Guilherme Zanini Rocha

Civilian Gunshot Wound to the Spine: 87 Cases

Introduction Penetrating spinal cord injury (SCI) by gunshot is relatively common in Brazil, and the literature available is scarce. This study aims to report the experience of a level I trauma center, exploring epidemiological data, clinical features, treatment, and outcomes of victims of gunshot wound to the spine. Material and Methods A retrospective study was performed and included all victims of gunshot wound to the spine at João XXIII Hospital from April 2011 to March 2014 (36-month period). The epidemiological profile, topography of the injury, neurological status, treatment, and in-hospital morbidity and mortality are reported. Statistical analysis was performed on Epi Info 7.0 with Fisher exact test. Correlation with the current literature was conducted. Results A total of 1,088 patients were admitted with blunt and penetrating spinal injury in the 36 months evaluated. A total of 87 cases were gunshot wounds (8% of the 1,088 cases). A majority of the patients were men (93.1%) and young (76.1% are under 30 years). Topographically, 48% affected the cervical spine, followed by 32% in the thoracic spine. The motor status had a dichotomous presentation, with complete neurological deficit (ASIA A, 58.6%) and no neurological deficit (ASIA E, 27.6%). Incomplete neurological deficits represented a small number of cases. The vertebral instability, defined as the presence of acute or delayed deformity, was unusual (three cases, 3.4%). Almost 50% (n = 44) of the patients had isolated spinal trauma and the remaining presented with associated traumas. Thoracic trauma was the most prevalent, followed by abdominal and facial injury. Only 10 patients (11.5%) required surgical treatment: laminectomy with bullet removal in 7 cases and instrumented fixation in the remaining 3. Infection was present in five cases: four postoperative infections and one in a patient with nonoperative management. Surgical treatment was associated with a 50-fold increase risk of infection (p = 0.0004). CSF fistula was observed in only one case after surgical treatment and because of the rarity of the event, a statistical analysis could not be performed. Overall mortality was 14.9% (13 patients) and was more common in patients with cervical lesions (10 patients). Associated trauma was present in 70% of the patients who died, but did not acquire statistical significance (p = 0.1) with mortality risk. Conclusion Gunshot wound to the spine is common in our population, affecting especially young men, associated with neurological deficit in two-thirds of the patients. Instability is a rare event in these patients (3.4%) and surgical treatment was associated with a significant risk of infection.

Powdered Vancomycin versus Povidone Iodine in Spinal Fusion Deep Infection Prophylaxis: A Comparative Study in Trauma Patients

Introduction Incidence of deep surgical site infection (SSI) in spinal fusion varies from 0.3 to 20% according to the international literature. Instrumentation is a well-established risk factor for this complication. Higher morbidity and mortality rates and increased cost of treatment up to fourfold are associated with this complication. Prophylaxis with intravenous antibiotic is consensual, but few studies have evaluated the efficacy of topical agents in the surgical site with prophylactic intent. Irrigation with 3.5% povidone iodine and application of lyophilized vancomycin powder in surgical site have shown benefit, but there are no studies comparing these two methods. A comparative study using topic povidone iodine and vancomycin powder was conducted to reduce this knowledge gap. Patients and Methods The medical records of 439 patients who underwent spinal fusion with instrumentation for traumatic spinal lesion treatment were analyzed. Procedures were consecutively performed at Joao XXIII Hospital (level 1 trauma center). Patients were combined in the following two groups, according to the prophylactic agent used: Povidone iodine (PVPI) historical series (n = 181), performed from January 2009 to April 2012 and vancomycin (VANCO) cohort study (n = 239) conducted from May 2012 to December 2013. The surgical site in PVPI group was irrigated with 5% topic iodine solution during 3 minutes, before deep lumbar fascia closure. One gram of vancomycin powder was applied directly to the hardware in VANCO group. Both the groups received 2 g of intravenous cefazolin 30 minutes before surgery and had surgical site exhaustively washed with saline 0.9%, before closure in PVPI group and prior to apply vancomycin powder in VANCO group. Results No difference according to mean age, sex, and lesion level distribution (cervical × thoracolumbar) was observed between the two groups. Number of levels instrumented, coexisting infection, and surgical access were not compared because of a lack of information in medical records, especially those from PVPI series. SSI rate was lower in VANCO group (1.67%) compared with PVPI group (6.62%), this difference was statistically significant (chi-square test with Yates correction = 5.618; p = 0.018; IC 0.069–0.824). Conclusion The application of 1 g vancomycin powder in surgical site was superior to irrigation with 5% povidone iodine in the prophylaxis of deep surgical site infection. These results are valid for patients with spinal trauma who underwent instrumented fusion. Variability in surgical team, difference in the interval admission surgery (patients recently are being operated earlier), and number of levels instrumented are possible bias to this study. The low cost and easy applicability of topic prophylactic measures justify new studies with better statistical power (multicenter and randomized).

Project BHTRM: new strategy of monitoring and acting in spinal cord injuries in the city of Belo Horizonte

Objetivo: O Projeto BHTRM tem como objetivo estudar a epidemiologia do trauma raquimedular (TRM) na cidade de Belo Horizonte e fornecer meios de monitoramento desses pacientes. Método: Para avaliação da eficácia e resolubilidade do projeto, comparamos dois grupos de pacientes atendidos no Hospital João XXIII, em dois períodos distintos. Grupo 1: de 1o de maio de 2011 a 31 de julho de 2011, meses de início do projeto e Grupo 2: de 1º de dezembro de 2012 a 28 de fevereiro de 2013. Resultados: Apesar do aumento de 34% no número de pacientes atendidos, observa-se uma queda de 30% na média de dias de internação, assim como a diminuição na média de dias de espera para cirurgia dos pacientes que necessitavam tratamento cirúrgico, de 10,9 para 4,84, uma queda de 56%. Conclusão: O Projeto BHTRM é uma ferramenta útil em gestão de saúde pública. Otimiza o tratamento do paciente com trauma raquimedular, diminuindo o tempo entre internação e cirurgia. Oferece acompanhamento ativo do paciente assegurando melhor atendimento e inserção dos cuidados de reabilitação.

Proyecto BHTRM: nueva estrategia de monitoreo y actuación en las lesiones de la médula espinal en la ciudad de Belo Horizonte

Objetivo: O Projeto BHTRM tem como objetivo estudar a epidemiologia do trauma raquimedular (TRM) na cidade de Belo Horizonte e fornecer meios de monitoramento desses pacientes. Método: Para avaliação da eficácia e resolubilidade do projeto, comparamos dois grupos de pacientes atendidos no Hospital João XXIII, em dois períodos distintos. Grupo 1: de 1o de maio de 2011 a 31 de julho de 2011, meses de início do projeto e Grupo 2: de 1º de dezembro de 2012 a 28 de fevereiro de 2013. Resultados: Apesar do aumento de 34% no número de pacientes atendidos, observa-se uma queda de 30% na média de dias de internação, assim como a diminuição na média de dias de espera para cirurgia dos pacientes que necessitavam tratamento cirúrgico, de 10,9 para 4,84, uma queda de 56%. Conclusão: O Projeto BHTRM é uma ferramenta útil em gestão de saúde pública. Otimiza o tratamento do paciente com trauma raquimedular, diminuindo o tempo entre internação e cirurgia. Oferece acompanhamento ativo do paciente assegurando melhor atendimento e inserção dos cuidados de reabilitação.

Head support for spinal surgery: technical note

Se describe un soporte de cabeza para la cirugia de columna vertebral que permite la colocacion de la cabeza del paciente en alineacion neutra con el cuerpo y el control de la posicion de ojos, boca, nariz y tubo oro-traqueal, evitando los danos causados por el posicionamiento incorrecto durante la cirugia.

Suporte de cabeça para cirurgia da coluna vertebral: nota técnica

Se describe un soporte de cabeza para la cirugia de columna vertebral que permite la colocacion de la cabeza del paciente en alineacion neutra con el cuerpo y el control de la posicion de ojos, boca, nariz y tubo oro-traqueal, evitando los danos causados por el posicionamiento incorrecto durante la cirugia.

Soporte de cabeza para cirúgia de columna vertebral: nota técnica

Se describe un soporte de cabeza para la cirugia de columna vertebral que permite la colocacion de la cabeza del paciente en alineacion neutra con el cuerpo y el control de la posicion de ojos, boca, nariz y tubo oro-traqueal, evitando los danos causados por el posicionamiento incorrecto durante la cirugia.

Evaluation of the trajectory of the bicortical screws in relation to the internal carotid artery, in fixation by the harms and melcher technique: an experimental study in cadavers

OBJECTIVE: The objective of this study is to study the relationship between bicortical screws and the internal carotid artery, in anatomical body parts, in screw fixation by the Harms and Melcher technique. METHODS: Our sample consisted of five cadavers. RESULTS: The results were as follows: the average shortest distance between the outlet of the screw and the medial edge of the right internal carotid artery was 11.55 mm (range 10.05 to 14.23 mm), while on the left side, the average was 7.50 mm (ranging from 2.75 to 12.42 mm). The average shortest distance between the posterior edge of the internal carotid artery and the anterior cortical C1 lateral mass on the right was 4.24 mm (ranging from 2.08 to 7.48 mm), while the left side, the average was 2.98 mm (ranging from 1.83 to 3.83 mm). CONCLUSION: The results are consistent with similar studies in the literature that emphasize the need for a careful assessment of images of anatomical position of the internal carotid artery prior to the use of bicortical screws in the C1 lateral mass by posterior access.OBJETIVO: O objetivo deste trabalho e estudar, em pecas anatomicas; a relacao entre os parafusos bicorticais pela tecnica de Harms e Melcher e a arteria carotida interna. METODOS: Nossa amostra consiste em cinco cadaveres. RESULTADOS: Os resultados encontrados foram: a media da menor distância entre o orificio de saida do parafuso e a borda medial da arteria carotida interna direita foi de 11,55 mm (com variacao de 10,05 a 14,23 mm), enquanto do lado esquerdo a media foi de 7,50 mm (variando de 2,75 a 12,42 mm). A media da menor distância entre a borda posterior da arteria carotida interna e a cortical anterior da massa lateral de C1 a direita foi de 4,24 mm (variando de 2,08 a 7,48 mm), enquanto do lado esquerdo a media obtida foi de 2,98 mm (com variacao de 1,83 a 3,83 mm). CONCLUSAO: Os resultados encontrados estao de acordo com os estudos similares existentes na literatura que enfatizam a necessidade de uma avaliacao imaginologica criteriosa da posicao anatomica da arteria carotida interna antes da utilizacao de parafusos bicorticais na massa lateral de C1 por via posterior.

Evaluación de la trayectoria de los tornillos bicorticales en la técnica de harms y melcher en relación con la arteria carótida interna: un estudio experimental en cadáveres

OBJECTIVE: The objective of this study is to study the relationship between bicortical screws and the internal carotid artery, in anatomical body parts, in screw fixation by the Harms and Melcher technique. METHODS: Our sample consisted of five cadavers. RESULTS: The results were as follows: the average shortest distance between the outlet of the screw and the medial edge of the right internal carotid artery was 11.55 mm (range 10.05 to 14.23 mm), while on the left side, the average was 7.50 mm (ranging from 2.75 to 12.42 mm). The average shortest distance between the posterior edge of the internal carotid artery and the anterior cortical C1 lateral mass on the right was 4.24 mm (ranging from 2.08 to 7.48 mm), while the left side, the average was 2.98 mm (ranging from 1.83 to 3.83 mm). CONCLUSION: The results are consistent with similar studies in the literature that emphasize the need for a careful assessment of images of anatomical position of the internal carotid artery prior to the use of bicortical screws in the C1 lateral mass by posterior access.OBJETIVO: O objetivo deste trabalho e estudar, em pecas anatomicas; a relacao entre os parafusos bicorticais pela tecnica de Harms e Melcher e a arteria carotida interna. METODOS: Nossa amostra consiste em cinco cadaveres. RESULTADOS: Os resultados encontrados foram: a media da menor distância entre o orificio de saida do parafuso e a borda medial da arteria carotida interna direita foi de 11,55 mm (com variacao de 10,05 a 14,23 mm), enquanto do lado esquerdo a media foi de 7,50 mm (variando de 2,75 a 12,42 mm). A media da menor distância entre a borda posterior da arteria carotida interna e a cortical anterior da massa lateral de C1 a direita foi de 4,24 mm (variando de 2,08 a 7,48 mm), enquanto do lado esquerdo a media obtida foi de 2,98 mm (com variacao de 1,83 a 3,83 mm). CONCLUSAO: Os resultados encontrados estao de acordo com os estudos similares existentes na literatura que enfatizam a necessidade de uma avaliacao imaginologica criteriosa da posicao anatomica da arteria carotida interna antes da utilizacao de parafusos bicorticais na massa lateral de C1 por via posterior.

Avaliação da trajetória dos parafusos bicorticais pela técnica de harms e melcher em relação à artéria carótida interna: estudo experimental em cadáveres

OBJECTIVE: The objective of this study is to study the relationship between bicortical screws and the internal carotid artery, in anatomical body parts, in screw fixation by the Harms and Melcher technique. METHODS: Our sample consisted of five cadavers. RESULTS: The results were as follows: the average shortest distance between the outlet of the screw and the medial edge of the right internal carotid artery was 11.55 mm (range 10.05 to 14.23 mm), while on the left side, the average was 7.50 mm (ranging from 2.75 to 12.42 mm). The average shortest distance between the posterior edge of the internal carotid artery and the anterior cortical C1 lateral mass on the right was 4.24 mm (ranging from 2.08 to 7.48 mm), while the left side, the average was 2.98 mm (ranging from 1.83 to 3.83 mm). CONCLUSION: The results are consistent with similar studies in the literature that emphasize the need for a careful assessment of images of anatomical position of the internal carotid artery prior to the use of bicortical screws in the C1 lateral mass by posterior access.OBJETIVO: O objetivo deste trabalho e estudar, em pecas anatomicas; a relacao entre os parafusos bicorticais pela tecnica de Harms e Melcher e a arteria carotida interna. METODOS: Nossa amostra consiste em cinco cadaveres. RESULTADOS: Os resultados encontrados foram: a media da menor distância entre o orificio de saida do parafuso e a borda medial da arteria carotida interna direita foi de 11,55 mm (com variacao de 10,05 a 14,23 mm), enquanto do lado esquerdo a media foi de 7,50 mm (variando de 2,75 a 12,42 mm). A media da menor distância entre a borda posterior da arteria carotida interna e a cortical anterior da massa lateral de C1 a direita foi de 4,24 mm (variando de 2,08 a 7,48 mm), enquanto do lado esquerdo a media obtida foi de 2,98 mm (com variacao de 1,83 a 3,83 mm). CONCLUSAO: Os resultados encontrados estao de acordo com os estudos similares existentes na literatura que enfatizam a necessidade de uma avaliacao imaginologica criteriosa da posicao anatomica da arteria carotida interna antes da utilizacao de parafusos bicorticais na massa lateral de C1 por via posterior.