Alexandre Fogaça Cristante

Gunshot injuries in the spine.

Study design:Review article.Objectives:To review the literature regarding treatment approaches in cases of gunshot wounds (GSWs) affecting the spine.Setting:Brazil.Methods:Narrative review of medical literature.Results:GSWs are an increasing cause of morbidity and mortality. Most patients with spinal GSW have complete neurological deficit. The injury is more common in young men and is frequently immobilizing. The initial approach should follow advanced trauma life support, and broad-spectrum antibiotic therapy should be initiated immediately, especially in patients with perforation of the gastrointestinal tract. The indications for surgery in spinal GSW are deterioration of the neurologic condition in a patient with incomplete neurological deficit, the presence of liquor fistula, spinal instability, intoxication by the metal from the bullet or risk of bullet migration.Conclusion:Surgical treatment is associated with a higher complication rate than conservative treatment. Therefore, the surgeon must know the treatment limitations and recognize patients who would truly benefit from surgery.

Estudo epidemiológico da síndrome da cauda equina

Objective: The primary purpose of this study was to determine the characteristics and outcomes of the patients admitted at our clinics diagnosed with cauda equina syndrome (CES). Secondarily, this study will serve as a basis for other comparative studies aiming at a better understanding of this condition and its epidemiology. Methods: We conducted a retrospective study by reviewing the medical records of patients diagnosed with CES and neurogenic bladder between 2005 and 2011. The following variables were analyzed: gender, age, etiology, topographic level of the lesion, time between disease onset and diagnosis, presence of neurogenic bladder, time between diagnosis and surgery, neurological damage and neurogenic bladder persistence. Results: Considering that CES is a rare condition, we were not able to establish statistic correlation between the analyzed variables and the outcomes of the disease. However, this study brought to light the inadequacy of our public health system in treating that kind of patient. Conclusion: The study shows that despite the well-defined basis for managing CES, we noted a greater number of patients with sequels caused by this condition, than is seen in the literature. The delayed diagnosis and, consequently, delayed treatment, were the main causes for the results observed. Level of Evidence IV, Case Series.OBJECTIVE : The primary purpose of this study was to determine the characteristics and outcomes of the patients admitted at our clinics diagnosed with cauda equina syndrome (CES). Secondarily, this study will serve as a basis for other comparative studies aiming at a better understanding of this condition and its epidemiology. METHODS : We conducted a retrospective study by reviewing the medical records of patients diagnosed with CES and neurogenic bladder between 2005 and 2011. The following variables were analyzed: gender, age, etiology, topographic level of the lesion, time between disease onset and diagnosis, presence of neurogenic bladder, time between diagnosis and surgery, neurological damage and neurogenic bladder persistence. RESULTS : Considering that CES is a rare condition, we were not able to establish statistic correlation between the analyzed variables and the outcomes of the disease. However, this study brought to light the inadequacy of our public health system in treating that kind of patient. CONCLUSION : The study shows that despite the well-defined basis for managing CES, we noted a greater number of patients with sequels caused by this condition, than is seen in the literature. The delayed diagnosis and, consequently, delayed treatment, were the main causes for the results observed. Level of Evidence IV, Case Series.

DNA polymorphisms as tools for spinal cord injury research

Study Design:Data mining of single nucleotide polymorphisms (SNPs) in gene pathways related to spinal cord injury (SCI).Objectives:To identify gene polymorphisms putatively implicated with neuronal damage evolution pathways, potentially useful to SCI study.Setting:Departments of Psychiatry and Orthopedics, Faculdade de Medicina, Universidade de São Paulo, Brazil.Methods:Genes involved with processes related to SCI, such as apoptosis, inflammatory response, axonogenesis, peripheral nervous system development and axon ensheathment, were determined by evaluating the ‘Biological Process’ annotation of Gene Ontology (GO). Each gene of these pathways was mapped using MapViewer, and gene coordinates were used to identify their polymorphisms in the SNP database. As a proof of concept, the frequency of subset of SNPs, located in four genes (ALOX12, APOE, BDNF and NINJ1) was evaluated in the DNA of a group of 28 SCI patients and 38 individuals with no SC lesions.Results:We could identify a total of 95 276 SNPs in a set of 588 genes associated with the selected GO terms, including 3912 nucleotide alterations located in coding regions of genes. The five non-synonymous SNPs genotyped in our small group of patients, showed a significant frequency, reinforcing their potential use for the investigation of SCI evolution.Conclusion:Despite the importance of SNPs in many aspects of gene expression and protein activity, these gene alterations have not been explored in SCI research. Here we describe a set of potentially useful SNPs, some of which could underlie the genetic mechanisms involved in the post trauma spinal cord damage.

Controlled medial branch anesthetic block in the diagnosis of chronic lumbar facet joint pain: the value of a three-month follow-up

OBJECTIVES: To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables. METHODS: Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients. RESULTS: A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05). CONCLUSION: Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives.

Monossialogangliosídeo transdérmico com laser no tratamento de lesão medular espinal de ratos

OBJECTIVES: To evaluate the effects of monosialoganglioside (GM1) administered transdermally with laser in the recovery of spinal cord injury in rats. METHODS: Forty male Wistar rats underwent spinal cord contusion using the NYU Impactor. In Group 1, the rats received 0,2 ml of saline intraperitoneally daily; in Group 2, GM1 was administered intraperitoneally at a concentration of 30 mg/kg per day; in Group 3, rats were treated daily with laser at low temperature on the skin, and in Group 4, the daily laser session also contained GM1. All the groups were treated for 42 days. The animals were evaluated by the Basso, Baettie and Bresnahan (BBB) functional scale on days 7, 14, 21, 28, 35 and 42 after the injury, and by histopathology and motor evoked potential after 42 days of injury. RESULTS: The animals in Group 4 had higher BBB scores compared with the other groups. There were no differences between the groups, or in the comparisons over time. Histological evaluation showed no differences, and no differences were found in the motor evoked potential tests either. CONCLUSION: GM1 associated with the use of low-temperature laser shows no superior functional, neurological or histological results in the treatment of spinal cord lesions in rats. Evidence Level I, Experimental, Controlled, Animal Study.

Estudo retrospectivo das infecções pós-operatórias em cirurgia de coluna: correlação com o número de limpezas cirúrgicas realizadas

OBJECTIVE: To evaluate the characteristics of post-operative infections and determine their resolution in relation to the number of surgical debridement and infectious agents. METHOD: We collected all records of patients who developed post-operative infection for 30 months and several variables were analyzed and correlated. In those 30 months, 40 patients developed post-operative infection of a total of 410 surgeries. We excluded cases of primary infection of the spine (osteomyelitis or spondylodiscitis) totaling 3 cases. Variables related to the patient, procedure and outcome were evaluated and correlated with the key variables: number of surgical debridement and infectious agents isolated from cultures. RESULTS: The rate of infection after surgery was 9.83%. Several variables were related to the number of surgical debridement performed and it was not possible to establish any relationship. However, it was found that patients with higher number of surgical procedures had a higher rate of post-operative pain. CONCLUSION: Patients receiving a greater number of procedures had more post-operative pain . There was no statistically significant correlation between the number of debridement or infectious agents or with other variables. A study with a larger number of patients may be needed to identify other relationships.

SUBAXIAL CERVICAL FRACTURE: APPLICATION AND CORRELATION OF AO AND SLIC

Objetivo:Evaluar las clasificaciones AO/Magerl y SLIC (Subaxial Cervical Spine Injury Classification) utilizadas en las fracturas de la columna cervical y evaluar si tienen correlacion con la gravedad neurologica de los pacientes, la eleccion de la via de acceso, la duracion de la cirugia y si estan correlacionados entre si.Metodo:Analisis retrospectivo de registros medicos y coleccion de imagenes radiologicas de 77 pacientes tratados quirurgicamente de fractura o dislocacion de la columna cervical subaxial, desde agosto 2010 a septiembre 2012.Resultados:La clasificacion SLIC mostro una fuerte correlacion con deficit neurologico y el valor de correlacion de Pearson de -0,600. La clasificacion AO no se correlaciono con la escala de Frankel y el valor de Pearson fue 0,06, con una significacion estadistica de 0,682 (p < 0,05), es decir, incapaz de determinar o sugerir la gravedad del deficit. Cuando se compararon entre si, las dos clasificaciones mostraron correlacion estadistica y el valor de Pearson fue de 0,282, con valor de significacion de 0,022 (p < 0,05).Conclusion:Entre las clasificaciones mas utilizadas, la calificacion SLIC ha sido capaz de definir estadisticamente la necesidad de tratamiento quirurgico y la gravedad del estado neurologico, pero fue incapaz de predecir la via de acceso o la duracion de la cirugia; la clasificacion AO no logro predecir la gravedad de la lesion neurologica, el tiempo quirurgico ni auxilio a elegir la via de acceso, siendo solo una clasificacion morfologica.Objetivo:Evaluar las clasificaciones AO/Magerl y SLIC (Subaxial Cervical Spine Injury Classification) utilizadas en las fracturas de la columna cervical y evaluar si tienen correlacion con la gravedad neurologica de los pacientes, la eleccion de la via de acceso, la duracion de la cirugia y si estan correlacionados entre si.Metodo:Analisis retrospectivo de registros medicos y coleccion de imagenes radiologicas de 77 pacientes tratados quirurgicamente de fractura o dislocacion de la columna cervical subaxial, desde agosto 2010 a septiembre 2012.Resultados:La clasificacion SLIC mostro una fuerte correlacion con deficit neurologico y el valor de correlacion de Pearson de -0,600. La clasificacion AO no se correlaciono con la escala de Frankel y el valor de Pearson fue 0,06, con una significacion estadistica de 0,682 (p < 0,05), es decir, incapaz de determinar o sugerir la gravedad del deficit. Cuando se compararon entre si, las dos clasificaciones mostraron correlacion estadistica y el valor de Pearson fue de 0,282, con valor de significacion de 0,022 (p < 0,05).Conclusion:Entre las clasificaciones mas utilizadas, la calificacion SLIC ha sido capaz de definir estadisticamente la necesidad de tratamiento quirurgico y la gravedad del estado neurologico, pero fue incapaz de predecir la via de acceso o la duracion de la cirugia; la clasificacion AO no logro predecir la gravedad de la lesion neurologica, el tiempo quirurgico ni auxilio a elegir la via de acceso, siendo solo una clasificacion morfologica.

Functional assessment of patients with cervical myelopathy who underwent surgical treatment

OBJETIVO: Evaluar y correlacionar la respuesta funcional de los pacientes con mielopatia cervical con las puntuaciones clinicas vigentes en pacientes sometidos a tratamiento quirurgico. METODOS: Se analizaron los registros medicos de 34 pacientes con mielopatia cervical que se sometieron a cuatro diferentes tipos de cirugia. Todos los pacientes fueron evaluados antes y despues de la cirugia con la aplicacion de los cuestionarios JOA y Nurick. RESULTADOS: La mejoria clinica funcional fue estadisticamente significativa. El JOA preoperatorio promedio fue de 8,5 ± 3,06 y 10,7 ± 3,9 en el postoperatorio. El Nurick antes de la operacion fue 3,2 ± 1,1 y 2,8 ± 1,3 despues de la operacion. CONCLUSION: Existe beneficio con el tratamiento quirurgico en pacientes con mielopatia cervical. La funcion neurologica despues de la cirugia depende de la funcion previa (cuanto mayor sea la duracion de los sintomas anteriores, mayor sera la progresion de la enfermedad y, por lo tanto, peor es la funcion neurologica) y la edad no es un factor relevante de la mejora, como ya se ha demostrado en otras series. La mejora clinica funcional de los pacientes es visible con el tratamiento quirurgico, independientemente de la tecnica quirurgica y esto esta directamente relacionado con su condicion antes de la cirugia.Objective: Evaluate and correlate the functional response of patients with cervical myelopathy with the current clinical scores in patients who underwent surgical treatment. Methods: We analyzed medical records of 34 patients with cervical myelopathy who underwent four different types of surgery. All patients were evaluated preoperatively and postoperatively with the application of the JOA and Nurick questionnaires. Results: Functional clinical improvement was statistically significant. The mean preoperative JOA was 8.5 ± 3.06 and 10.7 ± 3.9 in the postoperative; Nurick was 3.2 ± 1.1 preoperatively and 2.8 ± 1.3 postoperatively. Conclusion: There is benefit with the surgical procedure in patients with cervical myelopathy. The neurological function after surgery depends on the previous function (the higher the duration of the previous symptoms, the greater the progression of the disease and, therefore, worse the neurological function) and the age is not a relevant factor of improvement, as already shown in other series. The clinical functional improvement of patients is visible with surgical treatment, regardless of surgical technique.

Transcorporeal cervical foraminotomy: description of technique and results

OBJETIVO: Analise retrospectiva de 216 pacientes submetidos a descompressao foraminal cervical por abordagem transcorporal e revisao da tecnica cirurgica. METODO: Duzentos e dezesseis pacientes com seguimento minimo de 2 anos e media de 41,8 meses foram incluidos no estudo. Os prontuarios desses pacientes foram revisados quanto a complicacoes, NDI (neck disability index) e EVA (escala visual analogica). Radiografias pre e pos-operatorias foram usadas para avaliar a altura discal. RESULTADOS: Ao final do seguimento, os pacientes obtiveram uma melhora clinica significativa com reducao do NDI de 88,3% e de 86,5% e 68,3% da EVA para o membro superior e regiao cervical, respectivamente (p < 0,05). Uma reducao de 8,8% da altura discal foi observada sem outras complicacoes associadas (p < 0,05). CONCLUSAO: A descompressao radicular por abordagem transcorporal e uma alternativa que proporciona bons resultados clinicos, sem a necessidade de uma fusao e com poucas complicacoes.OBJETIVO: Analisis retrospectivo de 216 pacientes sometidos a descompresion foraminal cervical por abordaje transcorporal y revision de la tecnica quirurgica. METODO: Doscientos dieciseis pacientes con seguimiento minimo de 2 anos y promedio de 41,8 meses fueron incluidos en el estudio. Los prontuarios de esos pacientes fueron revisados cuanto a complicaciones, NDI (neck disability index) y EVA (escala visual analogica). Radiografias pre y postoperatorias fueron usadas para evaluar la altura discal. RESULTADOS: Al final del seguimiento, los pacientes obtuvieron una mejora clinica significativa con reduccion del NDI de 88,3% y de 86,5% y 68,3% de la EVA para el miembro superior y region cervical, respectivamente (p < 0,05). Una reduccion de 8,8% de la altura discal fue observada sin otras complicaciones asociadas (p < 0,05). CONCLUSION: La descompresion radicular por abordaje transcorporal es una alternativa que proporciona buenos resultados clinicos, sin la necesidad de una fusion y con pocas complicaciones.