David Del Curto

Histochemical analysis of paraspinal rotator muscles from patients with adolescent idiopathic scoliosis: a cross-sectional study.

Abstract Morphological, biochemical, and histopathological alterations in the paraspinal skeletal muscle of patients with adolescent idiopathic scoliosis (AIS) have been extensively reported. We evaluated rotator muscle fibers from the apex vertebra of AIS patients through histological and immunohistochemical analysis. A population of 21 female AIS patients who underwent corrective surgery between 2010 and 2013 had biopsies taken from the paraspinal muscle in the convex and concave sides of the thoracic curve apical vertebra. Serial sections were stained following routine protocols for hematoxylin and eosin (HE), Sudan red, Gomori trichrome, NADH, ATPase, and cytochrome oxidase. We assessed muscular atrophy and hypertrophy, fatty proliferation, endomysial and perimysial fibrosis, the presence of hyaline fibers, mitochondrial proliferation, muscular necrosis, nuclear centralization, and inflammation. Two independent professionals evaluated the slices. The thoracic curves had an average Cobb angle of 68 degree. Comparative analysis of the concave and convex sides was performed with McNemar test at a significance level of 5%. Results showed significant differences in both endomysial and perimysial fibrosis and fatty involution between the two sides of the apex vertebra. Paraspinal muscles in the concave side of the scoliosis apex had significantly more fibrosis and fatty involution. However, both sides showed signs of myopathy, muscular atrophy due to necrosis, presence of hyaline fibers, and mitochondrial proliferation.

Impact of surgeons’ experience on accuracy of radiographic segmental kyphosis assessment in thoracolumbar fractures: a prospective observational study

BackgroundThe thoracolumbar region is where most fractures of the spine are located. Segmental kyphosis is an important factor for treatment decisions. There are various methods for measuring segmental kyphosis in thoracolumbar fractures. Our objective was to evaluate if the experience of the surgeon has any influence on kyphosis measurement by analyzing three different categories of orthopedic surgeons and evaluate possible clinical impacts.Material and methodsSix physicians separated into three categories according to the level of experience evaluated 30 lateral view radiographs of the thoracic spine of patients with single-level fracture taken during their outpatient follow-up visits. Images had segmental kyphosis measured by five distinct methods. The x-rays were evaluated twice and in a random order after an eight-week interval. The reproducibility of the measurements was analyzed by the intraclass correlation coefficient (ICC) and its respective 95% confidence interval.ResultsThe intraclass correlation coefficient (ICC) was calculated to evaluate the inter- and intra-examiner reliability for each method. The methods that disregard the fractured vertebra (1 and 4) achieved the highest intra and inter-observers reliability among the participants. The measurements from methods 3 and 5 were poorly reproducible between examiners. The difference between the averages of the measurements of the five methods studied was greater than 5 degrees in methods 1 and 2, suggesting risk for patient safety.ConclusionMethods that exclude the fractured vertebra were more reproducible for the evaluation of segmental kyphosis in thoracolumbar fractures. The evaluation of the spine fracture must be coupled with other radiographic criteria, more complex image exams and the patient’s clinical state to assist the surgeon in deciding between conservative or surgical treatment. The authors suggest that the measurements should be performed by methods that exclude the fractured vertebra and conducted by experienced doctors.

Minimally invasive posterior cervical microforaminotomy in the lower cervical spine and C-T junction assisted by O-arm-based navigation

Navigated posterior cervical microforaminotomy (PCM) is a promising minimally invasive technique for treating radiculopathy caused by lateral disc herniations and foraminal stenosis. Between December 2009 and October 2010, 14 patients with unilateral foraminal disc herniations or foraminal stenosis at the C6-7 or C7-T1 level underwent PCM assisted by O-arm navigation using the METRx tubular retractor. The main symptoms were radicular arm pain with no significant neck pain. Successful relief of radicular pain was achieved in all 14 patients. Two of the patients were lost during follow-up, and three had to undergo further decompression due to remnant foraminal stenosis being discovered on intraoperative O-arm images. There were no cases of instability or recurrence, and the only complication observed was a dural tear in one patient, which was adequately treated with fibrin glue and bed rest. The duration of symptoms was 4.5 months on average. The mean operation time was 136 minutes, with the additional time required for the image guided surgery assisted by O-arm-based navigation being approximately 28 minutes on average. There were no other complications during the surgical procedure or in the immediate postoperative period. Posterior cervical microforaminotomy assisted by O-arm-based navigation is a safe, effective and minimally invasive procedure for the treatment of lateral disc herniations and foraminal stenosis of the lower cervical spine and C-T junction, offering the possibility of an accurate decompression with a reduced risk of segmental instability.

Mensuração da curva escoliótica pela técnica de cobb intraobservadores e interobservadores e sua importância clínica

OBJETIVO: Analizar la medicion manual del angulo de Cobb entre profesionales con diferentes experiencias de Ortopedia y Traumatologia y Cirugia de la Columna Vertebral, para ver si hay diferencias en la evaluacion de radiografias de pacientes con escoliosis idiopatica intra e interobservadores, al punto para influir en el tratamiento y el seguimiento de estos pacientes. METODOS: Se utilizaron para este estudio, 22 radiografias simples de la columna toracolumbar, posteroanterior en pacientes con escoliosis idiopatica, y con seguimiento regular en la clinica de consulta externa del Grupo de Columna Vertebral del Hospital San Pablo. Los examenes fueron evaluados por cuatro categorias diferentes de profesionales ortopedistas y cirujanos de la columna vertebral, y se hizo la medicion de las curvas de escoliosis por el metodo de Cobb. Vertebras terminales de las curvas no fueron marcados previamente. Solo las curvas principales se midieron (considerado el mayor angulo de valor) en cada radiografia. La reproducibilidad de las mediciones realizadas por distintos observadores (interobservadores) y entre las dos mediciones de cada observador (intraobservador) fue analizada por el Coeficiente de Correlacion Intraclase (CCI). RESULTADOS: Se observo, en las medidas de los angulos, excelentes concordancias entre las evaluaciones intraobservadores y fueron observadas excelentes concordancias entre las evaluaciones interobservadores, ya que el CCI en todas las situaciones se mantuvo superior a 0,75, lo que representa una excelente reproducibilidad. CONCLUSION: Se concluye en que hay un excelente acuerdo (CCI> 0,75) en la evaluacion de los angulos en las mediciones de las curvas de escoliosis intra e interobservadores. Al mismo tiempo, las mediciones mostraron variaciones de hasta 13,58o intraobservadores, y de hasta 12, 72o ·interobservadores.OBJETIVO: Analizar la medicion manual del angulo de Cobb entre profesionales con diferentes experiencias de Ortopedia y Traumatologia y Cirugia de la Columna Vertebral, para ver si hay diferencias en la evaluacion de radiografias de pacientes con escoliosis idiopatica intra e interobservadores, al punto para influir en el tratamiento y el seguimiento de estos pacientes. METODOS: Se utilizaron para este estudio, 22 radiografias simples de la columna toracolumbar, posteroanterior en pacientes con escoliosis idiopatica, y con seguimiento regular en la clinica de consulta externa del Grupo de Columna Vertebral del Hospital San Pablo. Los examenes fueron evaluados por cuatro categorias diferentes de profesionales ortopedistas y cirujanos de la columna vertebral, y se hizo la medicion de las curvas de escoliosis por el metodo de Cobb. Vertebras terminales de las curvas no fueron marcados previamente. Solo las curvas principales se midieron (considerado el mayor angulo de valor) en cada radiografia. La reproducibilidad de las mediciones realizadas por distintos observadores (interobservadores) y entre las dos mediciones de cada observador (intraobservador) fue analizada por el Coeficiente de Correlacion Intraclase (CCI). RESULTADOS: Se observo, en las medidas de los angulos, excelentes concordancias entre las evaluaciones intraobservadores y fueron observadas excelentes concordancias entre las evaluaciones interobservadores, ya que el CCI en todas las situaciones se mantuvo superior a 0,75, lo que representa una excelente reproducibilidad. CONCLUSION: Se concluye en que hay un excelente acuerdo (CCI> 0,75) en la evaluacion de los angulos en las mediciones de las curvas de escoliosis intra e interobservadores. Al mismo tiempo, las mediciones mostraron variaciones de hasta 13,58o intraobservadores, y de hasta 12, 72o ·interobservadores.

Variações na apresentação fenotípica da escoliose idiopática do adolescente

OBJECTIVE: to discuss which elements, according to literature, are responsible for phenotypic discordance in monozygotic twins. METHODS: the data from a pair of female monozygotic twins were gathered. These data included their age at the time of the diagnosis, type of curve, Cobb angle of the deformity at the time of the initial consultation, dates of the start of treatment and the last follow-up, the apex of the curve and Cobb angle measured from radiological images in lateral view. RESULTS: child I: major lumbar curve to the left, with a Cobb angle of 17° between T11 and L4, and a thoracic curve to the right, with an angle of 14° between T5 and T11. The apices were at the L1-L2 disc and at the T8 vertebra, respectively. One year after the first consultation, there had been significant progression of the deformity, with the lumbar curve of 24° (T11-L4) and the thoracic curve of 23° (T5-T11). Child II: small thoracolumbar deformity to the right, which was confirmed radiographically with a Cobb angle of 18° between T9 and L3. The apex was located at the T12 vertebra. One year later, it was observed that the curve had increased, and the Cobb angle had become 40°. CONCLUSION: notwithstanding the evidence for a genetic origin for the development of scoliosis, it is accepted that other factors influence its manifestation and progression. In literature, the development of this disease has been explained in terms of the structural tissue deficiencies found in specific syndromes and conditions, asymmetrical growth of limbs and trunk, changes in sagittal configuration of the spine and factors relating to the environment, such as nutrition.

Apophyseal ring fracture associated with two levels extruded disc herniation: case report and review of the literature

ABSTRACT Apophyseal ring fractures are rare injuries that may be associated with lumbar disc herniation in young patients. We report a unique case in the literature of a 15-year-old male patient who played football and was admitted at our service complaining of sciatica radiating into the left leg. An apophysial ring injury of L5 vertebral body was observed. This injury caused two extruded disc herniation in adjacent levels. Surgical procedure was indicated after failure of conservative treatment.

Adolescent idiopathic scoliosis without limb weakness: a differential diagnosis of core myopathy?

BackgroundCore myopathies are a clinically and genetically heterogeneous group of congenital myopathies with the common defined histopathological feature of focally reduced oxidative activity on muscle biopsy. It has a low incidence, however, recent articles show broad clinical spectrum, suggesting that the real incidence should be considerably larger than previously described. Due to the important association between scoliosis and paravertebral muscle imbalance, numerous authors study, by biopsy of the spinal rotator muscles, potential changes that may elucidate the etiology of adolescent idiopathic scoliosis.Case presentationTwo patients have been followed at Spine Group of Department of Orthopedics at Federal University of São Paulo, with an initial diagnosis of idiopathic scoliosis. Both patients had clinical and radiological findings compatible with it. The patients authorized, through the Term of Consent, intraoperative biopsy of muscle multifidus from the apex of the thoracic curve on concave and convex sides. After muscle biopsy was performed a histopathological analysis. As regard to the histopathological features: in both patients were identified, the presence of core structures in extensive areas with reduced oxidative activity running along the muscle fiber.ConclusionsAll patients with ‘idiopathic’ scoliosis deserve a careful neurological evaluation, even if they have minimal muscle symptoms in the extremities. The frequent occurrence of scoliosis in patients with CORE Myopathies, supports the thesis that the change in the paravertebral muscle fiber must be the underlying pathogenic factor in scoliosis and may help us understand the onset and progression of curves in patients previously diagnosed with idiopathic scoliosis.

Hystological paraspinal muscle comparison between curve concavity and convexity in adolescent idiopathic scoliosis

Background Several studies have presented morphological, biochemical and histopathological changes in the paraspinal skeletal muscle of patients with adolescent idiopathic scoliosis (AIS). Some abnormalities have been demonstrated such as an increased amount of type I fibers in the concavity and the decreased number of type II in the convexity, an increase in the intracellular concentration of glycogen and lipids, structural changes in the sarcolemma and myotendinous junction, changes in the activity muscle enzyme, an increase in intracellular calcium concentration.

Variations in the phenotypic presentation of adolescent idiopathic scoliosis

OBJECTIVE: to discuss which elements, according to literature, are responsible for phenotypic discordance in monozygotic twins. METHODS: the data from a pair of female monozygotic twins were gathered. These data included their age at the time of the diagnosis, type of curve, Cobb angle of the deformity at the time of the initial consultation, dates of the start of treatment and the last follow-up, the apex of the curve and Cobb angle measured from radiological images in lateral view. RESULTS: child I: major lumbar curve to the left, with a Cobb angle of 17° between T11 and L4, and a thoracic curve to the right, with an angle of 14° between T5 and T11. The apices were at the L1-L2 disc and at the T8 vertebra, respectively. One year after the first consultation, there had been significant progression of the deformity, with the lumbar curve of 24° (T11-L4) and the thoracic curve of 23° (T5-T11). Child II: small thoracolumbar deformity to the right, which was confirmed radiographically with a Cobb angle of 18° between T9 and L3. The apex was located at the T12 vertebra. One year later, it was observed that the curve had increased, and the Cobb angle had become 40°. CONCLUSION: notwithstanding the evidence for a genetic origin for the development of scoliosis, it is accepted that other factors influence its manifestation and progression. In literature, the development of this disease has been explained in terms of the structural tissue deficiencies found in specific syndromes and conditions, asymmetrical growth of limbs and trunk, changes in sagittal configuration of the spine and factors relating to the environment, such as nutrition.

Study of Spine Rotator Muscles in Adolescent Idiopathic Scoliosis Patients

Introduction Several studies have presented morphological, biochemical, and histopathological changes in the paraspinal skeletal muscle of patients with adolescent idiopathic scoliosis (AIS). Some abnormalities, such as an increased amount of type I fibers in the concavity and the decreased number of type II in the convexity, an increase in the intracellular concentration of glycogen and lipids, structural changes in the sarcolemma and myotendinous junction, changes in the activity muscle enzyme, and an increase in intracellular calcium concentration, have been demonstrated. The aim of this article is to evaluate the rotator muscle fibers at the apical vertebra of curves of patients with AIS by histological and immunohistochemical analysis. Materials and Methods Twenty-one patients with AIS submitted to surgical correction between 2010 and 2013 had the spinal rotator muscles biopsied in the concavity and convexity of the apical vertebra of the thoracic curve during the surgery. Serial cryosections were stained with hematoxylin and eosin (HE), Sudan Red, NADH, ATPase, and Cytochrome oxidase. We evaluated muscle atrophy and hypertrophy, fatty proliferation, presence of endomysial and perimysial fibrosis, presence of hyaline fibers, mitochondrial proliferation, muscle necrosis, nuclear centralization, and inflammation. Two independent observers evaluated the sections. Results The average value of the angle of the main thoracic curve was 68 degrees Cobb. For analysis of nonparametric paired variables between the concave and convex sides, McNemar test was used with a significance level of 5%. The results of relative frequency and “p” values showed significant differences in both endomysial and perimysial fibrosis and fatty involution when compared with both sides of the apical vertebra. Conclusion The paraspinal muscles at the apex of the deformity had a higher involvement in the concavity when analyzing the fatty involution and fibrosis. However, both sides showed signs of myopathy, muscle atrophy through areas of necrosis, presence of hyaline fibers, and mitochondrial proliferation.