Osmar Avanzi

Correlation between neurological deficit and spinal canal compromise in 198 patients with thoracolumbar and lumbar fractures

Study Design. Review the correlation between loss of spinal canal diameter and neurological deficits in patients with thoracolumbar and lumbar burst fractures. Objectives. To try to establish a correlation between neurological deficits and the degree of narrowing of the spinal canal. Summary of Background Data. The correlation between the degree of protrusion of the bone fragments into the spinal canal and the incidence of neurological deficits in thoracolumbar and lumbar burst fractures has not been well established, raising a lot of controversies in the literature. Methods. Manual measurements of axial-computed tomography scan films using a millimetric ruler were made from the spinal canal of 198 patients admitted to the hospital with thoracolumbar and lumbar burst fractures, from 1989 to 2000. Results. The probability of neurological deficit in a patient with 25, 50, and 75% narrowing of the thoracolumbar spinal canal was found to be 12, 41, and 78%, and in the lumbar spinal canal it was 8, 30, and 68%, respectively. Conclusions. The narrowing of the spinal canal proved to be a predictive factor in establishing early neurological deficits in thoracolumbar and lumbar burst fractures, showing a positive correlation between narrowing of the spinal canal and the severity of the incomplete neurological deficit by the Frankel classification. Patients with complete spinal cord injuries (Frankel A) did not show this correlation.

Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures.

Study Design. Review the association between injury severity, narrowing of the spinal canal, and neurologic deficit in thoracolumbar burst fractures. Objective. To determine which variable has a stronger association with neurologic deficit: spinal canal compromise or injury severity. Summary of Background Data. Literature has not reached a consensus regarding the cause of neurologic deficits in these fractures. Some believe it to be the spinal canal compromise and others the energy of trauma. Methods. A review of the clinical data and axial computerized tomography of 184 patients was performed. The injury severity was determined by subtracting neurologic data from the Injury Severity Score and New Injury Severity Score (ISSM and NISSM) to avoid the bias of overestimating neurologic lesions. Results. Patients with neurologic deficit presented higher canal compromise (52% vs. 34%), higher Injury Severity Score (24 vs. 11), New Injury Severity Score (26 vs. 13), ISSM (10 vs. 7), and NISSM (11 vs. 8, respectively). A positive correlation was found among these scores and the spinal canal compromise (P < 0.005; r < 0.35). In the current methodology, logistic regression proved narrowing of the spinal canal to be the only independent variable associated with neurologic deficit. Conclusions. Narrowing of the spinal canal has a stronger association with neurologic deficit than injury severity in thoracolumbar burst fractures.

Objective assessment of the cardiorespiratory function of adolescents with idiopathic scoliosis through the six-minute walk test.

Study Design. Clinical prospective, random study. Objective. Analyze the results of the six-minute walk test (6MWT) in patients with adolescent idiopathic scoliosis. Summary of Background Data. Although it is widely believed that Adolescent Idiopathic Scoliosis (AIS) causes cardiorespiratory dysfunctions, there is no report in literature of objective measurements of this restriction in the ventilatory performance during physical exertion. Methods. One hundred twenty-six adolescents matched by gender and age were prospectively studied at a tertiary teaching institution: 40 patients without spine deformities (group I–controls), and 86 patients with AIS with a spine curve ranging from 45° to 138° (group II). All patients underwent radiographic evaluations and the 6MWT. Results. Normal controls presented significantly lower mean heart rate and Borg scores, as well as higher oxygen saturation and walked longer distances on the 6MWT. Conclusion. The 6MWT effectively demonstrated the cardiorespiratory restrictions presented by patients with AIS.

Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery.

Study Design: Prospective observational study. Objective: To assess patient quality of life before and after surgical treatment of adolescent idiopathic scoliosis (AIS) and determine whether an association exists between quality of life and curve magnitude, curve correction, and type of instrumentation. Summary of Background Data: Assessment of AIS surgery outcomes has always been based on analysis of radiographic measurements and postoperative curve correction. However, there is a current trend toward greater emphasis on patient-centered outcomes. Assessment of treatment success on the basis of these outcomes requires prospective use of quality-of-life surveys before and after AIS treatment. Methods: Prospective study of 33 patients undergoing surgical treatment of AIS. Mean age was 15.6 years and mean Cobb angle was 70.5 degrees. Patients were randomly allocated into one of 2 instrumentation groups (hybrid and pedicle screws alone), and the Scoliosis Research Society-30 questionnaire (SRS-30) and Short Form-36 Health Survey (SF-36) questionnaires were administered preoperatively and at 3-, 6-, and 12-month follow-up. Statistical testing was performed to determine whether survey scores correlated with Cobb angle, curve correction, or type of instrumentation. Results: SRS-30 and SF-36 scores improved significantly. The greatest changes occurred in the self-image and satisfaction with management domains of the SRS-30 survey. SRS-30 and SF-36 scores showed worsening pain and decreased function at 3-month follow-up, but significant improvement from baseline at 12 months. Total SRS-30 scores were significantly improved at 6- and 12-month follow-up, as were subscores in the general health, vitality, and social functioning domains of SF-36. Curve magnitude, percent curve correction, and type of instrumentation had no significant influence on final SRS-30 and SF-36 scores. Conclusions: Surgical treatment of AIS improved patient quality of life, as shown by significant improvement on all SRS-30 and SF-36 domains. Questionnaire scores did not correlate with Cobb angle, curve correction, or type of instrumentation.

Cross-cultural adaptation and validity of an adapted Brazilian Portuguese version of Scoliosis Research Society-30 questionnaire.

Study Design. Prospective clinical study developed at a tertiary teaching facility to test an adapted Brazilian Portuguese version of the Scoliosis Research Society–30 (SRS-30) questionnaire. Objective. To perform cross-cultural adaptation and evaluate the validity of the adapted Brazilian Portuguese version of SRS-30 questionnaire. Summary of Background Data. Quality-of-life measurement is a common practice to assess spine diseases. The SRS questionnaires have been proven to be a valid tool in the clinical evaluation of patients diagnosed with idiopathic scoliosis in United States. However, adaptation into languages other than the source language is necessary to allow multinational use respecting cultural and lingual differences. Methods. A translation/retranslation of the English version of the SRS-30 into Brazilian Portuguese was conducted, and all steps for cross-cultural adaptation process were performed, including a pretest with 20 patients. Sixty-four postoperative patients were submitted to the final version of the Brazilian SRS-30 questionnaire, through oral interviews. The average age of all patients who joined the study was 18.5 years. Internal consistency of the instrument was determined with Cronbach &agr; coefficient. Results. The study demonstrated high Cronbach &agr; values for 4 of the corresponding domains (pain, 0.68; self-image, 0.75; mental health, 0.78; and function/activity, 0.57). However, the Cronbach &agr; value for satisfaction domain (0.28) was considerably lower than the original English questionnaire. The overall Cronbach &agr; values achieved 0.85 for all domains. Conclusion. The adapted Brazilian version of the SRS-30 questionnaire can be used to assess the outcome of treatment for Brazilian Portuguese-speaking patients with idiopathic scoliosis.

Techniques of lumbar-sacral spine fusion in spondylosis: systematic literature review and meta-analysis of randomized clinical trials

BACKGROUND CONTEXT Spine fusions can be performed through different techniques and are used to treat a number of vertebral pathologies. However, there seems to be no consensus regarding which technique of fusion is best suited to treat each distinct spinal disease or group of diseases. PURPOSE To study the effectiveness and complications of the different techniques used for spinal fusion in patients with lumbar spondylosis. STUDY DESIGN Systematic literature review and meta-analysis. SAMPLE Randomized clinical studies comparing the most commonly performed surgical techniques for spine fusion in lumbar-sacral spondylosis, as well as those reporting patient outcome were selected. OUTCOME MEASURES Identify which technique, if any, presents the best clinical, functional, and radiographic outcome. METHODS Systematic literature review and meta-analysis based on scientific articles published and indexed to the following databases: PubMed (1966-2009), Cochrane Collaboration-CENTRAL, EMBASE (1980-2009), and LILACS (1982-2009). The general search strategy focused on the surgical treatment of patients with lumbar-sacral spondylosis. RESULTS Eight studies met the inclusion criteria and were selected with a total of 1,136 patients. Meta-analysis showed that patients who underwent interbody fusion presented a significantly smaller blood loss (p=.001) and a greater rate of bone fusion (p=.02). Patients submitted to fusion using the posterolateral approach had a significantly shorter operative time (p=.007) and less perioperative complications (p=.03). No statistically significant difference was found for the other studied variables (pain, functional impairment, and return to work). CONCLUSIONS The most commonly used techniques for lumbar spine fusion in patients with spondylosis were interbody fusion and posterolateral approach. Both techniques were comparable in final outcome, but the former presented better rates of fusion and the latter the less complications.

Intraoperative neurophysiologic spinal cord monitoring in thoracolumbar burst fractures.

Study Design. Clinical prospective cohort study in academic tertiary setting. Objective. Evaluate intraoperative neurophysiologic monitoring of the spinal cord in patients with thoracolumbar burst fractures. Summary of Background Data. The majority of clinical studies using intraoperative neurophysiologic monitoring in spinal trauma focus exclusively on somatosensory-evoked potentials (SSEP), and there are no specific article on the use of transcranial motor-evoked potentials (TcMEP), and stimulated electromyography (SEMG) by direct stimulation of the pedicular screws in thoracolumbar burst type fractures. In addition, controversy regarding the relation between spinal cord decompression and improvement in spinal cord function in such patients remains. Methods. Eighteen patients with thoracolumbar burst type fractures (<3 weeks) who underwent indirect posterior spinal cord decompression was carried out from 2002 to 2006. Patients were monitored intraoperatively by SSEP, TcMEP, and SEMG. Findings that suggested worsening of spinal cord function were as follows: reduction in SSEP amplitude greater than 50% or increased latency time of 10%; and increased TcMEP of 100 V. Signs of improvement were 20% increase in SSEP amplitude and 20% decrease in TcMEP stimuli intensity. Four (22%) patients presented neurologic deficit. The mean American Spinal Injury Association (1993) score for motor function was 99 ± 29 (range, 90-100). The mean American Spinal Injury Association (1993) score for sensory function was 111 ± 32 (range, 107-112). Results. There were no significant changes in the spinal cord function during the surgical procedure, although a decrease in the mean latency could be observed after spinal cord decompression (43.21 × 40.86; P < 0.01). Two screws triggered SEMG responses and were replaced. All cases were true negatives. Conclusion. No significant changes in spinal cord function (to better or worse) were found in the current series after indirect spinal cord decompression through a posterior approach in patients with mild or no neurologic deficits. Further studies with larger series of patients presenting severe neurologic deficits are necessary to better establish these findings.

Laminar Fractures as a Severity Marker in Burst Fractures of the Thoracolumbar Spine

Purpose. To assess the correlation between the presence of lamina fractures, narrowing of the spinal canal, and the severity of injury. Methods. Records of 146 men and 44 women aged 13 to 84 (mean, 39) years diagnosed with burst fractures of the thoracolumbar spine were retrospectively reviewed. The laminar fractures and narrowing of the spinal canal were measured using computed tomography. The severity of injury was determined using the Injury Severity Score (ISS) and the New Injury Severity Score (NISS). The ISS and NISS of patients with and without laminar fractures were compared. The sensitivity and specificity of ISS, NISS, and narrowing of the spinal canal in association with laminar fractures were also compared. Results. 92 (48%) of the patients had laminar fractures. The mean narrowing of the spinal canal was more severe in patients with laminar fractures than those without (47% vs 28%, p<0.001). Patients with laminar fractures had a significantly higher mean ISS (17 vs 12, p<0.001) and NISS (19 vs 13, p<0.001). Narrowing of the spinal canal is more sensitive and specific than the ISS and NISS when correlating laminar fractures. Conclusion. In patients with burst fractures of the thoracolumbar spine, the presence of laminar fractures indicates a more severe injury.

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.

Fratura da coluna vertebral tipo explosão na área da cauda eqüina: correlação entre função neurológica e alterações estruturais no canal vertebral

OBJETIVO: Avaliar se ha correlacao entre o estreitamento traumatico do canal vertebral e as possiveis fraturas associadas da lâmina, com o quadro neurologico inicial dos pacientes com fratura tipo explosao na area da cauda equina. MATERIAL E METODOS: Foi realizada uma revisao retrospectiva de 42 pacientes que apresentaram 43 fraturas tipo explosao de L3, L4 e L5, no periodo compreendido entre janeiro de 1990 a dezembro de 2004. Os resultados foram avaliados de acordo com a disfuncao neurologica inicial e o diâmetro sagital medio do canal vertebral acometido. RESULTADOS: A unica variavel preditiva independente do comprometimento neurologico foi o estreitamento do canal vertebral (p = 0,008). A porcentagem media de estreitamento do canal vertebral foi significativamente (p < 0,001) maior nos casos em que havia a fratura da lâmina associada. Porem, na analise multipla, verificou-se que a fratura da lâmina nao e um fator preditivo independente para que ocorra a lesao neurologica. CONCLUSAO: O estreitamento do canal vertebral, causado pelo fragmento osseo da fratura, com ou sem a associacao de fraturas da lâmina, nas fraturas tipo explosao na area da cauda equina, tem correlacao direta e estatisticamente significativa com a alteracao da funcao neurologica.