Maria Fernanda Silber Caffaro

Escoliose idiopática do adolescente (eia): perfil clínico e radiográfico da lista de espera para tratamento cirúrgico em hospital terciário de alta complexidade do Sistema Público de Saúde Brasileiro

OBJETIVO: Descrever atraves de estudo coorte transversal descritivo, os parâmetros clinicos e radiograficos dos pacientes portadores de escoliose idiopatica do adolescente (EIA) que estao na lista de espera para tratamento cirurgico eletivo em hospital universitario terciario de alta complexidade do Sistema Publico de Saude Brasileiro (SUS). METODOS: Para definir o perfil clinico e radiografico, coletamos os dados referentes a menarca, sexo, idade e dados radiograficos (sinal de Risser, ângulo de Cobb, Nash-Moe, classificacao de King e classificacao de Lenke), no momento da indicacao do procedimento cirurgico, e tempo de espera para a cirurgia. RESULTADOS: Dos 51 pacientes, 42 eram do sexo feminino e 9 do sexo masculino, com idade media de 15,53 anos (10-46 anos). Todos os pacientes apresentavam idade entre 10 e 17 anos no momento do diagnostico. Em media a espera foi de 25,41 meses (variando de 2 a 180 meses). A idade media no momento da menarca foi 12,13 anos (11-14 anos), 10 pacientes nao apresentavam menarca, e 23 pacientes esqueleticamente imaturas (Risser zero a tres). O valor medio da curva principal foi 60,4 graus (variando de 40 a 120 graus). Os tipos de curva mais frequentes foram o tipo King III com 19 pacientes e Lenke 1BN com 11 pacientes. CONCLUSAO: Em funcao da morbidade definida na literatura nos portadores de EIA nao tratados e do tamanho da amostra, justifica-se medidas em termos de politica publica para o tratamento destes pacientes no nosso meio.

Can the interpedicular distance reliably assess the severity of thoracolumbar burst fractures

Study Design. Retrospective analysis of 260 patients with acute spine fractures treated at a tertiary trauma center from 1989 to 2009. Objective. To correlate the Interpedicular distance (IPD) to the percentage of narrowing of the spinal canal and to the presence of neurological deficit and laminar fracture in thoracolumbar burst fractures. Summary of Background Data. Several reports use radiographic findings such as severity of vertebrae collapse, comminution of the vertebral body, and grade of localized kyphosis to determine the severity of spinal traumas and establish appropriate management. However, the importance of the IPD in burst fractures has rarely been mentioned, and no report specifically describes the correlation between an increased IPD and the severity of the lesion or a higher occurrence of lamina fractures. Methods. Plain radiographs of 260 patients with acute thoracolumbar burst fractures were studied. The percentage of widening between the pedicles of the fractured vertebra (IPD) was established by comparing this distance with that of the vertebrae immediately above and below. Data concerning neurological status, percentage of narrowing of the spinal canal, and the presence of laminar fracture were correlated to the IPD. Results. A significant correlation between IPD and the percentage of narrowing of the spinal canal was found (r = 0.39; t = 6.78; P = 0.00). IPD was significantly increased in patients with neurological deficit (24.7% ± 12.6%) and in patients with lamina fractures (24.6% ± 16.2%). Conclusion. IPD measured from plain radiographs proved to be a reliable instrument to assess narrowing of the spinal canal, neurological deficits, and laminar fractures.

FRATURA TORACOLOMBAR TIPO EXPLOSÃO: CLASSIFICAÇÃO DE MCCORMACK E FALHA DE INSTRUMENTAÇÃO POSTERIOR

OBJECTIVES: To assess the relationship between sagittal collapse, implant failure and load sharing classification of patients suffering a thoracolumbar burst fracture treated with posterior instrumentation. METHODS: Retrospective review of radiographs and medical records of 26 patients operated on between January 1990 and December 2006. Kyphotic worsening (Cobb), neurologic dysfunction (Frankel) and the failure of surgical treatment (implant breaking or loosening) were studied. RESULTS: No relationship was found between kyphotic deformity and higher scores in the load sharing classification (r = 0,221; P = 0,322). No relationship was found between implant failure and this classification. (p = 0.85). CONCLUSION: Our findings suggest that this classification is not applicable in patients with an arthrodesis larger than one unit above and below the fracture.

Análise radiológica comparativa entre espondilodiscite tuberculosa e inespecífica

OBJETIVO: comparar las imagenes radiologicas de la espondilodiscitis tuberculosis y la no especifica. METODOS: estudio retrospectivo mediante la revision de registros medicos y los estudios radiologicos de los pacientes con discitis inespecifica y especifica por Mycobacterium tuberculosis (mal de Pott), que se sometieron a tratamiento, en el Grupo de la Columna Vertebral del Departamento de Ortopedia y Traumatologia en el periodo de 1989 a agosto de 2009. RESULTADOS: se analizaron 48 historias clinicas y archivos de imagen de los pacientes con discitis tuberculosis (Tbc) y 31 pacientes con discitis no especifica. De los pacientes con mal de Pott, el 54% eran del sexo masculino. La edad oscilo entre 3 a 87 anos con una media de 44,1 anos. En los pacientes con discitis no especifica, el 68% eran del sexo masculino, la edad oscilo entre 2 meses a 76 anos. El patron radiologico predominante en discitis tuberculosis fue el acunamiento del cuerpo vertebral anterior en 88,2% de los casos. En los pacientes con discitis no especifica, la disminucion de espacio en el disco fue el hallazgo mas frecuente, que se encuentra en el 87% de los casos. CONCLUSION: la discitis tuberculosis presento en esta serie un mayor prevalencia de cambios estructurales importantes en la columna vertebral, como la cifosis y la reaccion paravertebral en relacion a la discitis no especifica. Por lo cuanto, la prevalencia de infeccion no especifica fue mayor en pacientes pediatricos, la discitis tuberculosis tubo una prevalencia progresivamente mayor con el aumento de la edad de los pacientes.OBJECTIVE: to compare the radiological images of tuberculosis and nonspecific spondylodiscitis. METHODS: a retrospective study by reviewing medical records and imaging studies of patients, with nonspecific and specific discitis by Mycobacterium tuberculosis (Pott disease), who underwent treatment at the Spine Group, Department of Orthopedics and Traumatology in the period from 1989 to August 2009. RESULTS: we analyzed 48 medical records and image files of patients with Tbcs discitis and 31 patients with non-specific discitis. Of the patients with Pott disease, 54% were male, and the age ranged from 3 to 87 with a mean of 44.1 years. In patients with non-specific discitis, 68% were male, and the age ranged from 2 months to 76 years. The predominant radiographic pattern on tuberculosis discitis was the wedging of the anterior vertebral body in 88.2% of the cases. In patients with non-specific discitis, decreased disc space was the most prevalent finding, found in 87% of the cases. CONCLUSION: Tbcs discitis has presented more structural changes in the spine, such as kyphosis, and paravertebral reaction in relation to non-specific discitis. Led to fewer and not as severe vertebral abnormalities generally progressed well with only conservative treatment. While the prevalence of non-specific infection was higher in pediatric patients, Tbcs discitis was more prevalent with the increase of the age of patients.

Escoliose idiopática do adolescente King II (Lenke B e C): predição da descompensação coronal

Objective: To identify the predictive radiographic signs of trunk decompensation in King II AIS patients (Lenke B and C) who underwent selective thoracic arthrodesis with third generation material. Methods. A retrospective analysis was carried out of the preoperative radiographies, and those from the most recent follow-up, of twenty-two patients. The sample was divided in two groups: patients compensated after treatment (n=18) and patients who presented coronal decompensation (n=4). The two groups were compared to analyze possible postoperative predictive radiographic criteria of trunk decompensation. Results: The patients who developed coronal trunk decompensation showed a greater angular value, greater apical vertebral translation (AVT) and rotation (AVR) of the lumbar curve, and greater L4 obliquity in relation to the pelvis. Furthermore, the relationship between the thoracic curve AVT and AVR, for the angular value criteria, was smaller than for the patients with good evolution. Conclusions: Compensatory lumbar curves with similar angular value to the main thoracic curve, with greater translation and rotation of the apical vertebra and greater L4 slope, have a high probability of trunk decompensation after this surgical treatment. The small number of decompensated patients did not enable any predictive values of these variables to be defined.

Fratura na coluna vertebral por mieloma múltiplo: correlação entre sobrevida e índices de Tomita e Tokuhashi

OBJETIVO: o mieloma multiplo (MM) e a neoplasia ossea primaria mais frequente na coluna vertebral. Em razao da grande morbi-mortalidade destas lesoes, discute-se qual o melhor tratamento nestes pacientes. Na pratica, observamos similaridade das opcoes de tratamento entre os pacientes portadores de metastases osseas e MM. Os indices de sobrevida de Tomita e Tokuhashi sao utilizados com o intuito de auxiliar na escolha do tratamento nos portadores de metastases. Faltam estudos sobre a aplicabilidade destes indices em pacientes portadores de MM. Neste trabalho vamos avaliar a aplicabilidade dos indices de Tomita e Tokuhashi nos pacientes portadores de MM e lesao vertebral. METODOS: estudo retrospectivo mediante avaliacao de prontuarios e radiografias de portadores de MM por meio da aplicacao dos criterios de Tomita e Tokuhashi. RESULTADOS: em um ano, 19 (63,3%) estavam vivos, em dois anos 13 (43,3%) e em cinco anos quatro (13,3%) pacientes estavam vivos. Nao houve correlacao entre os indices (Tomita e Tokuhashi) e a taxa de sobrevida nestes pacientes (p= 0,2255). CONCLUSAO: ha necessidade de adaptacao dos indices de Tomita e Tokuhashi para apresentarem aplicabilidade nos portadores de MM na coluna.

Classificação de McCormack e colapso sagital na fratura toracolombar explosão

The increasing incidence of thoracolumbar kyphosis after conservative treatment of burst fractures is a complication reported by several authors. We performed a retrospective study on a consecutive series of 33 patients with thoracolumbar burst fractures treated with cast or brace immobilization between 1992 and 2004 to check for a correlation between thoracolumbar kyphosis and Load Sharing Classification, which provides fracture severity scores according to body comminution, vertebral body fragments displacement and the amount of kyphosis correction delivered after treatment. After an average of 30 months of follow-up we found a correlation between Load Sharing Classification scores (also known as McCormacks Classification), and the sagittal kyphotic deformity on these patients (p<0.05;r=0.65). Despite of being described for assessing sagittal deformity after surgical treatment, the applicability of this Classification can be considered for patients with thoracolumbar burst fractures submitted to conservative treatment.

Predictors for Postoperative Shoulder Balance in Lenke 1 Adolescent Idiopathic Scoliosis: A Prospective Cohort Study.

STUDY DESIGN Prospective cohort. OBJECTIVES To determine the predictors of the shoulder balance after main thoracic (MT) fusion in patients with Lenke 1 adolescent idiopathic scoliosis (AIS). Imbalanced shoulders are a major cause of dissatisfaction in AIS patients. In Lenke 1 curves, MT curve fusion is supposed to lead to spontaneous correction of the proximal thoracic (PT) curve and thereby promote shoulder balance. However, this is not always observed. METHODS Fifty-two Lenke 1 AIS patients who underwent MT fusion by a posterior approach were prospectively evaluated preoperatively, immediately postoperatively and two years after the surgical procedure. The shoulder balance was determined using the biacromial angle. The clinical results were examined for their correlation with several radiographic measurements. RESULTS Spontaneous correction of the PT Cobb angle after MT fusion was noted in 52% of cases, similar to that observed on preoperative bending films. A total of 51% of patients had unbalanced shoulders before surgery (right side higher). Two years after surgery, 30.77% showed unbalanced shoulders (p <.001). However, 17.1% of patients presented with a higher left shoulder, a reversion of the initial deformity. This phenomenon was more common among the patients with mild or no shoulder asymmetry (biacromial angle inferior to 1°) before surgery (p < .001). It was also determined that for each degree measured for the clavicle angle, there was an elevation of 0.14° for the ipsilateral shoulder. CONCLUSIONS In Lenke 1 cases with higher right shoulder and absence of abnormalities in the sagittal plane view, the correction of the main right thoracic curve could be enough to balance the shoulders. No correlation was found between shoulder balance and the amount of correction of the PT and MT curves.

Kyphosis in fractures: evaluation of digital measuring

Objetivo: Evaluar la fiabilidad y reproducibilidad manual y digital de los cinco metodos de medicion de la deformidad (cifosis) en las fracturas toracolumbares por explosion. Metodos: Fueron evaluadas 90 imagenes de tomografia computadorizada y, en cada caso, se midio el valor angular de la deformidad cifotica, tanto en forma manual como digital, mediante los cinco metodos mas relevantes descritos en la literatura actual. Se midieron de nuevo 20 examenes para valorar el error intra-evaluador. Resultados: Los resultados muestran que los cinco metodos son muy fiables y reproducibles en forma digital, con un error estimado cercano o inferior al indicado en el analisis de error intra-evaluador, siendo que el metodo de Cobb presento la mayor concordancia (96%) y el indice sagital, la concordancia mas baja (75%). Tambien se sugiere que la medicion digital tiene fiabilidad superior a la manual. Conclusion: Todos los metodos testados son altamente fiables y reproducibles en forma digital.

Fratura toracolombar do tipo explosão: correlação entre a cifose residual e função após o tratamento cirúrgico

OBJETIVO: Avaliar a correlacao entre a cifose pos-traumatica em portadores de fratura toracolombar explosao, submetidos a tratamento cirurgico e resultado funcional do tratamento. METODOS: Realizado estudo retrospectivo em 27 pacientes com fratura toracolombar do tipo A3 da classificacao de Denis e Margerl, que preencheram os criterios de inclusao para esta amostra e foram submetidos a tratamento cirurgico com um tempo minimo de acompanhamento de seis meses. A media de idade foi de 46,96, variando entre 16 e 73 anos. O resultado do tratamento foi avaliado com base na aplicacao do questionario de qualidade de vida Short-Form 36 (SF-36), nas escalas de dor e trabalho de Denis e na escala visual de dor. A cifose foi medida conforme o metodo de Cobb ao final do seguimento. RESULTADOS: Nao foi observada correlacao entre a cifose residual e o SF-36, a escala de Denis para dor e trabalho e a escala visual de dor (p > 0,05). CONCLUSAO: Nao ha correlacao entre o resultado clinico final e a cifose residual em pacientes com fraturas toracolombares do tipo explosao submetidos a tratamento cirurgico.