Andrei Fernandes Joaquim

Evaluation of the Thoracolumbar Injury Classification System in Thoracic and Lumbar Spinal Trauma

Study Design. Retrospective study. Objective. Evaluate the relationship among the neurologic status, the Thoracolumbar Injury Classification System (TLICS) score, and the Magerl/AO classification system. Summary of the Background Data. A wide range of classification schemes for thoracic and lumbar spine trauma have been described, but none has achieved widespread acceptance. A recent system proposed by Vaccaro et al has been developed to improve injury classification and guide surgical decision making. Methods. Analysis of 49 patients treated surgically for thoracic and lumbar spine trauma from 2003 to 2009 in 2 spine trauma centers. Clinical and radiologic data were evaluated, classifying the trauma according to American Spinal Injury Association status, the Magerl/AO classification for fractures, and the TLICS score. Results. The mean age was 37 years (range, 17–72). Thirty-five (71%) patients had a thoracolumbar fracture (T11–L2). A posterior approach was used in all the cases. American Spinal Injury Association status remained unchanged in 44 (4 had some improvement and 1 worsened). A total of 61.1% of the patients with a type A fracture were neurologically intact compared with 80% with complete neurologic deficit for type C fractures. The TLICS score range from 2 to 9 (average of 6.2). Forty-seven of 49 (96%) patients had a TLICS score greater than 4, suggesting surgical treatment. Seventy percentage of the patients with a TLICS score from 4 to 6 were neurologically intact compared with 87.5% of complete neurologic deficits in patients with TLICS 7 to 9. A statistic correlation was established between the neurologic status and AO type fracture (P = 0.0041) and the TLICS score (P < 0.0001). An association between the AO type fracture and the TLICS score was also found (P = 0.0088). Conclusion. The TLICS score treatment recommendation matched surgical treatment in 47 of 49 patients (96%). The TLICS was found to correlate to the AO classification. This suggests that the TLICS can be used to classify thoracolumbar trauma and can accurately predict surgical management.

Dysphagia after anterior cervical spine surgery: a systematic review of potential preventative measures

BACKGROUND CONTEXT Anterior cervical spine surgery is one of the most common spinal procedures performed around the world, but dysphagia is a frequent postoperative complication. Many factors have been associated with an increased risk of swallowing difficulties, including multilevel surgery, revision surgery, and female gender. PURPOSE The objective of this study was to review and define potential preventative measures that can decrease the incidence of dysphagia after anterior cervical spine surgery. STUDY DESIGN This was a systematic literature review. METHODS A systematic review in the Medline database was performed. Articles related to dysphagia after anterior cervical spine surgery and potential preventative measures were included. RESULTS Twenty articles met all inclusion and exclusion criteria. These articles reported several potential preventative measures to avoid postoperative dysphagia. Preoperative measures include performing tracheal exercises before the surgical procedure. Intraoperative measures can be summarized as avoiding a prolonged operative time and the use of recombinant human bone morphogenetic protein in routine anterior cervical spine surgery, using small and smoother cervical plates, using anchored spacers instead of plates, application of steroid before wound closure, performing arthroplasty instead of anterior cervical fusion for one-level disease, decreasing tracheal cuff pressure during medial retraction, using specific retractors, and changing the dissection plan. CONCLUSIONS Current literature supports several preventative measures that may decrease the incidence of postoperative dysphagia. Although the evidence is limited and weak, most of these measures did not appear to increase other complications and can be easily incorporated into a surgical practice, especially in patients who are at high risk for postoperative dysphagia.

Cervical spine involvement in rheumatoid arthritis — A systematic review ☆ ☆☆

Rheumatoid arthritis (RA) is a systemic chronic inflammatory disorder that can compromise the cervical spine in up to 80% of the cases. The most common radiological presentations of cervical involvement are atlantoaxial subluxation (AAS), cranial settling and subaxial subluxation (SAS). We performed a systematic review in the PubMed Database of articles published later 2005 to evaluate the prevalence, progression and risk factors for cervical spine involvement in RA patients. Articles were classified according to their level of evidence. Our literature review reported a wide range in the prevalence of cervical spine disease, probably explained by the different studied populations and disease characteristics. Uncontrolled RA is probably the main risk factor for developing a spinal instability. Adequate treatment with DMARD and BA can prevent development of cervical instabilities but did not avoid progression of a pre-existing injury. MRI is the best radiological method for diagnosis cervical spine involvement. AAS is the most common form of RA. Long term radiological follow-up is necessary to diagnosis patients with late instabilities and monitoring progression of diagnosed injuries.

Retrospective evaluation of the validity of the Thoracolumbar Injury Classification System in 458 consecutively treated patients

BACKGROUND CONTEXT The Thoracolumbar Injury Classification System (TLICS) system has been developed to improve injury classification and guide surgical decision-making, yet validation of this new system remains sparse. PURPOSE This study evaluates the use of the TLICS in a large, consecutive series of patients. STUDY DESIGN/SETTING This is a retrospective case series. PATIENT SAMPLE A total of 458 patients treated for thoracic or lumbar spine trauma between 2000 and 2010 at a single, tertiary medical center were included in this study. OUTCOME MEASURES American Spinal Injury Association (ASIA) status and crossover from conservative to surgical treatment were measured. METHODS Clinical and radiological data were evaluated, classifying the injuries by ASIA status, the Magerl/AO classification, and the TLICS system. RESULTS A total of 310 patients (67.6%) was treated conservatively (group 1) and 148 patients (32.3%) were surgically (group 2) treated. All patients in group 1 were ASIA E, except one (ASIA C). In this group, 305 patients (98%) had an AO type A fracture. The TLICS score ranged from 1 to 7 (mean 1.53, median 1). A total of 307/310 (99%) patients matched TLICS treatment recommendation (TLICS≤4), except three with distractive injuries (TLICS 7) initially misdiagnosed. Nine patients (2.9%) were converted to surgical management. In group 2, 105 (70.9%) were ASIA E, whereas 43 (29%) had neurological deficits (ASIA A-D). One hundred and three patients (69.5%) were classified as AO type A, 36 (24.3%) as type B, and 9 (6%) as type C. The TLICS score ranged from 2 to 10 (mean 4.29, median of 2). Sixty-nine patients (46.6%) matched the TLICS recommendation; all discordant patients (53.4%) were treated for stable burst fractures (TLICS=2). No neurological complications occurred in either group. CONCLUSIONS The TLICS recommendation matched treatment in 307/310 patients (99%) in the conservative group. However, in the surgical group, 53.4% of patients did not match TLICS recommendations, all were burst fractures without neurological injury (TLICS=2). The TLICS system can be used to effectively classify thoracolumbar injuries and guide conservative treatment. Inconsistencies, however, remain in the treatment thoracolumbar burst fractures.

Neuropsychiatric manifestations in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic disease characterized by persistent synovitis, systemic inflammation, and the presence of autoantibodies. Neuropsychiatric manifestations are quite common in RA, including depression, cognitive dysfunction, behavior changes, spinal cord compression and peripheral nerve involvement. Potential causes include systemic inflammatory process, neural compression due to bone and joint destruction, side effects of medications and copying difficulties due to the chronicity of the disease. A high level of suspicious is required for an adequate diagnosis and treatment. In this review, we will discuss topographically the main neuropsychiatric manifestations described in RA patients, in an attempt to help in the management of these complex and multifaceted disease.

Radiocirurgia estereotáxica para metástases de coluna vertebral: revisão de literatura

ABSTRACT Objective: The spine is the most common location for bone metastases. Since cure is not possible, local control and relief of symptoms is the basis for treatment, which is grounded on the use of conventional radiotherapy. Recently, spinal radiosurgery has been proposed for the local control of spinal metastases, whether as primary or salvage treatment. Consequently, we carried out a literature review in order to analyze the indications, efficacy, and safety of radiosurgery in the treatment of spinal metastases. Methods: We have reviewed the literature using the PubMed gateway with data from the MEDLINE library on studies related to the use of radiosurgery in treatment of bone metastases in spine. The studies were reviewed by all the authors and classified as to level of evidence, using the criterion defined by Wright. Results: The indications found for radiosurgery were primary control of epidural metastases (evidence level II), myeloma (level III), and metastases known to be poor responders to conventional radiotherapy – melanoma and renal cell carcinoma (level III). Spinal radiosurgery was also proposed for salvage treatment after conventional radiotherapy (level II). There is also some evidence as to the safety and efficacy of radiosurgery in cases of extramedullar and intramedullar intradural metastatic tumors (level III) and after spinal decompression and stabilization surgery. Conclusion: Radiosurgery can be used in primary or salvage treatment of spinal metastases, improving local disease control and patient symptoms. It should also be considered as initial treatment for radioresistant tumors, such as melanoma and renal cell carcinoma.

Degenerative lumbar stenosis: update

We present a literature review of the diagnosis and treatment of acquired lumbar spinal stenosis (LS), with a brief description of new surgical techniques. LS is the most common cause of spinal surgery in individuals older than 65 years of age. Neurogenic claudication and radiculopathy result from compression of the cauda equina and lumbosacral nerve roots by degenerated spinal elements. Surgical decompression is a well established treatment for patients with refractory, or moderate to severe clinical symptoms. However, the variety of surgical options is vast. New techniques have been developed with the goal of increasing long term functional outcomes. In this article we review lumbar decompression and fusion as treatment options for LS but also present other recent developments. Prospective long term studies are necessary to know which procedures would result in optimal patient outcome.

Thoracolumbar spine trauma: Evaluation and surgical decision-making.

Introduction: Thoracolumbar spine trauma is the most common site of spinal cord injury, with clinical and epidemiological importance. Materials and Methods: We performed a comprehensive literature review on the management and treatment of TLST. Results: Currently, computed tomography is frequently used as the primary diagnostic test in TLST, with magnetic resonance imaging used in addition to assess disc, ligamentous, and neurological injury. The Thoracolumbar Injury Classification System is a new injury severity score created to help the decision-making process between conservative versus surgical treatment. When decision for surgery is made, early procedures are feasible, safe, can improve outcomes, and reduce healthcare costs. Surgical treatment is individualized based on the injury characteristics and surgeons experience, as there is no evidence-based for the superiority of one technique over the other. Conclusions: The correct management of TLST involves multiple steps, such as a precise diagnosis, classification, and treatment. The TLICS can improve care and communication between spine surgeons, resulting in a more standardized treatment.

Radiological evaluation of cervical spine involvement in rheumatoid arthritis

Cervical spine involvement commonly occurs in patients with rheumatoid arthritis (RA), especially those with inadequate treatment or severe disease forms. The most common site affected by RA is the atlantoaxial joint, potentially resulting in atlantoaxial instability, with cervical pain and neurological deficits. The second most common site of involvement is the subaxial cervical spine, often with subluxation, resulting in nerve root or spinal cord compression. In this paper, the authors review the most commonly used plain radiographic criteria to diagnose cervical instabilities seen with RA. Finally, we discuss the advantages and disadvantages of cervical CT and MRI in the setting of cervical involvement in RA.

Upper cervical injuries – A rational approach to guide surgical management

Abstract Context The complex anatomy and the importance of ligaments in providing stability at the upper cervical spine region (O–C1–C2) require the use of many imaging modalities to evaluate upper cervical injuries (UCI). While separate classifications have been developed for distinct injuries, a more practical treatment algorithm can be derived from the injury pattern in UCI. Objective To propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI. Methods A literature review was performed on the Pubmed database using the following keywords: (1) “occipital condyle injury”; (2) “craniocervical dislocation or atlanto-occipital dislocation or craniocervical dislocation”; (3) “atlas fractures”; and (4) “axis fractures”. Just articles containing the diagnosis, classification, and treatment of specific UCI were included. The data obtained were analyzed by the authors, dividing the UCI into two groups: Group 1 – patients with clear ligamentous injury and Group 2 – patients with fractures without ligament disruption. Results Injuries with ligamentous disruption, suggesting surgical treatment, include: atlanto-occipital dislocation, mid-substance transverse ligament injury, and C1–2 and C2–3 ligamentous injuries. In contrast, condyle, atlas, and axis fractures without significant displacement/misalignment can be initially treated using external orthoses. Odontoid fractures with risk factors for non-union are an exception in Group 2 once they are better treated surgically. Patients with neurological deficits may have more unstable injuries. Conclusions Ascertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.