Olavo Biraghi Letaif

Therapeutic approaches for spinal cord injury

This study reviews the literature concerning possible therapeutic approaches for spinal cord injury. Spinal cord injury is a disabling and irreversible condition that has high economic and social costs. There are both primary and secondary mechanisms of damage to the spinal cord. The primary lesion is the mechanical injury itself. The secondary lesion results from one or more biochemical and cellular processes that are triggered by the primary lesion. The frustration of health professionals in treating a severe spinal cord injury was described in 1700 BC in an Egyptian surgical papyrus that was translated by Edwin Smith; the papyrus reported spinal fractures as a “disease that should not be treated.” Over the last two decades, several studies have been performed to obtain more effective treatments for spinal cord injury. Most of these studies approach a patient with acute spinal cord injury in one of four manners: corrective surgery or a physical, biological or pharmacological treatment method. Science is unraveling the mechanisms of cell protection and neuroregeneration, but clinically, we only provide supportive care for patients with spinal cord injuries. By combining these treatments, researchers attempt to enhance the functional recovery of patients with spinal cord injuries. Advances in the last decade have allowed us to encourage the development of experimental studies in the field of spinal cord regeneration. The combination of several therapeutic strategies should, at minimum, allow for partial functional recoveries for these patients, which could improve their quality of life.

Estudo epidemiológico da síndrome da cauda equina

Objective: The primary purpose of this study was to determine the characteristics and outcomes of the patients admitted at our clinics diagnosed with cauda equina syndrome (CES). Secondarily, this study will serve as a basis for other comparative studies aiming at a better understanding of this condition and its epidemiology. Methods: We conducted a retrospective study by reviewing the medical records of patients diagnosed with CES and neurogenic bladder between 2005 and 2011. The following variables were analyzed: gender, age, etiology, topographic level of the lesion, time between disease onset and diagnosis, presence of neurogenic bladder, time between diagnosis and surgery, neurological damage and neurogenic bladder persistence. Results: Considering that CES is a rare condition, we were not able to establish statistic correlation between the analyzed variables and the outcomes of the disease. However, this study brought to light the inadequacy of our public health system in treating that kind of patient. Conclusion: The study shows that despite the well-defined basis for managing CES, we noted a greater number of patients with sequels caused by this condition, than is seen in the literature. The delayed diagnosis and, consequently, delayed treatment, were the main causes for the results observed. Level of Evidence IV, Case Series.OBJECTIVE : The primary purpose of this study was to determine the characteristics and outcomes of the patients admitted at our clinics diagnosed with cauda equina syndrome (CES). Secondarily, this study will serve as a basis for other comparative studies aiming at a better understanding of this condition and its epidemiology. METHODS : We conducted a retrospective study by reviewing the medical records of patients diagnosed with CES and neurogenic bladder between 2005 and 2011. The following variables were analyzed: gender, age, etiology, topographic level of the lesion, time between disease onset and diagnosis, presence of neurogenic bladder, time between diagnosis and surgery, neurological damage and neurogenic bladder persistence. RESULTS : Considering that CES is a rare condition, we were not able to establish statistic correlation between the analyzed variables and the outcomes of the disease. However, this study brought to light the inadequacy of our public health system in treating that kind of patient. CONCLUSION : The study shows that despite the well-defined basis for managing CES, we noted a greater number of patients with sequels caused by this condition, than is seen in the literature. The delayed diagnosis and, consequently, delayed treatment, were the main causes for the results observed. Level of Evidence IV, Case Series.

Espondilolistese traumática do áxis: epidemiologia, conduta e evolução

OBJECTIVE: To evaluate cases of traumatic spondylolisthesis of the axis and describe them in relation to epidemiology, classification, neurological deficit, healing time and treatment method. METHOD: A retrospective analysis of the medical records of patients treated between 2002 and 2010 at IOT-FMUSP. Inclusion criteria: pars interarticularis fracture of C2. RESULTS: 68% were male patients, with a mean age of 39.1 years. We used the classification by Effendi, modified by Levine-Edwards. Type I fractures were observed in five patients (31.2%) and type II in eight patients (50%). Only three patients (18%) had type IIa fracture. There were no cases of type III. Mechanism: Eight car accidents and four falls. Other mechanisms: being run over, and diving accidents. Treatment with halo traction was used in eleven patients, using minerva cast and halo-cast. Healing time: 3.6 months. Follow-up time: 9.6 months. DISCUSSION: In general, hangman fracture has a good prognosis, which is confirmed by our results. There was no need for surgery in any of the cases. The incidence of neurological deficit is low. No patient had unstable fracture (type III). CONCLUSION: This paper suggests that traumatic spondylolisthesis of the axis continues to be an injury that is successfully treated by conservative treatment in most cases. Level of Evidence -IV, Case series.Objective To evaluate cases of traumatic spondylolisthesis of the axis and describe them in relation to epidemiology, classification, neurological deficit, healing time and treatment method. Method A retrospective analysis of the medical records of patients treated between 2002 and 2010 at IOT-FMUSP. Inclusion criteria: pars interarticularis fracture of C2. Results 68% were male patients, with a mean age of 39.1 years. We used the classification by Effendi, modified by Levine-Edwards. Type I fractures were observed in five patients (31.2%) and type II in eight patients (50%). Only three patients (18%) had type IIa fracture. There were no cases of type III. Mechanism: Eight car accidents and four falls. Other mechanisms: being run over, and diving accidents. Treatment with halo traction was used in eleven patients, using minerva cast and halo-cast. Healing time: 3.6 months. Follow-up time: 9.6 months. Discussion In general, hangman fracture has a good prognosis, which is confirmed by our results. There was no need for surgery in any of the cases. The incidence of neurological deficit is low. No patient had unstable fracture (type III). Conclusion This paper suggests that traumatic spondylolisthesis of the axis continues to be an injury that is successfully treated by conservative treatment in most cases. Level of Evidence -IV, Case series.

Predictive factors for perioperative blood transfusion in surgeries for correction of idiopathic, neuromuscular or congenital scoliosis

OBJECTIVE: To evaluate the association of clinical and demographic variables in patients requiring blood transfusion during elective surgery to treat scoliosis with the aim of identifying markers predictive of the need for blood transfusion. METHODS: Based on the review of medical charts at a public university hospital, this retrospective study evaluated whether the following variables were associated with the need for red blood cell transfusion (measured by the number of packs used) during scoliosis surgery: scoliotic angle, extent of arthrodesis (number of fused levels), sex of the patient, surgery duration and type of scoliosis (neuromuscular, congenital or idiopathic). RESULTS: Of the 94 patients evaluated in a 55-month period, none required a massive blood transfusion (most patients needed less than two red blood cell packs). The number of packs was not significantly associated with sex or type of scoliosis. The extent of arthrodesis (r = 0.103), surgery duration (r = 0.144) and scoliotic angle (r = 0.004) were weakly correlated with the need for blood transfusion. Linear regression analysis showed an association between the number of spine levels submitted to arthrodesis and the volume of blood used in transfusions (p = 0.001). CONCLUSION: This study did not reveal any evidence of a significant association between the need for red blood cell transfusion and scoliotic angle, sex or surgery duration in scoliosis correction surgery. Submission of more spinal levels to arthrodesis was associated with the use of a greater number of blood packs.

Controlled medial branch anesthetic block in the diagnosis of chronic lumbar facet joint pain: the value of a three-month follow-up

OBJECTIVES: To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables. METHODS: Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients. RESULTS: A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05). CONCLUSION: Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives.

Comparação funcional entre revisão de artroplastia de joelho séptica e asséptica

INTRODUCAO: A artroplastia total de joelho (ATJ) nao e um procedimento isento de riscos. A infeccao na ATJ nao e a complicacao mais comum, porem e uma das mais graves. A revisao em 2 tempos e a escolha nos casos de infeccao profunda da protese de joelho. Por outro lado, a soltura asseptica chega a quase metade das indicacoes de revisao de artroplastias primarias. A queda do nivel de satisfacao do paciente pode cair nas revisoes. OBJETIVO: O objetivo do presente estudo foi comparar atraves dos resultados obtidos nos escores funcionais e de qualidade de vida entre cirurgia de revisao de ATJ por soltura septica e asseptica. METODO: Realizamos escores HSS e SF-36 para avaliar a qualidade de vida e o resultado funcional entre pacientes submetidos a cirurgia de revisao da ATJ entre dois grupos, um que realizou a substituicao da protese em dois tempos (septica) e outro no qual a substituicao ocorreu em tempo unico (asseptica). RESULTADOS: A analise dos dados obtidos mostra melhor desempenho do segundo grupo na pontuacao do HSS e em 06 dos 08 dominios do SF-36. Conclusao: A revisao de ATJ em tempo unico apresenta melhores resultados funcionais.

Effects of estrogen on functional and neurological recovery after spinal cord injury: An experimental study with rats

OBJECTIVES: To evaluate the functional and histological effects of estrogen as a neuroprotective agent after a standard experimentally induced spinal cord lesion. METHODS: In this experimental study, 20 male Wistar rats were divided into two groups: one group with rats undergoing spinal cord injury (SCI) at T10 and receiving estrogen therapy with 17-beta estradiol (4mg/kg) immediately following the injury and after the placement of skin sutures and a control group with rats only subjected to SCI. A moderate standard experimentally induced SCI was produced using a computerized device that dropped a weight on the rats spine from a height of 12.5 mm. Functional recovery was verified with the Basso, Beattie and Bresnahan scale on the 2nd, 7th, 14th, 21st, 28th, 35th and 42nd days after injury and by quantifying the motor-evoked potential on the 42nd day after injury. Histopathological evaluation of the SCI area was performed after euthanasia on the 42nd day. RESULTS: The experimental group showed a significantly greater functional improvement from the 28th to the 42nd day of observation compared to the control group. The experimental group showed statistically significant improvements in the motor-evoked potential compared with the control group. The results of pathological histomorphometry evaluations showed a better neurological recovery in the experimental group, with respect to the proportion and diameter of the quantified nerve fibers. CONCLUSIONS: Estrogen administration provided benefits in neurological and functional motor recovery in rats with SCI beginning at the 28th day after injury.

The sagital balance in idiopatic and neuromuscular scoliosis

OBJECTIVES: To describe and compare the distribution of spinopelvic parameters (SPP) in a Brazilian population with idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS), and evaluate the association between pelvic incidence (PI) and lumbar lordosis (LL). METHOD: Medical records investigation was performed. Sagital balance angles were measured in patients with neuromuscular and idiopathic scoliosis. RESULTS: IS sample means (in degrees): PI 55.55; Sacral Slope (SS) 45.35; Pelvic Tilt (PT) 10.19; Lumbar Lordosis (LL) 43.48; and Thoracic Kyphosis (TK) 32.10. In NMS: PI 53.77; SS 42.31; PT 11.46; LL 49.46; and TK 45.69. No statistically significant differences in PEP distribution were found between the two types of scoliosis (p=0,057). The association between pelvic incidence and lumbar lordosis is low among idiopathic scoliosis (R=0,074) and neuromuscular scoliosis (R=0,274). CONCLUSION: PEP measurements in a Brazilian population of idiopathic scoliosis and neuromuscular scoliosis patients are similar to those in the international literature and do not differ statistically between them. The association between LL and PI could not be assessed in this study. Level of Evidence IV, Case Series.

Estudo retrospectivo dos resultados da utilização do halo craniano nas fraturas-luxações subaxiais

OBJETIVO: evaluar el uso de halo craneal en fracturas cervicales y luxaciones de los cuidados iniciales, en relacion con el porcentaje de reduccion cerrada con exito de las lesiones cervicales en los diferentes tipos de fracturas. METODOS: investigacion retrospectiva de los informes de los pacientes ingresados y tratados desde enero de 2004 hasta marzo de 2009, en un total de 222 pacientes, las lesiones se clasificaron segun la clasificacion AO. RESULTADOS: se encontro un alto porcentaje de exito de la reduccion cerrada en pacientes con lesiones cervicales por compresion axial (AO tipo A), en el uso de halo craneal; en las lesiones por distraccion (AO tipo B) y el movimiento de rotacion (AO tipo C) se observo aproximadamente el 50% de la reduccion cerrada de la luxacion. Por otra parte, las lesiones en los niveles mas craneales tienen una tasa de exito mayor en su reduccion. CONCLUSION: el uso del halo craneal es alentado porque, ademas de realizar un papel en la atencion inicial inmovilizador, produce resultados satisfactorios en el intento de reduccion cerrada de la lesion cervical, mejorando la comodidad del paciente, facilitando el abordaje quirurgico y los cuidados posteriores del equipo de enfermeria.ABSTRACT Objective: to evaluate the use of cranial halo cervical fractures and dislocations in the initial care related to the rate of successful closed reduction of cervical lesions in different types of fractures. Methods: retrospective investigation of reports of patients admitted and treated from January 2004 to March 2009, a total of 222 patients. The lesions were categorized according to the AO classification. Results: a high success rate of closed reduction in patients with cervical lesions by axial compression (AO type A) in the use of cranial halo; in distraction injuries (AO type B) and rotational motion (AO type C) we observed approximately 50% of closed reduction of dislocation; furthermore, lesions in more cranial levels have a higher RESUMEN Objetivo: evaluar el uso de halo craneal en fracturas cervicales y luxaciones de los cuidados iniciales, en relacion con el porcentaje de reduccion cerrada con exito de las lesiones cervicales en los diferentes tipos de fracturas. Metodos:

The choice of surgical approach for treatment of cervical fractures

OBJETIVO: definir las caracteristicas epidemiologicas de la poblacion victima, clasificar las fracturas subaxiales, y analizar como los tratamientos quirurgicos fueron realizados, teniendo ellos mismos como resultado la manera quirurgica elegida - anterior, posterior o combinada -, y juntar estos datos para observar estandares del tratamiento para el cuidado optimo de esta gente enferma. METODOS: analisis retrospectiva en prontuarios medicos de 222 pacientes atendidos y tratados, entre 2004 y Marzo de 2009 con fracturas, fracturas-luxaciones y luxaciones cervicales. De estos 222 pacientes, 163 correspondieron a los que tenian fracturas subaxiales clasificables por el metodo AO, es decir, aproximadamente un 73.4% del total. RESULTADOS: los 83% de los pacientes eran hombres y el aproximadamente 78% tenian entre 21 y 60 anos de la edad. Habian sido clasificados como Tipo A, 54 pacientes, el 50% habian sido operados - el 85.18%, via anterior, con corpectomia asociada o no a la artrodese; fueron clasificados como Tipo B, 77 pacientes, y el 85.7% que habian sido operados - el 77.3% via posterior, teniendo en cuenta el lesion ligamentar; como Tipo C, 21 pacientes fueron clasificados, y el 81% que habian sido operados - el 94.1% de la via posterior; y como Niveles Multiples, 11 pacientes fueron considerados, 54.5% fueron operados - el 83.3% de la via posterior, ningun por la via anterior sola. CONCLUSION: los datos obtenidos pueden contribuir con la normalizacion del cuidado del paciente con traumatismo cervical y tornar los resultados mas predecibles. La experiencia acumulada y invertida en numeros facilitara la eleccion de los medios quirurgicos.