Douglas Kenji Narazaki

Prognostic factors in pathologic fractures secondary to metastatic tumors.

OBJECTIVE Pathological fractures caused by metastases sharply decrease the quality of life and increase mortality rates for patients with malignant neoplasias. Orthopedic advances in osteosynthesis and endoprosthesis have been beneficial in the prevention and treatment of such fractures. The objective of our study was to determine which prognostic factors for pathologic fractures treated in our Service were significant. METHOD This was a retrospective study enrolling 112 patients treated for pathologic fractures secondary to metastatic tumors between April 1994 and December 2004 in our Service. Patients were analyzed according to sex, age, bone metastasis site, visceral metastases, origin of primary tumor, treatment type, serum hemoglobin, and survival. RESULTS The most affected site was the femur (44%), the most frequent primary tumor was breast cancer (25%); the most frequently employed surgical treatment was unconventional endoprosthesis (66%). Sex, age, primary tumor, site affected, non-bone metastasis, and clinical versus surgical treatment variables were not good predictors for survival. The only significant predictor was the type of surgery employed. Patients who received an endoprosthesis presented a worse prognosis (21.6 months) than patients undergoing osteosynthesis (47.8 months). CONCLUSION Patients undergoing osteosynthesis, with a less morbid surgical technique and earlier rehabilitation, had longer survival times than patients who received endoprostheses. Our case series is similar to international ones, where the most frequent primary tumor is breast tumor, followed by tumors of undetermined origin, prostate, and lung tumors.

Spinal cord regeneration: the action of neurotrophin-3 in spinal cord injury in rats

OBJECTIVE For many years, it was believed that medullary regeneration could not occur, although currently there are many trials using neurotrophic factors, stem cells, fetal medulla grafts, peripheral nerve grafts, and antibodies against myelin-associated proteins that demonstrate the existence of the possibility of spinal cord regeneration. The purpose of this study was to investigate the action of neurotrophin-3, a novel neurotrophic factor. METHODS The New York University impactor, a standardized device for delivery of spinal cord injuries was used on 33 rats, which were divided into 2 groups: a control group receiving distilled water intraperitoneally and a treatment group receiving neurotrophin-3 intraperitoneally. RESULTS Using the Basso, Beattie, and Bresnahan scale, the locomotor recovery curve for the neurotrophin-3 treated group was superior to that of the control group (P < 0.05); the administration of neurotrophin-3 was associated with the absence of deaths, while the control group showed a 28.5% (P = 0.026) mortality rate. Other parameters (hematuria rate and histological analysis) showed no significant differences. CONCLUSIONS Based on these results, it appears that a strong relationship exists between the use of neurotrophin-3 in rats with spinal cord injury and better functional recovery.

Estudo anatômico do trajeto da artéria vertebral na coluna cervical inferior humana

SUMMARY The increasing use of new techniques and materials for surgical treatment of lower cervical spine conditions has come along with an increasing concern regarding potential complications that might occur. The transpedicular fixation technique, frequently used in other spine levels, is used on the cervical spine, while providing more stability than other techniques, it may cause serious complications such as vertebral artery injury, nervous root injury, or facet joint in- juries. However, the C7 vertebra is considered safer for performing this procedure, since, in the vast majority of people, according to available anatomical studies, does not have a vertebral artery passing through its cross-sectional foramen, because that vessel is inserted into such structure only on C6 vertebra. As there are only imaging studies available today for assessing the path of this artery and its anatomical variables, we conducted this anatomical study by dissecting 40 cadavers vertebral arteries in order to assess the incidence of anatomical variations. We found 3 cases where the vertebral artery penetrated into cross-sectional foramen at C7 (7.5%), a fact that enhances the risk of an undesired injury with a transpedicular technique at this level. The other remaining specimens showed a usual anatomy.

Tratamento da tuberculose da coluna vertebral: conservador ou cirúrgico?

SUMMARY Much has evolved since Percivall Potts first description of vertebral tuberculosis. However, there still is much controversy regarding the best approaches to prevent deformities. The objectives of this study were to evaluate the clinical and X-ray characteristics of patients with vertebral tuberculosis and to compare the conservative treat- ment alone to the surgical one associated with antibiotic therapy, particularly regarding residual deformity and neurological deficit. A retrospective evaluation of baseline and end-point X-ray studies and of the medical files was performed. The neurological status was evaluated by using the ASIA scale and the deformities were measured using the Cobb method. Thirty-eight patients were evaluated: 11 were surgically treated and 27 received only antibiotics. Fifteen patients presenting neurological deficit showed improvement regardless of the treatment method employed. The mean focal and regional thoracic kyphosis at baseline was 48.8o and 47.86o, respectively. An increased incidence of thoracic deformity was found, also being the most affected segment, from 6.3o focal and 9.8o regional after 5 years. The type of treatment has not interfered on kyphosis pro- gression. Patients below the age of 15 and with kyphosis above 30o had worse prognosis regarding deformity progression.

Giant-Cell Tumor of the Tendon Sheath in the Upper Cervical Spine

Introduction Giant-cell tumor of the tendon sheath (GCTTS) is part of the group of synovial tumors that can affect joints, bursas, and tendon sheaths. It is rare for GCTTS to involve the spine. When present, it is more common in the lower cervical spine. In the literature, there are only four cases described in the upper cervical spine. In this report, we describe a rare case of GCTTS in the upper cervical spine, which was treated with en-bloc marginal resection.

Avanços no uso de células-tronco em ortopedia

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.

Laminectomy without instrumentation for surgical treatment of metastatic spinal cord compression

OBJETIVO: Analisar o desenvolvimento de complicacoes mecânicas como resultado da descompressao medular ou da cauda equina de pacientes com doenca metastatica da coluna vertebral atraves de laminectomia ou laminoartrectomia sem fixacao. METODOS: Estudamos todos os prontuarios de pacientes que foram submetidos a descompressao da coluna vertebral por laminectomia sem fixacao. A descompressao foi indicada por compressao medular ou da cauda equina por tumores solidos em doenca metastatica. Os pacientes foram avaliados quanto ao desenvolvimento de instabilidade mecânica pos-operatoria atraves da comparacao dos exames radiologicos pre-operatorios com o ultimo exame disponivel no prontuario. Nessas imagens, avaliamos o surgimento de deformidade nova no plano sagital ou coronal e deformidade translacional. Consideramos como deformidade nova, sinais de deformidade maior ou igual a 5o no plano coronal ou sagital e sinais de aumento da translacao vertebral maior ou igual a 3 mm. RESULTADOS: Nenhum paciente evoluiu com instabilidade radiologica no periodo avaliado com tempo medio de seguimento de 163,24 dias (3-663). A taxa de complicacoes encontrada em nossa amostra nao foi superior a encontrada na literatura. CONCLUSAO: A laminectomia isolada em um ou mais niveis e um procedimento seguro para tratamento da compressao medular metastatica quando ha julgamento de que a coluna e estavel no momento da indicacao da cirurgia.RESUMO OBJETIVO: Esse estudo tem por objetivo analisar os resultados da descompressao medular ou da cauda equina de doentes com doenca metastatica da coluna vertebral atraves de laminectomia ou laminoartrectomia sem fixacao quanto ao desenvolvimento de complicacoes mecânicas METODOS: Estudamos todos prontuarios de doentes que foram submetidos a descompressao da coluna vertebral por laminectomia sem fixacao no Instituto do Câncer de Sao Paulo no periodo entre fevereiro de 2009 a janeiro de 2013. A descompressao foi indicada por compressao medular ou da cauda equina por tumores solidos em doenca metastatica. Os doentes foram avaliados quanto ao desenvolvimento de instabilidade mecânica pos-operatoria atraves da comparacao dos exames radiologicos pre-operatorios com o ultimo exame disponivel no prontuario. Nestas imagens, avaliamos o surgimento de deformidade nova no plano sagital ou coronal e deformidade translacional. Consideramos como deformidade nova, sinais de deformidade no plano coronal ou sagital maior ou igual a 5o e sinais de aumento na translacao vertebral maior ou igual a 3 mm. RESULTADOS: Nenhum doente evoluiu com instabilidade radiologica no periodo avaliado com tempo medio de seguimento de 163,24 dias (3-663). A taxa de complicacoes encontrada em nossa amostra nao foi superior a encontrada na literatura. CONCLUSAO: A laminectomia isolada em um ou mais niveis e um procedimento seguro para tratamento da compressao medular metastatica quando ha julgamento de que a coluna e estavel no momento da indicacao da cirurgia. Descritores: compressao medular, laminectomia, instrumentacao, estabilidade, complicacoes.

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.

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

ABSTRACT 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.

MINIMALLY INVASIVE EXTREME LATERAL APPROACH IN SPINAL LUMBAR METASTASIS

ABSTRACT Introduction The extreme lateral approach has been widely used for the treatment of degenerative diseases. The objective of this study is to present a minimally invasive extreme lateral approach for the treatment of metastatic lesions in the lumbar spine without the use of the evoked potential exam (MEP). Methods Two patients with spinal metastases and indication for surgery via the anterior approach were treated in a cancer referral center in Brazil. They were placed in right lateral decubitus, and an oblique incision was made, exposing the psoas muscle. The anterior approach permitted the release of the psoas muscle from vertebral body and disc, without the need for MEP. Conclusions When cancer cure is no longer possible, a minimally invasive extreme lateral approach to treat tumor metastases in the lumbar spine is a viable option, with short hospitalization time and low morbidity. The dislocation of the psoas muscle avoids the use of the transpsoas approach, which requires MEP equipment and a trained physician. Clinical studies are needed to extend these benefits to oncological patients who have treatment options for their primary disease. Level of Evidence IV; Case series.