Carlos Sola

Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: A comparison between surgeries performed with and without a vertical exponential filtered air-flow system

Study Design. This study retrospectively compared infection rates between adult patients after posterior spinal instrumentation procedures performed in a conventional versus an ultraclean air operating room. Objective. To evaluate if the use of ultraclean air technology could decrease the infection rate after posterior spinal arthrodesis with instrumentation. Summary of Background Data. Postoperative wound infection after posterior arthrodesis remains a feared complication in spinal surgery. Although this frequent complication results in a significant problem, the employment of ultraclean air technology, as it is commonly used for arthroplasty, has not been reported as a possible alternative to reduce the infection rate after complex spine surgery. Methods. One hundred seventy-nine patients having posterior spinal fusion with instrumentation were divided into 2 groups: group I included 139 patients operated in a conventional operating room, and group II included 40 patients operated in a vertical laminar flow operating room. Patient selection was performed favoring ultraclean air technology for elective cases in which high infection risk was considered. A statistical analysis of the infection rate and its associated risk factors between both groups was assessed. Results. We observed 18 wound infections in group I and 0 in group II. Comparison of infection rates using the chi-squared test showed a statistically significant difference (P <0.017). Conclusion. The use of ultraclean air technology reduced the infection rate after complex spinal procedures and appears to be an interesting alternative that still needs to be prospectively studied with a randomized protocol.

Giant sacral schwannoma. A case report.

Study Design Case report. Objectives To present a rare case of a previously operated giant schwannoma located in the sacrum, and to make some considerations regarding diagnostic modalities and treatment options. Summary of Background Data Large sacral schwannomas with anterior cortex erosion and associated intrapelvic extension are uncommon. Only a few case reports and small series have been published. There is no established consensus regarding diagnostic modalities, necessity for histologic diagnosis before surgery, or best surgical option. Methods The patient presented with a 2‐month history of right sciatica and severe low back pain. After a histopathologic diagnosis and a complete set of image studies, the resection of the tumoral mass was planned posteriorly. Results Seventeen months after tumor resection, the patient has a good clinical outcome, and there are no radiologic signs of instability or recurrence. Conclusions Considering the experience of the few cases reported in the world literature, the management of this tumor appears to grant favorable results, recurrence being the most frequent complication.

Overdistraction of cervical spine injuries with the use of skull traction: a report of two cases.

Two cases in which cervical spine overdistraction occurred with the use of skull traction are described. A summary of the clinical presentations and definitive treatment together with some bibliographic references are discussed. Finally, suggestions regarding how to avoid overdistraction when using skull traction are given.

Use of CT-guided periradicular injection for the treatment of foraminal and extraforaminal disc herniations

Study design: Retrospective case series. Evidence level IV. Objectives: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery. Methods: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years. Results: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded. Conclusion: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain. Final Class of evidence (CoE)-treatment Yes Study design: RCT Cohort Case control Case series • Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥85% • Adequate sample size • Control for confounding Overall class of evidence IV The definiton of the different classes of evidence is available on page 59.

Percutaneous cement discoplasty for the treatment of advanced degenerative disk disease in elderly patients

PurposeThe authors describe a percutaneous technique to treat advanced degenerative disk disease in elderly patients.MethodA step-by-step technical description based on our experience in selected cases.ResultPostoperative imaging results are presented as well as indications and recommendations.ConclusionPercutaneous discoplasty can result as an alternative minimal invasive strategy for the treatment of advanced degenerative disk disease.

The influence of anatomy (normal versus scoliosis) on the free-hand placement of pedicle screws: Is misplacement more frequent in patients with anatomical deformity?

Study design: Retrospective prognostic study. Objective: To evaluate whether patients with anatomical deformity due to scoliosis have a higher frequency of inaccurate pedicle screw insertion and related complications using the free-hand technique compared with those whose normal anatomy had been impacted by trauma. Methods: Consecutively treated trauma patients with otherwise normal anatomy (48 patients instrumented with 291 screws, group A) and scoliosis patients (24 patients instrumented with 287 screws, group B) were evaluated. Screw position on CT was evaluated using the classification by Gertzbein and Robbins with modification by Karagoz Guzey. (See web appendix at www.aospine.org/ebsj for complete classification description.) Images were examined by two fellows and one junior staff member none of whom participated in patient management. Screw position was determined by consensus. Results: In group A, five (1.7%) out of 289 screws were severely misplaced and 26 (9%) screws caused either medial (3.8%) or lateral (5.2%) cortical breeches. The other 258 (89.3%) screws were fully contained within the cortical boundaries of the pedicle. In group B, seven (2.8%) out of 256 screws were severely misplaced. Thirty-three (13%) screws caused cortical breeches, either medial (9%), lateral (2%), or anterior (2%), and 216 (84.3%) screws were fully contained within the cortical boundaries of the pedicle and the vertebra. Neurological complications were reported in one patient with scoliosis. No vascular complications were reported in either group. Conclusions: The percentage of incorrectly placed screws was similar in both groups, trauma and deformity patients. The presence of vertebral anatomical changes related to adult scoliosis was not associated with an increase in the screw-related neurological or vascular complications. Methods evaluation and class of evidence (CoE) Methodological principle: Study design: Prospective cohort Retrospective cohort • Case control Case series Methods Patients at similar point in course of treatment Follow-up ≥85% • Similarity of treatment protocols for patient groups • Patients followed for long enough for outcomes to occur • Control for extraneous risk factors Evidence class: III The definiton of the different classes of evidence is available on page 73.

Analysis of Risk Factors for New Vertebral Fracture After Percutaneous Vertebroplasty

Study Design: Retrospective analysis. Level of evidence III. Objectives: Low-energy vertebral compression fractures are an increasing socioeconomic problem among elderly patients. Percutaneous vertebroplasty has been extensively used for the treatment of painful fractures because of its effectiveness. However, some complications have been described; among them, new vertebral compression fractures, whether adjacent or not to the treated vertebra, are commonly reported complications (8% to 52%). Methods: We retrospectively analyzed epidemiological and technical variables presumably associated with new vertebral compression fractures. To determine the relationship between new vertebral compression fracture and percutaneous vertebroplasty, 30 patients (study group) with this complication were compared with 60 patients treated with percutaneous vertebroplasty without this condition (control group). Results: A higher cement percentage was found in the study group (40.3%) compared with the control group (30.5%). Initial vertebral kyphosis was significantly higher in the first group (15°) compared with the control group (9°). Epidemiological factors were similar in both groups. Conclusions: In our study, increased cement percentage injected and a higher kyphosis were associated with new vertebral compression fractures.

Factores asociados a recidiva de hernia de disco lumbar luego de una microdiscectomía

INTRODUCTION Lumbar disc hernias are a common cause of spinal surgery. Hernia recurrence is a prevalent complication. OBJECTIVE To analyse the risk factors associated with hernia recurrence in patients undergoing surgery in our institution. MATERIALS AND METHODS Lumbar microdiscectomies between 2010 and 2014 were analysed, patients with previous surgeries, extraforaminales and foraminal hernias were excluded. Patients with recurrent hernia were the case group and those who showed no recurrence were the control group. RESULTS 177 patients with lumbar microdiscectomy, of whom 30 experienced recurrence (16%), and of these 27 were reoperated. Among the risk factors associated with recurrence, we observed a higher rate of disc height, higher percentage of spinal canal occupied by the hernia and presence of degenerative facet joint changes; we observed no differences in sex, body mass index or age. DISCUSSION Previous studies show increased disc height and young patients as possible factors associated with recurrence. CONCLUSION In our series we found that the higher rate of disc height, the percentage of spinal canal occupied by the hernia and degenerative facet joint changes were associated with hernia recurrence.

Craniocervical spinal instability after type 1 Arnold Chiari decompression: a case report.

To present and describe an unusual case of spinal instability after craniocervical spinal decompression for a type-1 Chiari malformation. Type-1 Chiari malformation is a craniocervical disorder characterized by tonsillar displacement greater than 5 mm into the vertebral canal; posterior fossa decompression is the most common surgical treatment for this condition. Postoperative complications have been described: cerebrospinal fluid leak, pseudomeningocele, aseptic meningitis, wound infection, and neurological deficit. However, instability after decompression is unusual. A 9-year-old female presented with symptomatic torticollis after cervical decompression for a type-1 Chiari malformation. Spinal instability was diagnosed; craniocervical stabilization was performed. After a 12-month follow-up, spinal stability was achieved, with a satisfactory clinical neck alignment. We present a craniocervical instability secondary to surgical decompression; clinical and radiological symptoms, and definitive treatment were described.

Osteosintesis directa en espondilolistesis traumática del axis. Reporte de un caso y revision bibliografica.

La espondilolistesis traumatica del axis representa un 5% de las fracturas cervicales y es definida por una fractura de la pars interarticularis de la segunda vertebral cervical. El mecanismo de esta fractura usualmente implica fuerzas de hiperextension. Los aspectos mas importantes realcionados al pronostico y tratamiento son el compromiso discal C2-C3, el compromiso neurologico y la presencia de luxacion facetaria. En relacion al tratamiento conservador o quirurgicos en patrones no desplazados, el tratamiento quirurgico podria resultar en una recuperacion precoz. Por otro lado se han descrito buenos resultados con el uso de Halo chaleco. A continuacion se presenta un caso de espondilolistesis traumatica del axis tratado con osteosintesis directa a traves de un abordaje posterior en un paciente que rechazo el tratamiento conservador.