equina syndrome (CES) at the Institute of Orthopedics and Traumatology (IOT) from 2005 to 2015. Secondly, this article is a continuation of the epidemiological work of the same base published in 2013, and will be important for other comparative studies to a greater understanding of the disease and its epidemiology.

Methods

This was a retrospective study of the medical records of admissions due to CES at IOT in the period 2005–2015 with diagnosis of CES and neuropathic bladder. The following variables were analyzed: gender, age, etiology of the disease, topographic level of the injury, time interval between injury and diagnosis, presence of neurogenic bladder, time interval between diagnosis of the CES and surgery, and reversal of the deficit or of the neurogenic bladder.

Results

Since this is a rare disease, with a low global incidence, it was not possible, just with the current study to establish statistically significant correlations between the variables and outcomes of the disease. However, this study demonstrates the shortcomings of the Brazilian public health system, both with the initial management of these patients and the need for urgent surgical treatment.

Conclusion

The study shows that despite well-defined basis for the conduct of CES, a higher number of sequelae caused by the pathology is observed in Brazil. The delay in diagnosis and, therefore, for definitive treatment, remains as the major cause for the high number of sequelae. Level of evidence: 4, case series.

A Comparative Study of Sagittal Balance in Patients with Neuromuscular Scoliosis

OBJECTIVES:

Spinopelvic alignment has been associated with improved quality of life in patients with vertebral deformities, and it helps to compensate for imbalances in gait. Although surgical treatment of scoliosis in patients with neuromuscular spinal deformities promotes correction of coronal scoliotic deformities, it remains poorly established whether this results in large changes in sagittal balance parameters in this specific population. The objective of this study is to compare these parameters before and after the current procedure under the hypothesis is that there is no significant modification.

METHODS:

Sampling included all records of patients with neuromuscular scoliosis with adequate radiographic records treated at Institute of Orthopedics and Traumatology of Clinics Hospital of University of São Paulo (IOT-HCFMUSP) from January 2009 to December 2013. Parameters analyzed were incidence, sacral inclination, pelvic tilt, lumbar lordosis, thoracic kyphosis, spinosacral angle, spinal inclination and spinopelvic inclination obtained using the iSite-Philips digital display system with Surgimap and a validated method for digital measurements of scoliosis radiographs. Comparison between the pre- and post-operative conditions involved means and standard deviations and the t-test.

RESULTS:

Based on 101 medical records only, 16 patients met the inclusion criteria for this study, including 7 males and 9 females, with an age range of 9-20 and a mean age of 12.9±3.06; 14 were diagnosed with cerebral palsy. No significant differences were found between pre and postoperative parameters.

CONCLUSIONS:

Despite correction of coronal scoliotic deformity in patients with neuromuscular deformities, there were no changes in spinopelvic alignment parameters in the group studied.

Anatomical and radiological characteristics in adolescent idiopathic scoliosis with surgical indication

OBJECTIVE

This study aims to analyze the anatomical and radiological characteristics of adolescent idiopathic scoliosis patients with surgical indication.

METHODS

Retrospective, descriptive study of 100 medical records pertaining to patients included in the group of scoliosis with surgical indication from the years 2008 to 2015. Descriptive statistics were used for statistical analysis.

RESULTS

28 patients met the inclusion and exclusion criteria, and were selected for the study. The average age was 15.4 (SD ± 1.2 years); in the selected sample, the female/male ratio was 6:1; the kyphosis measured in degrees by Cobb angle between T5-T12 had an average 32.10 (SD ± 13.37); according to the Lenke classification, the most prevalent type was type 2, representing 28.6% of cases.

CONCLUSION

The mean patient age in the present study was 15.4 (SD ± 1.2 years); the most prevalent type was type 2 in the Lenke classification. There is a need for new anatomical and radiological studies to elucidate the morphological characteristics common in adolescent idiopathic scoliosis patients.

The influence of body image on surgical decisions in adolescent idiopathic scoliosis patients

OBJECTIVES:

The objective of this study was to evaluate whether the severity of deformities in patients with adolescent idiopathic scoliosis contributes to patients' decision regarding whether to undergo an operation.

METHODS:

We evaluated body image factors in adolescent idiopathic scoliosis patients. We evaluated the magnitude of the main scoliotic curve, gibbosity (magnitude and location), shoulder height asymmetry and patient's age. We analyzed the correlation of these data with the number of years the patient was willing to trade for surgery, as measured by the time-trade-off method.

RESULTS:

A total of 52 patients were studied. We did not find a correlation between any of the parameters that were studied and the number of years that the patient would trade for the surgery.

CONCLUSIONS:

The magnitude of body deformities in patients with adolescent idiopathic scoliosis does not interfere with the decision to undertake surgical treatment.

Correlation between the degree of correction of neuromuscular scoliosis and patient quality of life

OBJECTIVE:

There are few data on patient satisfaction with surgery for the correction of neuromuscular scoliosis or on the correlation between patient satisfaction and the degree of curve correction achieved by surgery. Our aim was to determine the correlations between both patient satisfaction and perception of quality of life and the degree of curve correction.

METHODS:

We interviewed 18 patients and administered a questionnaire that collected social and economic data and information about functional ability, comorbidities and satisfaction. Statistical analysis was performed using chi-square tests, Pearson correlation and paired t-tests.

RESULTS:

The mean correction achieved was 42.8%, i.e., 34.17 degrees. Early and late complication rates were low (11.1% each). Almost all of the patients (94.4%) were satisfied with the surgery, and expectations were met for 61.1% of them. Quality of life and aesthetics were improved in 83.4% and 94.4% of cases, respectively. No correlation was found between satisfaction and degree of correction.

CONCLUSION:

Our surgical results are similar to those of other studies with respect to the degree of correction and patient satisfaction. The disparity between satisfaction and fulfillment of expectations may be due to unrealistic initial expectations or misunderstanding of the objective of surgery. Our findings corroborate the hypothesis that satisfaction is multifactorial and not restricted to a quantitative goal. The satisfaction of patients who undergo operation for neuromuscular scoliosis does not depend directly on the degree of deformity correction. The relationship between satisfaction and the success of the correction procedure is complex and multifactorial.

TOMOGRAPHIC MORPHOLOGICAL STUDY OF THE CRANIUM AND ITS CORRELATION WITH CRANIAL HALO USE IN ADULTS

Objective:

To evaluate using tomographic study the thickness of the cranial board at the insertions points of the cranial halo pins in adults

Methods:

This is a retrospective, cross-sectional, descriptive analysis of Computed Tomography (CT) scans of adult patients' crania. The study included adults between 20 and 50 years without cranial abnormalities. We excluded any exam with cranial abnormalities

Results:

We analyzed 50 CT scans, including 27 men and 23 women, at the original insertion points and alternative points (1 and 2 cm above the frontal and parietal bones). The average values were 7.4333 mm in the frontal bone and 6.0290 mm in the parietal bone

Conclusion:

There was no statistically significant difference between the classical and alternative points, making room for alternative fixings and safer introduction of the pins, if necessary.Level of Evidence II, Retrospective Study.

CHANGES IN THE SAGITTAL BALANCE IN CONGENITAL SCOLIOSIS CORRECTION SURGERY

ABSTRACT Objective: This study aimed to determine whether surgery leads to changes in sagittal balance in patients with congenital scoliosis. Methods: We retrospectively reviewed all cases of scoliosis operated in a tertiary hospital between January 2009 and January 2013. In all cases the deformity in the coronal and sagittal planes, kyphosis, and lordosis were measured, using the Cobb method, and spinopelvic parameters: pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT). Results A hundred and eleven medical records were analyzed, but the sample resulted in 10 patients, six of whom were females (60%). The average age was 13.4 years. In the comparative analysis between pre and postoperative, only the coronal deformity (12.37; CI 95% [7.88-16.86]; p<0.001), the sagittal deformity (12.71; CI 95% [4.21-21.22]; p=0.011), and the lumbar lordosis (9.9; CI 95% [0.38-19.42]; p=0.043) showed significant change. Conclusion: There was no change in the spinopelvic parameters of patients with congenital scoliosis undergoing surgery at IOF-FMUSP between 2009 and 2013; however, it was observed decrease in lumbar lordosis, and deformity angle in the sagittal and coronal planes.

Effect of muscle contractions on cartilage: morphological and functional magnetic resonance imaging evaluation of the knee after spinal cord injury

Objective

To evaluate the effect of complete absence of muscle contractions on normal human cartilage in the presence of joint motion.

Methods

Patients with complete acute spinal cord injuries were enrolled. All patients underwent magnetic resonance imaging (MRI) on both knees as soon as their medical condition was stable and at six months after the primary lesion. All patients received rehabilitation treatment that included lower-limb passive motion exercises twice a day. The MRIs were analyzed by two radiologists with expertise in musculoskeletal disorders. A region of interest was established at the patellar facets and trochlea, and T2 relaxation times were calculated. The area under the cartilage T2 relaxation time curve was calculated and standardized.

Results

Fourteen patients with complete spinal cord injuries were enrolled, but only eight patients agreed to participate in the study and signed the informed consent statement. Two patients could not undergo knee MRI due to their clinical conditions. Initial knee MRIs were performed on six patients. After six months, only two patients underwent the second bilateral knee MRI. Both patients were neurologically classified as Frankel A. An increase in T2 values on the six-month MRI was observed for both knees, especially in the patellofemoral joint.

Conclusion

The absence of muscle contractions seems to be deleterious to normal human knee cartilage even in the presence of a normal range of motion. Further studies with a larger number of patients, despite their high logistical complexity, must be performed to confirm this hypothesis.

Effects of ganglioside G(M1) and erythropoietin on spinal cord lesions in rats: functional and histological evaluations

OBJECTIVE

To evaluate the functional and histological effects of ganglioside G(M1) and erythropoietin after experimental spinal cord contusion injury.

METHODS

Fifty male Wistar rats underwent experimental spinal cord lesioning using an NYU-Impactor device and were randomly divided into the following groups, which received treatment intraperitoneally. The G(M1) group received ganglioside G(M1) (30 mg/kg); the erythropoietin group received erythropoietin (1000 IU/kg); the combined group received both drugs; and the saline group received saline (0.9%) as a control. A fifth group was the laminectomy group, in which the animals were subjected to laminectomy alone, without spinal lesioning or treatment. The animals were evaluated according to the Basso, Beattie and Bresnahan (BBB) scale, motor evoked potential recordings and, after euthanasia, histological analysis of spinal cord tissue.

RESULTS

The erythropoietin group had higher BBB scores than the G(M1) group. The combined group had the highest BBB scores, and the saline group had the lowest BBB scores. No significant difference in latency was observed between the three groups that underwent spinal cord lesioning and intervention. However, the combined group showed a significantly higher signal amplitude than the other treatment groups or the saline group (p<0.01). Histological tissue analysis showed no significant difference between the groups. Axonal index was significantly enhanced in the combined group than any other intervention (p<0.01).

CONCLUSION

G(M1) and erythropoietin exert therapeutic effects on axonal regeneration and electrophysiological and motor functions in rats subjected to experimental spinal cord lesioning and administering these two substances in combination potentiates their effects.

TOMOGRAPHIC ANALYSIS OF T-1 VERTEBRA TO INSERT LAMINAR SCREWS IN CHILDREN FROM 0 TO 12 YEARS

Objective : Tomographic analysis of the T1 vertebra in children from 0 to 12 years of age, in order to obtain anatomical parameters that assist intralaminar fixation in this pediatric population. Methods : Retrospectively analysis of the spine with CT (cervical and thoracic) of individuals aged between 0 and 12 years old, of both sexes, without anatomical deformities. The CT scans were evaluated separately, on each side, for length and thickness of the laminas as well as spinolaminar angle. The morphometric analysis was performed with iSite PACS Philips Healthcare Informatics(r) program and the values were expressed in millimeters (mm). The variables were correlated with age groups and sex of individuals. Statistical analysis was performed using t test and the results were considered significant when p<0.05. Results : By means of tomographic analysis of 24 patients it was found that age has no correlation with the angle of attack for intralaminar screws T1. However, the length and thickness of the T1 lamina increase proportionally with age. The total average length of the laminas was 28.62 ± 4.42 mm. The total average thickness was 4.75 ± 0.95 mm (3.2 to 6.5). Conclusion : This study shows relevant data on the use of Tran laminar screws currently commercially available with a minimum thickness of 3.5 mm. It is thus possible to say in this sample, they can be used in 87.5% of all laminas, being applicable in all lamina in patients older than 44 months of age.

ADVANCES IN THE USE OF STEM CELLS IN ORTHOPEDICS

Primordial cells or stem cells are multipotent undifferentiated cells with the capacity to originate any type of cell in the organism. They may have their origins in the blastocyst and thus are classified as embryonic, or tissues developed in fetuses, newborns or adults and thus are known as somatic stem cells. Bone marrow is one of the main locations for isolating primordial cells, and there are two lineages: hematopoietic and mesenchymal progenitor cells. There are several uses for these undifferentiated cells in orthopedics, going from cartilaginous lesions in osteoarthrosis, osteochondritis dissecans and patellar chondromalacia, to bone lesions like in pseudarthrosis or bone losses, or nerve lesions like in spinal cord trauma. Studying stem cells is probably the most promising field of study of all within medicine, and this is shortly going to revolutionize all medical specialties (both clinical and surgical) and thus provide solutions for diseases that today are difficult to deal with.

Late failure of posterior fixation without bone fusion for vertebral metastases

OBJECTIVE

: To verify the frequency of late radiological com-plications in spinal fixation surgeries performed without fu-sion in oncological patients

METHODS

: This is a retrospective analysis analysing failure in cases of non-fused vertebral fixation in an oncology reference hospital between 2009 and 2014. Failure was defined as implant loosening or bre-akage, as well as new angular or translation deformities

RESULTS

: One hundred and five cases were analyzed. The most common site of primary tumor was the breast and the most common place of metastasis was the thoracic spine. The average follow-up was 22.7 months. Nine cases (8%) of failure were reported, with an average time until failure of 9.5 months. The most common failure was implant loosening. No case required further surgery

CONCLUSION

: The occurrence of failure was not different than that reported for fused cases. The time interval until failure was higher than the median of survival of the majority (88%) of cases. Level of Evidence IV, Therapeutic Study.

Effects of estrogen on functional and neurological recovery after spinal cord injury: An experimental study with rats

OBJECTIVES

To evaluate the functional and histological effects of estrogen as a neuroprotective agent after a standard experimentally induced spinal cord lesion.

METHODS

In this experimental study, 20 male Wistar rats were divided into two groups: one group with rats undergoing spinal cord injury (SCI) at T10 and receiving estrogen therapy with 17-beta estradiol (4mg/kg) immediately following the injury and after the placement of skin sutures and a control group with rats only subjected to SCI. A moderate standard experimentally induced SCI was produced using a computerized device that dropped a weight on the rat's spine from a height of 12.5 mm. Functional recovery was verified with the Basso, Beattie and Bresnahan scale on the 2nd, 7th, 14th, 21st, 28th, 35th and 42nd days after injury and by quantifying the motor-evoked potential on the 42nd day after injury. Histopathological evaluation of the SCI area was performed after euthanasia on the 42nd day.

RESULTS

The experimental group showed a significantly greater functional improvement from the 28th to the 42nd day of observation compared to the control group. The experimental group showed statistically significant improvements in the motor-evoked potential compared with the control group. The results of pathological histomorphometry evaluations showed a better neurological recovery in the experimental group, with respect to the proportion and diameter of the quantified nerve fibers.

CONCLUSIONS

Estrogen administration provided benefits in neurological and functional motor recovery in rats with SCI beginning at the 28th day after injury.