Nelson Astur

Adolescent idiopathic scoliosis: current concepts on neurological and muscular etiologies

Adolescent idiopathic scoliosis (AIS) is a frequent disease but its etiology remains unknown. Gender prevalence in females is already known and there are many suggested hypotheses to explain its origin and manifestation, like associated neurologic, muscular and connective tissue disorders. Literature reports have tried to analyze disease prevalence in selected populations, possible ways of inheritance, related genes location and their polymorphisms, which may play a role in the development of the deformity. The purpose of this paper is to review and update concepts on the origin and genetic influence on AIS.

Balloon Kyphoplasty in the Treatment of Neoplastic Spine Lesions: A Systematic Review

Study Design: Systematic review. Objectives: To assess the efficacy of kyphoplasty in controlling pain and improving quality of life in oncologic patients with metastatic spinal disease and pathologic compression fractures of the spine. Methods: A literature search through medical database was conducted (using PubMed, EMBASE, Cochrane, and LILACS) for randomized controlled trials comparing balloon kyphoplasty versus the traditional treatment for compression fractures of the spine due to metastatic disease. Two investigators independently assessed all titles and abstracts to select potential articles to be included. Inclusion criteria consisted of randomized controlled trials involving patients with pathologic compression fractures due to spinal metastasis or multiple myeloma treated with balloon kyphoplasty procedure as one of the study interventions, while the control group was any other treatment modality. The risk of bias in individual studies was assessed. Results: Two studies, with a combined total of 181 patients, met inclusion criteria. Because of data heterogeneity, the meta-analysis was not possible, and individual analysis of studies was performed. There is moderate evidence that patients treated with balloon kyphoplasty displayed better scores for pain (Numeric Rating Scale), disability (Roland-Morris Disability Questionnaire), quality of life (Short Form–36 Health Survey), and functional status (Karnofsky Performance Status) compared with those undergoing the conventional treatment. Patients treated with kyphoplasty also have better recovery of vertebral height. Conclusions: This study concluded that balloon kyphoplasty could be considered as an early treatment option for patients with symptomatic neoplastic spinal disease, although further randomized clinical trials should be performed for improvement of the quality of evidence.

Subclinical Propionibacterium acnes infection estimation in the intervertebral disc (SPInE-ID): protocol for a prospective cohort

Introduction Low back pain and vertebral endplate abnormalities are common conditions within the population. Subclinical infection caused by indolent pathogens can potentially lead to these findings, with differentiation between them notably challenging from a clinical perspective. Progressive infection of the intervertebral disc has been extensively associated with increasing low back pain, with Propionibacterium acnes specifically implicated with in relation to sciatica. The main purpose of this study is to identify if the presence of an infective pathogen within the intervertebral disc is primary or is a result of intraoperative contamination, and whether this correlates to low back pain. Methods and analysis An open prospective cohort study will be performed. Subjects included within the study will be between the ages of 18 and 65 years and have a diagnosis of lumbar disc herniation requiring open decompression surgery. Excised herniated disc fragments, muscle and ligamentum flavum samples will be collected during surgery and sent to microbiology for tissue culture and pathogen identification. Score questionnaires for pain, functionality and quality of life will be given preoperatively and at 1, 3, 6 and 12 months postoperatively. A MRI will be performed 12 months after surgery for analysis of Modic changes and baseline comparison. The primary endpoint is the rate of disc infection in patients with symptomatic degenerative disc disease. The secondary endpoints will be performance scores, Modic incidence and volume. Ethics and dissemination This study was approved by our Institutional Review Board and was only initiated after it (CAAE 65102617.2.0000.0071). Patients agreeing to participate will sign an informed consent form before entering the study. Results will be published in a peer reviewed medical journal irrespective of study findings. If shown to be the case, this would have profound effects on the way physicians treat chronic low back pain, even impacting health costs. Trials registration number NCT0315876; Pre-results.

NONOPERATIVE VERSUS OPERATIVE TREATMENT OF PATIENTS WITH DEGENERATIVE SPONDYLOLISTHESIS

Objetivo: Evaluar los resultados clinicos y funcionales de los pacientes con espondilolistesis degenerativa lumbar tratados quirurgicamente o sin cirugia. Metodos: Se realizo una evaluacion transversal de los pacientes con espondilolistesis degenerativa, registrados en la base de datos, tratados conservador o quirurgicamente desde 2004 hasta 2014. Las medidas de desenlace incluyeron: Escala Visual Analoga (EVA) de dolor lumbar y las piernas, criterios de Fischgrund, Short Form-36 (SF-36) e Indice de Discapacidad Oswestry modificado (IDO). Resultados: Se evaluaron 43 pacientes: 20 con tratamiento no quirurgico y 23 con tratamiento quirurgico. Las caracteristicas de base fueron similares, sin diferencias significativas entre los grupos. El tiempo medio de seguimiento fue de 43 meses (rango 10-72) para el grupo no quirurgico y 36 meses (rango 6-80) para el grupo quirurgico. Diferencias estadisticamente significativas a favor del grupo quirurgico fueron encontrados en EVA lumbar (media 4 contra 8, p=0,000), EVA pierna (media 3 contra 6, p=0,0015), SF-36 funcion (media 77 contra 35, p=0,000), e IDO (media 17 contra 46, p=0,000). Con respecto a los criterios de Fischgrund, solo el 10% de los pacientes del grupo que recibio tratamiento no quirurgico informo excelente o buen estado de salud en comparacion con 83% de los que recibieron manejo quirurgico (p = 0,000) Conclusion: En este estudio de corte transversal, se observo que los pacientes sintomaticos con espondilolistesis degenerativa que se sometieron a tratamiento quirurgico tienen puntuaciones clinicas y funcionales superiores en comparacion con los que se sometieron a tratamiento no quirurgico.

Cross-Sectional Study Evaluating Nonoperative and Surgical Treatment for Lumbar Degenerative Spondylolisthesis

Introduction Nonoperative treatment is the first prerogative for patients with degenerative spondylolisthesis without neurological deficit. In cases where persistent pain or neurological deficit becomes prevalent, surgery becomes an option. In this cross-sectional study, we evaluated clinical and functional results of patients with lumbar degenerative spondylolisthesis treated nonoperatively or surgically. Patients and Methods Patients with degenerative spondylolisthesis treated either nonoperatively or surgically from 2004 to 2014 were selected from databases and a cross-sectional evaluation was applied. Outcome measures included back and leg visual analog scales (VAS), Fischgrund criteria, short form-36 (SF-36) physical function, and the modified oswestry disability index (ODI). Results Of the 85 patients who met the inclusion criteria, we evaluated 43 in total: 20 with nonoperative treatment and 23 with surgical treatment. Baseline characteristics were similar without significant differences. The mean follow-up time was 43 months (range, 10–72 months) for nonsurgically and 36 months (range, 6–80 months) for surgically treated groups. The surgical group displayed better scores in back VAS (8 vs. 4), leg VAS (6 vs. 3), SF-36 physical function (35 vs. 77), and ODI (46 vs. 17). On the basis of the Fischgrund criteria, only 10% of patients reported excellent or good health post nonoperative treatment versus 83% for those treated surgically. Conclusion Symptomatic patients with lumbar degenerative spondylolisthesis treated surgically obtained better clinical and functional scores than patients treated nonoperatively. The limitations of the study do not permit statistical analysis and hence further review is necessary to draw firm conclusions.

Are Systematic Reviews and Meta-Analysis for Lumbar Spine Disorders Treatment Really Conclusive? A Systematic Review of Systematic Reviews

Introduction Low back pain is among the most frequent causes for medical appointments and increased health cost every year. Treatment for this disorder should be evidence-based through systematic reviews (SR) and meta-analysis (MA). However, methodological mistakes frequently seen in those studies put their credibility into question. Materials and Methods A literature search was conducted using established databases and gray literature for systematic reviews only, involving low back pain as population and surgical treatment as intervention. A previous protocol has been registered in the local research committee. SR for cervical or thoracic spine disorders were excluded. Four certified spine surgeons independently extracted data. Study quality was assessed through measurement tools specific for SR (PRISMA and AMSTAR). For both questionnaires, studies were rated as poor, fair, good, very good, and excellent according to their quality percentage (0–30, 30–50, 50–70, 70–90, > 90%, respectively). For each SR, data were extracted for population, intervention, primary outcomes (VAS, Oswestry disability index, SF-36 questionnaire) and secondary outcomes (fusion, complications, return to work). When a meta-analysis was performed, the outcomes were considered as conclusive or inconclusive. Similar studied diseases, interventions, and outcomes were grouped and analyzed independently. Results A total of 40 SR of low back pain with at least one surgical treatment were included. After a throughout analysis of the studies, most popular search database was Medline, followed by Cochrane and EMBASE. Majority of the SR were published within the last 10 years (90%). Average number of included studies was 17.7 per systematic review. According to the PRISMA quality tool, 7.5% of the SR were rated as poor, 30% fair, 37.5% good, 20% very good, and 5% excellent. AMSTAR rated 22.5% of the SR as poor, 15% as fair, 30% good, 25% very good, and 7.5% excellent. Most frequent mistakes identified by the PRISMA questionnaire was the lack of a review protocol followed by absent analysis of risk of bias within studies. AMSTAR indicated unreported conflict of interest as major error, followed by the lack of a previously reported protocol. Six analyzed lumbar spine diseases were identified and grouped as degenerative disk disease (DDD) (32.5%), spondylolisthesis (SL) (15%), lumbar stenosis (LS) (12.5%), lumbar disk herniation (LDH) (7.5%), spondylosis (S) (27.5%), and painful facet disease (PFD) (5%). Three SR presenting same population (DDD), intervention (arthroplasty vs. fusion) and outcome (Oswestry disability index) had a positive meta-analysis favoring the total disk replacement technique. Two SR analyzing fusion techniques for spondylolisthesis (posterolateral fusion vs. posterior lumbar interbody fusion) had positive meta-analysis for higher fusion rates with the interbody fusion technique. Conclusion Systematic reviews for lumbar spine diseases are still not effective to determine conclusive optimal treatment mostly due to methodological mistakes and lack of scientific evidence.

SURGICAL VS. CONSERVATIVE TREATMENT FOR DEGENERATIVE LUMBAR STENOSIS

Objetivos:Comparar los resultados clinicos entre los pacientes con estenosis lumbar degenerativa tratados mediante descompresion y los que esperan el procedimiento para la enfermedad.Metodos:Estudio retrospectivo que dividio a los pacientes con estenosis degenerativa lumbar con indicacion quirurgica en dos grupos, operado y en espera del procedimiento. Se aplicaron el cuestionario de Oswestry Disability Index (ODI), el SF36 y la escala visual analogica (EVA).Resultados:Se incluyeron 12 pacientes que recibieron tratamiento quirurgico y 18 pacientes en espera de la cirugia. La edad media de los operados fue de 59 anos (43-70), y de los que esperaban el procedimiento fue de 55 (37-82) (p = 0,3). El grupo operado tuvo ODI promedio de 38.67 contra 59.72 del grupo de espera (p 0,05) y 7,22 (p 0,05).Conclusion:Los pacientes operados mostraron una mejoria del dolor referido en las extremidades inferiores (EVA de la pierna) y mejoria de la funcion (Oswestry). Sin embargo, no se observaron cambios significativos con respecto al dolor lumbar (EVA lumbar) ni en la calidad de vida medida a traves del cuestionario SF-36.

TRATAMIENTO QUIRÚRGICO VS. CONSERVADOR PARA LA ESTENOSIS LUMBAR DEGENERATIVA

Objetivos:Comparar los resultados clinicos entre los pacientes con estenosis lumbar degenerativa tratados mediante descompresion y los que esperan el procedimiento para la enfermedad.Metodos:Estudio retrospectivo que dividio a los pacientes con estenosis degenerativa lumbar con indicacion quirurgica en dos grupos, operado y en espera del procedimiento. Se aplicaron el cuestionario de Oswestry Disability Index (ODI), el SF36 y la escala visual analogica (EVA).Resultados:Se incluyeron 12 pacientes que recibieron tratamiento quirurgico y 18 pacientes en espera de la cirugia. La edad media de los operados fue de 59 anos (43-70), y de los que esperaban el procedimiento fue de 55 (37-82) (p = 0,3). El grupo operado tuvo ODI promedio de 38.67 contra 59.72 del grupo de espera (p 0,05) y 7,22 (p 0,05).Conclusion:Los pacientes operados mostraron una mejoria del dolor referido en las extremidades inferiores (EVA de la pierna) y mejoria de la funcion (Oswestry). Sin embargo, no se observaron cambios significativos con respecto al dolor lumbar (EVA lumbar) ni en la calidad de vida medida a traves del cuestionario SF-36.

TRATAMENTO CIRÚRGICO VS. CONSERVADOR DE ESTENOSE LOMBAR DEGENERATIVA

Objetivos:Comparar los resultados clinicos entre los pacientes con estenosis lumbar degenerativa tratados mediante descompresion y los que esperan el procedimiento para la enfermedad.Metodos:Estudio retrospectivo que dividio a los pacientes con estenosis degenerativa lumbar con indicacion quirurgica en dos grupos, operado y en espera del procedimiento. Se aplicaron el cuestionario de Oswestry Disability Index (ODI), el SF36 y la escala visual analogica (EVA).Resultados:Se incluyeron 12 pacientes que recibieron tratamiento quirurgico y 18 pacientes en espera de la cirugia. La edad media de los operados fue de 59 anos (43-70), y de los que esperaban el procedimiento fue de 55 (37-82) (p = 0,3). El grupo operado tuvo ODI promedio de 38.67 contra 59.72 del grupo de espera (p 0,05) y 7,22 (p 0,05).Conclusion:Los pacientes operados mostraron una mejoria del dolor referido en las extremidades inferiores (EVA de la pierna) y mejoria de la funcion (Oswestry). Sin embargo, no se observaron cambios significativos con respecto al dolor lumbar (EVA lumbar) ni en la calidad de vida medida a traves del cuestionario SF-36.

ANALYSIS OF INTERBODY VERSUS POSTEROLATERAL FUSION FOR LUMBAR SPONDYLOSIS

Objetivo : Avaliar e comparar a evolucao radiografica e clinica dos pacientes submetidos a artrodese intersomatica em comparacao com a posterolateral na coluna lombar. Metodos : Estudo retrospectivo de pacientes com diagnostico de espondilose lombar, submetidos ao tratamento cirurgico no periodo de 2012 a 2014. Os resultados foram observados por avaliacao clinica pela aplicacao da Escala Visual Analogica (EVA) para dor com relacao a dor lombar e nos membros inferiores. Foram avaliados resultados funcionais e de qualidade de vida atraves dos questionarios Oswestry Disability Index (ODI) e o Short Form-36 (SF-36), respectivamente. A situacao pre e pos-operatoria foi comparada no Grupo 1 (artrodese intersomatica) e no Grupo 2 (artrodese posterolateral), alem da avaliacao da fusao por meio de radiografia pos-operatoria. Resultados : Foram avaliados 30 pacientes de 36 elegiveis, sendo 12 do Grupo 1 e 18 do Grupo 2. O seguimento medio dos pacientes foi de 10,1 meses. Os resultados da analise estatistica mostraram pontuacoes semelhantes para EVA lombar, EVA na perna, funcao no SF-36 e Oswestry entre os grupos com artrodese intersomatica e posterolateral, assim como na comparacao dentro desses grupos referente ao estado pre e pos-operatorio, sem significância estatistica. A fusao bem-sucedida foi semelhante nos grupos, com 11 de 12 no Grupo 1 mostrando sucesso e 17 de 18 no Grupo 2 tambem evidenciando artrodese. Conclusao: Nao foram observadas diferencas clinicas ou radiograficas entre pacientes submetidos a artrodese intersomatica e posterolateral. Ambos os metodos apresentaram melhora no resultado funcional e na reducao da dor.Objetivo : Examinar y comparar la evaluacion radiografica y clinica de los pacientes sometidos a la fusion intersomatica frente a la fusion posterolateral de la columna lumbar. Metodos : Estudio retrospectivo de los pacientes diagnosticados con espondilosis lumbar que fueron tratados quirurgicamente en el periodo desde 2012 hasta 2014. Se observaron los resultados de la evaluacion clinica por la Escala Visual Analoga (EVA) para el dolor en relacion con el dolor de lumbar y de los miembros inferiores. Evaluamos el resultado funcional y la calidad de vida por medio de los cuestionarios Indice Discapacidad de Oswestry (ODI) y el Short Form-36 (SF-36), respectivamente. Antes y despues de la intervencion se compararon el Grupo 1 (fusion intersomatica) y Grupo 2 (artrodesis posterolateral), ademas de la evaluacion de la fusion a traves de la radiografia postoperatoria. Resultados : Un total de 30 pacientes de 36 elegibles, 12 en el Grupo 1 y 18 en el Grupo 2. El seguimiento medio de los pacientes fue de 10,1 meses. Los resultados del analisis estadistico mostraron puntuaciones similares para EVA lumbar, EVA de las extremidades inferiores, SF-36 y Oswestry entre los grupos con artrodesis intersomatica y artrodesis posterolateral, asi como la comparacion dentro de estos grupos en relacion con el estado de pre y postoperatorio y sin significacion estadistica. La fusion fue similar en ambos grupos con 11 de 12 en el Grupo 1 que tuvieron exito y 17 de 18 en el Grupo 2 que presentaron artrodesis. Conclusion : No se observaron diferencias clinicas o radiograficas entre los pacientes sometidos a artrodesis intersomatica y posterolateral. Ambos metodos mostraron una mejoria en los resultados funcionales y la reduccion del dolor.