Robert Meves

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.

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.

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.

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 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.

Tratamento da discite na criança

BACKGROUND The authors reviewed nine patients presenting with discitis during infancy, demonstrating that its diverse forms of presentation lead to a delayed and difficult diagnosis. METHODS This study reports that initial radiographs may not show any alterations, enhancing the importance of scintillography or magnetic resonance for these cases. RESULTS AND CONCLUSIONS One patient was submitted to surgical treatment for lumbar canal decompression due to the presence of a disk abscess. The remaining patients were treated conservatively only with an appropriate antibiotic therapy, immobilization and restriction of physical activity. All of the young patients had a satisfactory evolution and stated no complaints about sequels during their final evaluation.

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.

Tratamento da instabilidade lombar com parafusos pediculares

The lumbar instability is a common desease in clinical practice. Several authors recommend the use of pedicular screws as a fixation system for posterior arthodesis since they provide better results compared to in situ stabilization. Objective: to evaluate the functional and radiographic results in patients assisted by the Spine Group of the Medical Sciences School of Santa Casa of Sao Paulo, presenting lumbar instability and who underwent posterior vertebral arthrodesis treatment by using melttalic fixation with pedicular screws. METHODS: Data from medical records of the Service of Medical Files (S.A.M.E) of the Irmandade da Santa Casa de Misericordia de Sao Paulo and evaluation through single radiographs (front, lateral, and oblique sections) for image studies besides a pre- and postoperative functional evaluation, with minimal follow-up of two years. RESULTS: From November 1995 to June 2000 ten patients with degenerative lumbar unstableness (48%), five patients with isthmic spondylolisthesis (23%) and six with degenerative lumbar stenosis (29%) were evaluated. As for functional evaluation, excellent and good results were obtained in 76%. Complications included superficial infection, pseudoarthrosis, and inappropriate positioning of screws (19%). CONCLUSIONS: The authors conclude that this fixation method is effective with arthrodesis fusion seen in 95% 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.