Emiliano Neves Vialle

Hérnia discal lombar

A hernia discal lombar e o diagnostico mais comum dentre as alteracoes degenerativas da coluna lombar (acomete 2 a 3% da populacao) e a principal causa de cirurgia de coluna na populacao adulta. O quadro clinico tipico inclui lombalgia inicial, seguida de lombociatalgia e, finalmente, de dor ciatica pura. A historia natural da hernia de disco e de resolucao rapida dos sintomas (quatro a seis semanas). O tratamento inicial deve ser conservador, com manejo medicamentoso e fisioterapico, podendo ser acompanhado ou nao por bloqueios percutâneos radiculares. O tratamento cirurgico esta indicado na falha do controle da dor, deficit motor maior que grau 3, dor radicular associada a estenose ossea foraminal ou sindrome de cauda equina, sendo esta ultima uma emergencia medica. Uma tecnica cirurgica refinada, com remocao do fragmento extruso, e preservacao do ligamento amarelo, resolve a sintomatologia da ciatica e reduz a possibilidade de recidiva em longo prazo.

Análise radiológica da degeneração discal experimental em coelhos

OBJECTIVE: To validate radiographic evaluation of a rabbit model for disc degeneration. METHODS: Lumbar intervertebral discs of New Zealand rabbits were stabbed three times with a 18G needle at a limited depth of 5mm, through lateral approach. Serial radiographic images were taken on the early pre-and postoperative periods, and after four, eight and 12 weeks of the procedure, with subsequent analysis of disc height, osteophyte formation, endplate sclerosis, and presence of disc degeneration. The statistical analysis of data was validated by the Kappa coefficient, with a confidence interval (CI) of 95%. RESULTS: A significant reduction of disc space was found on AP X-ray images after 12 postoperative weeks, with Kappa = 0.489 for CI 95% (0.25-0.72) with p < 0.001. X-ray signs of disc degeneration also presented Kappa = 0.63 for CI 95% (0.39-0.86) with p < 0.001. The remaining assessed criteria showed positive results, but with a lower Kappa value. CONCLUSION: The disc degeneration model using rabbits as proposed in this study was shown to be feasible, with positive X-ray correlation between pre- and postoperative images, validating the potential to induce disc degeneration in this animal model for future studies.

LUMBAR DISC HERNIATION.

Lumbar disc herniation is the most common diagnosis among the degenerative abnormalities of the lumbar spine (affecting 2 to 3% of the population), and is the principal cause of spinal surgery among the adult population. The typical clinical picture includes initial lumbalgia, followed by progressive sciatica. The natural history of disc herniation is one of rapid resolution of the symptoms (four to six weeks). The initial treatment should be conservative, managed through medication and physiotherapy, sometimes associated with percutaneous nerve root block. Surgical treatment is indicated if pain control is unsuccessful, if there is a motor deficit greater than grade 3, if there is radicular pain associated with foraminal stenosis, or if cauda equina syndrome is present. The latter represents a medical emergency. A refined surgical technique, with removal of the extruded fragment and preservation of the ligamentum flavum, resolves the sciatic symptoms and reduces the risk of recurrence over the long term.

Meningiomas: estudo epidemiológico e anátomo-patológico de 304 casos

The authors have retrospectively reviewed all tumors of central nervous system (CNS) operated at the most important neurosurgery hospitals of Curitiba in a 5-year period (1990-1994) and found 304 (22.4%) cases of meningioma. Age mean of the patients was 48.5 years, with a range of 3 to 90 years. A marked female preponderance (68.7%) was noted. The most common tumor location was brain (n = 280) and the remaining cases occurred in spinal cord (n = 10), cerebellum (n = 9) and cranial nerves (n = 5). Histologically, there were 294 (96.7%) meningiomas of the classical type, six malignant or anaplastic, three atypical and one papillary. Two hundred and sixty seven classical meningiomas were from the meningotelial subtype, ten psamomatousos, five fibroblastic, five microcystic, five transicional and two angiomatous. The authors conclude that meningiomas are one of the most common group of primary neoplasias of CNS and the definition of malignancy in those tumors is beset by frequent discordance between histologic and biologic features.No presente estudo, foram pesquisados os tumores do sistema nervoso central (SNC) diagnosticados na cidade de Curitiba entre 1990 e 1994. Realizaram-se 2371 biopsias de SNC das quais 1340 casos eram neoplasias primarias. Dentre as neoplasias primarias de SNC 304 (22,6%) eram meningiomas. Duzentos e nove meningiomas ocorreram em mulheres (68,7%) e 95 ocorreram em homens (31,3%). As idades variaram de 3 a 90 anos, com media de 45,8 anos. Duzentos e oitenta meningiomas localizavam-se no cerebro, 10 na medula espinhal, 9 no cerebelo e 5 na emergencia de nervos cranianos. Na classificacao histologica verificou-se que 294 (96,7%) eram do tipo classico, 6 malignos (ou anaplasicos), 3 atipicos e 1 papilar. No grupo dos meningiomas classicos 267 eram meningoteliais, 10 psamomatosos, 5 fibroblasticos, 5 microcisticos, 5 transicionais e 2 angiomatoses. Os autores concluem que as neoplasias meningeas representaram o grupo mais frequente de tumores primarios do SNC e apresentaram caracteristicas epidemiologicas e anatomo-patologicas similares as da literatura mundial, na qual e dada enfase a dificuldade de estabelecer criterios biologicos e histologicos de malignidade neste grupo de tumores.

Anatomical study on the relationship between the dorsal root ganglion and the intervertebral disc in the lumbar spine.

Objective To describe the location of the dorsal root ganglion in relation to the intervertebral disc, including the “triangular” safety zone for minimally invasive surgery in the lumbar spine. Methods Eight adult cadavers were dissected bilaterally in the lumbar region, using a posterolateral approach, so as to expose the L3L4 and L4L5 spaces, thereby obtaining measurements relating to the space between the intervertebral disc, pedicles cranial and caudal to the disc, path of the nerve root, dorsal ganglion and safety triangle. Results The measurements obtained were constant, without significant differences between levels or any laterality. The dorsal ganglion occupied the lateral border of the triangular safety zone in all the specimens analyzed. Conclusion Precise localization of the ganglion shows that the safety margin for minimally invasive procedures is less than what is presented in studies that only involve measurements of the nerve root, thus perhaps explaining the presence of neuropathic pain after some of these procedures.

Influence of mononuclear cell therapy on disc degeneration in rabbits

Objective The objective of this research was to evaluate the influence of autologous mononuclear stem cells injections on histological changes of collagen in the fibrous annulus of the intervertebral disk after experimental injury. Methods 32 New Zealand rabbits were submitted to intervertebral disk puncture, followed by intradiscal injection of mononuclear cells from the iliac crest versus saline injection in the following time periods: two months after the injury (SC2M and SS2M), two weeks (SC2W and SS2W) immediately after injury (SCCP and SSCP), and without inducing degeneration (SCSP and SSSP). Two months after cell therapy, the animals were euthanized and collagen changes in the intervertebral discs were histologically evaluated. Results There were significant differences in ELAF between SS2W and SS2S groups (p = 0.018). This difference was due to an increase in type I collagen in SS2W group (56.7%) compared to SC2S (13.28%). Conclusion Treatment with mononuclear mesenchymal stem cells reduced changes in the type I and III collagen distribution in rabbits AF degenerated discs up to two weeks after the induction of degeneration.

RADIOLOGICAL ANALYSIS OF EXPERIMENTAL DISC DEGENERATION IN RABBITS

Objective: To validate radiographic evaluation of a rabbit model for disc degeneration. Methods: Lumbar intervertebral discs of New Zealand rabbits were stabbed three times with a 18G needle at a limited depth of 5mm, through lateral approach. Serial radiographic images were taken on the early pre-and postoperative periods, and after four, eight and 12 weeks of the procedure, with subsequent analysis of disc height, osteophyte formation, endplate sclerosis, and presence of disc degeneration. The statistical analysis of data was validated by the Kappa coefficient, with a confidence interval (CI) of 95%. Results: A significant reduction of disc space was found on AP X-ray images after 12 postoperative weeks, with Kappa = 0.489 for CI 95% (0.25-0.72) with p < 0.001. X-ray signs of disc degeneration also presented Kappa = 0.63 for CI 95% (0.39-0.86) with p < 0.001. The remaining assessed criteria showed positive results, but with a lower Kappa value. Conclusion: The disc degeneration model using rabbits as proposed in this study was shown to be feasible, with positive X-ray correlation between pre- and postoperative images, validating the potential to induce disc degeneration in this animal model for future studies.

Discectomia lombar transforaminal: estudo quantitativo em cadáveres

OBJETIVO: avaliar a eficacia da discectomia lombar por via transforaminal, de modo quantitativo, em estudo experimental com cadaveres. METODOS: este estudo utilizou cinco cadaveres humanos frescos, submetidos a discectomia pela via de acesso postero-lateral nos niveis L3-L4 e L4-L5, visando remover a maior quantidade de material discal possivel. Uma abordagem anterior complementar, expondo os mesmos discos intervertebrais, permitiu a remocao do material discal remanescente, para posterior comparacao. RESULTADOS: em L3-L4, a remocao transforaminal do disco obteve, em media, 48% do volume total, e em L4-L5, cerca de 38%. CONCLUSAO: apesar de segura e de facil realizacao, a via transforaminal nao e tao eficaz quanto a via anterior na remocao do disco intervertebral.

Influência da artroplastia total de quadril sobre o equilíbrio sagital lombopélvico: avaliação dos parâmetros radiográficos

Objective  To prospectively analyze the radiographic variables of lumbosacral sagittal balance in the pre- and postoperative period of patients submitted to total hip arthroplasty (THA). Methods  A prospective, observational, comparative study that evaluated pre- and postoperative radiographic parameters of 71 patients, submitted to 72 total hip arthroplasties in a 3-year period (2014–2017) for primary coxarthrosis, of whom 28 performed late postoperative control (6 months) through the Surgimap Spine software (Surgimap, New York, NY, USA). Statistical analysis was performed using the Student t-test, the analysis of covariance (ANCOVA) model, and the Kolmogorov-Smirnov test. The data were analyzed using the IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA). A p-value < 0.05 indicated statistical significance. Results  A total of 72 cases, presenting a mean age of 57.9 years old, predominantly females (60.6%) and patients > 50 years old (71.8%). There was an overall decrease in lumbar lordosis values in the immediate postoperative period, without major global changes in late evolution. It was found that patients with a pelvic incidence ≥ 60° tended to have their other sagittal balance parameters elevated. Conclusion  There was no significant difference between the radiographic variables of sagittal lumbopelvic balance in the evaluated periods. Lumbar lordosis and pelvic incidence were the main modifying factors. Improvement of low back pain after THA, without changes in parameters, suggests different pathology mechanisms still to be clarified.

Desenvolvimento de um guia paciente‐específico para fixação de coluna cervical alta

Objective High cervical spine fixation represents a challenge for spine surgeons due to the complex anatomy and the risks of vascular and medullar injury. The recent advances in 3-D printing have unfolded a whole new range of options for these surgeons. Methods In the present study, a guide for the placement of the lateral mass screw in the C1 vertebra was developed using 3-D printing. Eight real-size models of the high cervical spine and their respective screw guides were built using computed tomography (CT) scan images. The guidewires were inserted with the help of the printed guides and then the models were analyzed with the help of CT scan images. Results All of the guidewires in the present study obtained a safe placement in the models, avoiding the superior and inferior articular surfaces, the vertebral foramen, and the vertebral artery. Conclusion The present study demonstrated the efficiency of the guide, a reliable tool for aiding the insertion of guidewires for screws in lateral masses of the C1.