Neurocirugía Abril 2014 (Vol 23)

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Neurocirugía Abril 2014 (Vol 23)

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Neurocirugía Abril 2014 (Vol 23)

  1. 1. Campos Hidrocefalia en pacientes….. Neurocirugía-Neurocirurgia / Vol 22/ 2012 1
  2. 2. Neurocirugía-Neurocirugía / Vol. 23 / 2014 2 N E U R O C I R U G I A – N E U R O C I R U R G I A Órgano Oficial de la Federación Latinoamericana de Sociedades de Neurocirugía (F LANC) EDITOR DE PUBLICACIONES FLANC GERMAN POSADAS NARRO Oficina Editorial: Jr. Camilo Carrillo 225 - 602 Jesús María, Lima-PERU Correo electrónico: neurogw@gmail.com Edición: David Urquizo Sánchez Email: durquizos@yahoo.com COMITE EDITORIAL MADJID SAMII (Alemania) ERNESTO HERRERA (El Salvador) CARLOS GAGLIARDI (Argentina) JOSE MARTIN RODRIGUEZ (España) JACQUES BROTCHI (Bélgica) TETSUO KANO (Japón) MILTON SHIBATA (Brasil) ENRIQUE VEGA (Nicaragua) HILDO AZEVEDO (Brasil) FREDDY SIMON ( Paraguay ) LEONIDAS QUINTANA (Chile ) HUGO HEINICKE ( Perú ) REMBERTO BURGOS (Colombia) ALVARO CORDOVA (Uruguay) OSSAMA AL-MEFTY (EE.UU.) ALFONSO GUZMAN (Venezuela) EDWARD LAWS (EE.UU) JESUS VAQUERO (España)
  3. 3. Neurocirugía-Neurocirugía / Vol. 23 / 2014 3 FEDERACION LATINOAMERICANA DE SOCIEDADES DE NEUROCIRUGIA (FLANC) DIRECTORIO Presidente ROBERTO SANTOS (Ecuador) Presidente Anterior ROGELIO REVUELTA (México) Vicepresidente EDGARDO SPAGNUOLO (Uruguay) Secretario General SERGIO VALENZUELA (Chile) Tesorero OSCAR APONTE (Colombia) Editor de Publicaciones GERMAN POSADAS (Perú) Editor de Internet CLAUDIO YAMPOLSKY (Argentina) Historiador PATRICIO TAGLE (Chile) Parlamentario FERNANDO RUEDA (México) Secretario Ejecutivo MARIO IZURIETA (Ecuador) Presidente CLANC MANUEL ROJAS (Venezuela) PRESIDENTES DE SOCIEDADES LATINOAMERICANAS DE NEUROCIRUGIA ARGENTINA Abraham Campero GUATEMALA Erny Leal BOLIVIA Hernan Jemio HONDURAS Osly Vásquez BRASIL-SOCIEDAD Sebastiao Gusmao MEXICO Blas Lopez BRASIL-ACADEMIA Paulo Pires de Aguiar NICARAGUA Marvín Salgado CHILE Marcos Baabor PANAMA Avelino Gutiérrez COLOMBIA Hernando Sifuente PARAGUAY Ramón Migliosiri COSTA RICA José Pérez PERU Jesús Felix CUBA Enrique de Jongh R. DOMINICANA Luis Suazo ECUADOR Julio Enriquez URUGUAY Pablo Hernández EL SALVADOR Guillermo Lara VENEZUELA José Finoccho E. UNIDOS-CANADÁ Fernando Díaz PRESIDENTES HONORARIOS Dr. A .Krivoy (Venezuela) Dr. L. Ditzel (Brasil) Dr. M. Loyo (México) Dr. U. Rocca (Perú) Dr. J. Mendoza (Colombia) Dr. H. Giocoli (Argentina) Dr. J. Méndez (Chile) Dr. M. Molina (Honduras) Dr. F. Rueda (México) Dr. N. Renzi (Argentina) Dr. T. Perilla (Colombia) Dr. M. Masini (Brasil) Dr. R. Burgos (Colombia) Dr. A. Basso (Argentina) Dr. L. Quintana (Chile) Dr. R. Revuelta (México) Dr. E. Herrera (El Salvador) Dr. J. Landeiro (Brasil)
  4. 4. Neurocirugía-Neurocirugía / Vol. 23 / 2014 4 FEDERACION LATINOAMERICANA DE SOCIEDADES DE NEUROCIRUGIA (FLANC) DELEGADOS ANTE WFNS Marco Molina 2º VICEPRESIDENTE REGIONAL Roberto Santos DELEGADO SENIOR Edgardo Spagnuolo SEGUNDO DELEGADO Sergio Valenzuela DELEGADO ALTERNO PRESIDENTES SOCIEDADES FEDERADAS REGIONALES Rafael de la Riva ASOCAN Ramiro Alvarado CONO SUR PRESIDENTES SOCIEDADES ADHERENTES EXTRACONTINENTALES Enrique Urculo ESPAÑA Marco Barboza PORTUGAL Massimo Collice ITALIA Marc Sindou LENGUA FRANCESA COMITÉS EDUCACIÓN Dr. Leonidas Quintana Dr. Rodrigo Ramos Dr. Alfredo Pedroza Dr. Paulo E. Pires de Aguilar CANDIDATURAS: Dr. Marco Molina Dr. Ernesto Herrera Dr. Oscar Aponte ESTATUTOS Dr. Marco Molina Dr. Leonidas Quintana Dr. Fernando Rueda Dr. Nestor Renzi MEDALLAS Dr. Leonidas Quintana Dr. Marcos Masini Dr. Rogelio Revuelta FINANZAS Dr. Eduardo Spagnuolo Dr. Marcos Masini Dr. Himmler Serato Dr. Ricardo Lungo Esquivel Dr. César Yano ÉTICA Comité Administrativo en pleno
  5. 5. Neurocirugía-Neurocirugía / Vol. 23 / 2014 5 FEDERACION LATINOAMERICANA DE SOCIEDADES DE NEUROCIRUGIA (FLANC) ____________________________________________________________________________________________ CAPITULOS 1.-CIRUGÍA CEREBROVASCULAR Dr. Edgardo Sapgnuolo 2.-COLUMNA VERTEBRAL Dr. José Soriano 3.-CIRUGÍA ESTEROTORÁXICA Y FUNCIONAL Dr. Jairo Espinoza 4.- NEUROCIRUGÍAPEDIÁTRICA Dr. Guzmán Aranda 5.- NEURO ONCOLOGÍA Dra. Alejandra Rabadan 6.-NEUROTRAUMATOLOGIA Y TERAPIA INTENSIVA Dr. Enrique Guzmán 7.- NERVIOS PERIFERICOS Dr. Fernando Guedes 8-. BASE DE CRÁNEO Dr. Gustavo Isolan
  6. 6. Neurocirugía-Neurocirugía / Vol. 23 / 2014 6 REVISTA LATINOAMERICANA DE NEUROCIRUGIA Abril, 2014. Volúmen 23 Contenido Editorial Dr. Remberto Burgos de la Espriella. ………………..….……….……………….……..7 Página del Presidente La FLANC en el Contexto Mundial. Dr. Efraín Ernesto Herrera Magaña………….………...………………...….…...…….10 Artículos Originales Treatment of thoracolumbars spine fractures and dislocations Its influence on the rehabilitation process. Dr. Masini M…….……………………………………………………………..............12 Hidrocefalia en paciente pediátricos con tumor de fosa posterior: Propuesta de escala predictiva. Hydrocephalus in pediatric patients with posterior fossa tumor: Proposed predictive scale. Drs. Campos D., García J., Zopfi A, Toledo M., Ramírez A., Solis F,.………..............46 Artículo de Revisión Absceso cerebral: Rol del neurocirujano. Brain Absces to the work concerning the neurosurgeon. Drs. Navas M., Alvis M., Gutierrez P., Alcala C., Moscote S……….……...……..…...57 Miscelánea en Neurociencias Enfermedades prevalentes, valoración funcional y situación socio-familiar del adulto mayor región callao 2006. Prevalent diseases functional assessment, and social family situation in older adults attending primary health care centers, Callao 2006. Drs. Ruiz L., Campos M, Peña N., …...…………..…..…...…………..….…...………..70 Ciencia y Arte Poemas: Rubén Darío………………………….………………….…………………83 Semblanza Atos Alves de Sousa Sebastião Gusmão …………….…………..…………………….………..….………..85 Reglamento de Publicaciones………………………………………….…..………..…….87
  7. 7. Neurocirugía-Neurocirugía / Vol. 23 / 2014 7 Editorial Remberto Burgos de la Espriella INSTRUIR, ENSEÑAR Y EDUCAR n Colombia, que lleva casi 20 años un sistema salud que ha alcanzado cerca del 100% en cobertura en salud a los colombianos, se discute una modificación estructural de esa ley, la cual es conocida como Ley 100 de 1993. La nueva reforma, pretende corregir sus defectos: la intermediación, la integración vertical y el modelo de salud que ha estado centrado en la atención de la enfermedad. Quedó en el olvido la prevención y sus medidas .Estas - las más eficaces- cuando miramos los resultados en costo efectividad. El Gobierno Nacional, bien intencionado, pero errado, buscando facilitar y agilizar la oportunidad para la atención de los especialistas, ha propuesto en el nuevo proyecto de Ley que hospitales con “experiencia” y sin control universitario, puedan otorgar títulos de Especialistas a Médicos que durante un periodo de tiempo hayan trabajado como hospitalarios en esa institución. Así, se aumentan en un periodo corto el número de ”especialistas” y se satisface la demanda. ¿Estamos preparados en Latinoamérica para que hospitales de tercer nivel, sin aval universitario, otorguen Título de Neurocirujano a Médicos hospitalarios que durante 5 años han trabajado como “médicos de planta” en un servicio de neurocirugía? Más allá de la pregunta planteada, llegamos al punto de la oferta y en esta la distribución y concentración de los especialistas en nuestros países. Tenemos casi en todos los países latinos 1 neurocirujano por 100.000 habitantes y esta cifra se aproxima a los estándares de la distribución adecuada que la WFNS sugiere. Pero si detallamos esta distribución, vemos que en las grandes ciudades se concentran y alcanzan casi cifras del 20/100.000. Los especialistas que se radican en las grandes ciudades encuentran oportunidades de trabajo asistencial y remuneración que apenas alcanza para los gastos esenciales de una familia. El sueño de hacer los grandes casos no existe, la ilusión del consultorio es una quimera y el horario de las grandes ciudades, donde el día tiene 18 horas (transporte, movilización,), solo permite trabajos en dos instituciones con cargas laborales de 8 horas que copan nuestra capacidad física. E
  8. 8. Neurocirugía-Neurocirugía / Vol. 23 / 2014 8 La carga asistencial los asfixia; cuando desean asistir a Jornadas de Actualización la responsabilidad laboral no se los permite y la fatiga del turno de la noche anterior los obnubila. Estos especialistas atiborrados en grandes capitales se frustran; nada más peligroso que especialistas fracasados, amargados y desconsolados que se han movilizado descrestados por las “luces académicas” que aparentemente ofrecen las grandes ciudades. La primera tarea como institución continental es facilitar la distribución de los especialistas en neurocirugía para que la densidad de nuestra especialidad no tiña solamente la ubicación geográfica de las grandes ciudades. Debemos llegar a las ciudades intermedias y como centro de pensamiento recomendar a nuestros gobiernos actualizar los recursos físicos para que el Medico Neurocirujano en esa región pueda solucionar el 90% de la patología que aqueja a esa comunidad. Esta es la neurocirugía general y básica. Así, podemos atender desde el tumor supratentorial, el aneurisma simple y la estenosis cervical. El tumor petroclival, el aneurisma de la basilar y la escoliosis compleja deben ser remitidos a centros altamente calificados en las ciudades, donde la experticia se nutre de la frecuencia y los resultados de calidad compensan los altos costos. ¿Cuál es el médico neurocirujano que necesita Latinoamérica? Detengámonos en el currículo; tengo la convicción que no hay un centro en América Latina que reúna las condiciones ideales para formar el neurocirujano integral. Necesitamos abolir las fronteras y fomentar los currículos flexibles para que el neurocirujano en formación se beneficie de las grandes oportunidades que nuestro continente ofrece. Hay centros en todos los países fuertes en áreas específicas y si nosotros en un gesto de madurez (dejemos ese prurito latino tonto: “me las se todas”) reconocemos sus bondades, podemos ofrecer a nuestros residentes y neurocirujanos este escenario autóctono de aprendizaje. Estos compensan el anhelo escondido de capacitación y prevenimos así esa migración triste a las grandes ciudades donde la frustración empaña la belleza del ejercicio de una elite privilegiada, como los neurocirujanos de un continente, donde el 50% de sus habitantes están clasificados como pobres. La pobreza no son los recursos materiales; la peor de las pobrezas es la indigencia intelectual: la ignorancia. Afligido vive el país con “pobres de bolsillo”; sin futuro la nación con “pobres de mente” y sin sueños la patria con “pobres de corazón”.
  9. 9. Neurocirugía-Neurocirugía / Vol. 23 / 2014 9 Aquí es donde la FLANC y sus sociedades federadas tienen que jugar el partido de su vida. Estimular los procesos de capacitación independientemente de quién los promueva, fomentar el desarrollo de más y mejores escenarios de formación. Apoyar liderazgos proactivos y ayudar a los servicios débiles para que crezcan sanos y se robustezcan. Llevar las experiencias exitosas para quienes se inician en estas actividades no repitan los mismos errores y sobretodo tener como punto diana el neurocirujano de provincia para que no se sienta distante de sus pares y pueda desde las regiones, convertirse en agente de cambio que promueva la salud integral de sus conciudadanos. Hacer fuerte a los débiles; debe ser el primer postulado en nuestros reglamentos y convicciones. Remberto Burgos de la Espriella
  10. 10. Neurocirugía-Neurocirugía / Vol. 23 / 2014 10 Página del Presidente Dr. Efrain Ernesto Herrera Magaña Presidente Honorario FLANC. La FLANC en el Contexto Mundial. n el inicio del siglo XX las ciencias en general inician un crecimiento exponencial en áreas como la Anatomía, la Fisiología y la Patología. Esto aunado al interés, perseverancia y afán investigativo de muchos hombres, promueve el desarrollo de muchas áreas como las Neurociencias. Indiscutiblemente el desarrollo tecnológico que acompaña a esta época permitió que los limitados recursos fuesen cada vez un menor impedimento para el desarrollo y crecimiento. A nivel mundial hombres como Cushing, Egaz Moniz, Olivecrona, Asenjo y una selecta lista de precursores de la Cirugía Neurológica abrieron las puertas para que se sentarán las bases de lo que hoy conocemos como la Neurocirugía Moderna, la cual continúa teniendo sus bases en aquellas investigaciones iniciales de la Anatomía, Fisiología y Patología. La epidemiologia de la patología Neuroquirúrgica ha ido cambiando de acuerdo a diferentes variables, dentro de las cuales el desarrollo no solo tecnológico sino también económico social que cada una de las regiones ha presentado ha influido definitivamente en estos cambios. Es indiscutible que en países desarrollados como Estados Unidos, Alemania, Japón, Francia o Inglaterra entre otros, las investigaciones y recursos tecnológicos se orienten en primera fila a la patología oncológica o cerebro vascular y es muy cierto que al igual que ellos en muchos países de América Latina dicha patología ocupa una ubicación entre sus primeras causas de muerte tal como sucede en países como Brasil, Argentina, México, Costa Rica o Cuba entre otras, y si revisamos en las estadísticas nacionales de países que se encuentran en "vías de desarrollo" como la región Centroamericana, encontraremos que también ocupan un sitial muy importante dentro de sus estadísticas de morbimortalidad. Por eso es muy importante conocer el aporte que estas Naciones nos ofrecen y poderlo brindar a nuestros pacientes. De allí la importancia del intercambio de conocimientos y experiencias que la FLANC ofrece a través de sus Congresos Latinoamericanos, cursos, becas a Neurocirujanos jóvenes o E
  11. 11. Neurocirugía-Neurocirugía / Vol. 23 / 2014 11 Residentes de Neurocirugía. La Revista de la FLANC es probablemente uno de los elementos más valiosos con los que contamos para lograr ese intercambio regional de experiencias que enriquecen nuestro Servicio a los Enfermos. La creación de los diferentes Capítulos Académicos es sin duda una de las ideas de mayor valor, ya que de una forma más definida se tiene la oportunidad de abordar diferentes temáticas, ya sea espinal, trauma, Oncología, vascular entre otras. Uno de los Capítulos que en mi opinión alcanza una relevancia muy especial en América Latina, es el Capítulo de Neurocirugía Pediátrica. Al revisar la Neuro epidemiologia Pediátrica, es muy fácil de apreciar la enorme brecha existente (al hablar de patología congénita) entre los países desarrollados y los llamados en vías de desarrollo. La presencia de una enorme estadística en patologías que se acompañan de disrafismo espinal y/o hidrocefalia en países del África o de América Latina al compararla con la de los países desarrollados, nos muestra (entre otras cosas) del enorme problema socio económico que invade estas regiones y que acompañan a nuestras poblaciones. Hablar de Investigación en América Latina resulta usualmente muy poco alentador. Sin embargo uno de los objetivos de la FLANC es promoverla y lograr a través de ella propuestas que incidan en el bienestar de aquellos a quienes nos debemos. Afortunadamente tenemos una organización académica activa y pujante. Cooperemos con la FLANC para que la investigación, propuestas y ejecución de las mismas se hagan realidad. América Latina tiene frente a sí, un enorme reto. Enfrentémoslo.
  12. 12. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 12 Artículo Original Tratamiento de la Columna Toracolumbar Fracturas y Dislocaciones y su Influencia en el Proceso de Rehabilitación Treatment of Thoracolumbar Spine Fractures and Dislocations Its Influence on the Rehabilitation Process Marcos Masini, MD, M. Sc., Ph. D Faculdade de Medicina do Planalto Central – FAMEPLAC Hospital Lago Sul, Brasília. Instituto Quéops Millennium, Neuroscience and Neurosurgery, Brasília, Brazil. ABSTRACT The author conducts a retrospective analysis of 121 patients suffering from fracture and/or dislocation of the thoracolumbar spine treated within the protocol and undergoing surgery between 1988 and 1995, with long outpatient monitoring treatment. An operative protocol and subsequent rehabilitation program were utilized in all patients. Ninety-five patients were men, in their third and fourth decades of life. Fifty- seven patients presented injuries caused by traffic accidents: forty-one by falls and twenty-three by local traumas. Eighty-eight bone injuries were located at the T11, T12 and L1 transition and 75 patients presented paraplegia upon hospital admission. All of them were classified by Frankel/ASIA scale at admission, discharge and last outpatient follow up. All patients underwent plain x-rays of the spine. Seventy-one examinations were complemented with computerized tomography and 50 with magnetic resonance. All of them received rectangle rods and segmental sublaminar wire fixation with bone graft fusion. Eighty-five patients needed concomitant decompression of the spinal canal due to associated neurological deficit. Patients admitted with a complete neurological deficit had no improvement during follow up, however 70 percent of patients with partial neurological injuries improved at least one Frankel/ASIA grade by the end of follow up. Lumbar injuries improved the neurological grade 5 times more than localized thoracic injuries. Antero-posterior dislocations of the vertebral body were corrected in average from 37 to 16 percent, lateral dislocations from 27 to 19 percent and anterior angulation from 21 to 12 degrees. The loss due to angulation in the 43 patients examined after discharge did not affect the functional independence. Patients’ functional independence measure improved from an average of 29 points at the admission to an average of 79 points after about 60 days in rehabilitation. Functional rehabilitation results in final measurement were poor, however, when related with brain injury. The shorter the
  13. 13. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 13 time between the injury and admission, the shorter the hospital stay, rehabilitation period, and the better the final independence measure and hospital efficiency ratio as well. The timing between injury and the surgical procedure did not influence the final neurological recovery of patients and those patients having immediate post injury surgery, however had better rehabilitation grade, i.e., the shorter the timing between injury and surgical procedure, the shorter the hospital stay. The timing between the injury and the surgical procedure also influences the efficiency ratio, i.e., the shorter the timing between injury and surgery, the better the evaluation of the hospital efficiency. Also, the shorter the timing between the injury and the patient admission, the shorter the hospital stay, the better the evaluation in the FIM scale and the better the Efficiency Ratio. The time patients waited for surgery, already at the hospital, also did not increase the stay. The only factor delaying spine surgery was concurrent with patients presenting thoracic, abdominal and brain injury. Burst fractures, differently from dislocation, were found to be prone to late re-angulation due to impairment in the anterior support of the spine. However, this did not influence the final functional independence measure and did not cause neurological deficit. The surgical technique used to treat patients with fractures and/or dislocation of thoracolumbar spine is efficient. Although most thoracolumbar spine injuries are statistically treated as non–surgical, the timing to conduct surgery must consider the total clinical condition of the patient at admission. Thus, the surgical procedure is elective. This method aims for concomitant spinal cord and root decompression and spinal arthrodesis fixation of the spine. Decompression of spinal cord and root should be always considered when deficit and misalignment on the spine canal is recognized. The spinal stabilization is immediate and there is no need for postoperative external immobilization. This method alleviates the pain and stabilizes the deformity, enabling to continue the rehabilitation program. Complications are similar to the ones of other methods and are treatable. The safety, simplicity and economy of this system justify it as an option in this treatment. Keywords: Thoracolumbar Spine Fractures and Dislocations, Neurosurgery, Surgical Treatment, Posterolateral Decompression, Rectangular Rods, Sublaminar Segmental Wires, Bone Graft. Rehabilitation. INTRODUCTION The spinal cord injury is one of the most devastating diseases for individuals of modern society, affecting mainly young healthy and economically active people, causing great economic and social impact¹. Estimates point out to more than 10,000 cases of spinal cord injury per year in Brazil. Trauma is the predominant cause. The
  14. 14. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 14 numbers are alarming, exceeding most of the statistics published relating to the incidence of spinal cord injuries in several countries. The United States and Japan, for example, show rates of 40 new cases per every million of inhabitants per year. In Brazil, the average rate in 1997, was 71 new cases per million of inhabitants. Southwest and Northeast regions showed, respectively, rates of 71 and 91 new cases per million. Half of the patients suffer from thoracolumbar spinal injuries 2, 3.This is a problem that grows with Brazil, requiring much attention in addition to education and prevention campaigns, as well as more efficient rehabilitation of the surviving population, currently calculated at more than 180 thousand individuals. In recent decades, there has been great progress in treatment practices for patients with spinal cord injuries, and clinical evaluation has been systematized. Radiological diagnosis methods have improved and the knowledge of spinal biomechanics has enabled better identification of instability. Rescuing methods have been improved as well as the clinical treatment of spinal cord injuries themselves and their complications. Several fixation systems for the unstable spine have been developed and the rehabilitation process has been systematized. Prevention programs have been focused on causal factors and even the profile of spinal cord injuries has changed in recent years, with the increase in spinal injuries due to aggression and the higher incidence in the elderly population. The thoracolumbar spine injuries have been the theme for a number of publications, however, there were only a few prospective protocol works with sufficient amounts of cases and monitored long enough to enable a statistical analysis with the use of Methylprednisolone (NASCIS 1, 2 and 3), Ganglioside (SYGEN), Fampridine (SR) and Cellular Therapy (Macrofage Trial)4. Thus, almost all aspects of treatment are still surrounded with controversy. Knowledge of the problem and its dimensions has become important to the surgeon once these patients require a multidisciplinary approach, specialized care and rehabilitation. Discussing technicalities such as fixation and arthrodesis of the thoracolumbar spine is a detail that encourages a deeper investigation of the magnitude of the issue. The monitoring of patients over time may enable a new clinical and psychological approach and find new possibilities and solutions. Our study on the topic began in January 1980. In the first 16 years of that period, we treated 1,090 patients with thoracolumbar spine fractures and dislocations. Considering those patients, 605 (55.5 percent) presented neurological deficit, 308 (28 percent) underwent surgery and 224 (73 percent) of them were instrumented by posterior approach. In temporal sequence, 53 (24 percent) were treated with Harrington instrumentation, 50 (22 percent) with Harrington-Luque instrumentation and 121 (54 percent) with rectangular instrumentation. The last 121 patients are the
  15. 15. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 15 focus of our study. The Pedicle Fixation system with Rods and their variants have been used in patients after the period of time of this study. PATIENTS AND METHOD This study includes 121 patients suffering from thoracolumbar spine fractures and dislocations who were surgically treated (DOVE)64, analyzed in 100 different items and monitored for an average period of five (5) years after the surgical procedure. This is a protocol study where the identification of the 121 patients was conducted through hospital record. The analysis period was from January 1988 to December 1995. All patients, with thoracic and lumbar spine injuries, most of them concentrated between T- 11 and L-3, such region defined as thoracolumbar transition. Based on the information collected from the admission protocol and the medical records, the following patient data were analyzed: gender, age, origin, cause of injury, related injuries, dates of fracture, hospital admission, surgery, discharge, and date of the last appointment at the hospital (base of analysis: December 1996), neurologic deficit on hospital admission, discharge and follow up appointment, grade of injury, grade fixed, number of grades fixed, rod type, size of the rod used, blood loss, surgery time, use or non-use of blood or derivatives, procedure details, date of deambulation after the procedure (Frankel/ASIA - D and E)5,7 and date of rehabilitation commencement (Frankel/ASIA-A, B and C)5,7, neurological level at hospital admission and discharge and number of follow-up days after discharge. Other records or procedures conducted included: complications before and after the surgical procedure at the rehabilitation hospital and later occurrences after hospital discharge, classification on the FIM (functional independence measure of the patient) scale on admission and discharge, date of the admission radiological study, postoperative control and late control conducted at discharge or in ambulatory at the time of the last appointment. During radiological studies the following aspects were analyzed: angulation, anteroposterior and laterolateral traslation, scoliosis; date of the computerized tomography and magnetic resonance, with analysis of the degree of commitment of the spinal canal, classification of fractures and dislocations by the MARGERL and GERTZBEIN (6) system, electrophysiological examinations conducted as Electromyoneurography and Evoked Potentials, graft removal site (whether from the site of the surgery or the iliac), bone healing and details of the aspect of the system along the radiological monitoring during the Rehabilitation Program.
  16. 16. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 16 STATISTICS We divided the database statistical analysis in vertical and horizontal. In the vertical statistical analysis, we grouped the data of the columns and showed the analysis in Graphs. We analyzed gender, age range, origin, causes, level of neurological injury at hospital admission, level of neurological injury at discharge, deficit in the Frankel/ASIA scale5, 7 on hospital admission, at discharge and on outpatient evaluation, location of fracture or dislocation, x-rays, classification of fractures and dislocations according to MARGERL and GERTZBEIN6, number of spine levels fixed, size of the rod used, blood loss and use or non-use of blood, average time of surgery, details of the procedure (decompression, iliac or site graft, use of single, double or multifilament wire), anteroposterior dislocation on hospital admission and discharge, lateral dislocation on hospital admission and discharge, lateral inclination on hospital admission and discharge, correction and loss of angulation and time between radiological checks, days between fracture and hospital admission, days between hospital admission and surgery, months between fracture and hospital discharged after rehabilitation, days between the surgery and discharge, semesters between the discharge and the last outpatient evaluation and the FIM (Functional Independence Measure) scale classification on hospital admission and discharge. In the horizontal statistical analysis, we used the following tests: statistical treatment of data involving descriptive and inferential analysis, Chi-square Test and Fisher's Exact Test when necessary, in order to analyze the significance of relations among the distributions of variables. The difference among the groups was tested through Variance Analysis, by using the Kruska-Wallis Test as well. We also evaluated the Rehabilitation Efficiency Ratio, which is equivalent to the Functional Independence Measure obtained at the end of the rehabilitation program divided by the Length of Stay in the Program.
  17. 17. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 17 DECOMPRESSION AND FIXATION TECHNIQUE FOR SPINAL ARTHRODESIS used in these patients FIGURE 1 - Patient positioning. Scheme of the posterolateral approach of spine with preservation of lamina for anterolateral fixation and decompression of the spinal canal. Set with 10 cm, 15 cm and 20 cm rods. Application of Hartshill Rectangle and direction for the first and second twist of Chanrley wires. Summary of Case 1 - Female patient, 28 years old, victim of running over six days before. Clinical condition of paraplegia (Frankel/ASIA A). Dislocation and fracture between L-1 and L-2. Submitted to decompression, reduction and fixation with rectangle between T-11 and L-3. Arthrodesis with grafts taken from the site of the surgery. FIGURE 2 – Magnetic Resonance and Computed FIGURE 3 – Radiography showing Tomography showing misalignment and the fracture and dislocation between L-1 and compression. L-2 and the reduction.
  18. 18. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 18 FIGURE 4 – Decompression of Spinal Canal FIGURE 5 – Result of Fixation and fusion after through posterolateral, fixation with the Hartshill 10 years. Rectangular Rod System with grafts The tables below refer to a vertical statistical analysis of results. We observed that 95 patients (78.5 percent) were male and 26 (21.5 percent) were female (Graph 1). The predominant age group was between 20 and 29 years, in a group of 48 patients, followed by 30 and 39 years, with 36 patients (Graph 2), with a single occurrence under 9 years old and two above 60 years old. The most common cause was traffic accident in 57 patients, followed by fall in 41 and direct trauma in 23 (Graph 4). The level of neurological injury at hospital admission was in T-12 (44), followed by T-11 (23) and L-1 in 21 cases. The other levels were affected in a proportion of less than four. The spinal level of fracture and/or dislocation enables to find most of the injuries in the dorsal lumbar transition between T-10 and L-2. The most frequent location of injury was T-12 with 74 patients, L-1 with 68, T-11 with 27 and L-2 with 14. As the injury often involves two segments, the numbers added exceed the 121 cases analyzed. The study of the neurological level of injury at discharge enabled an analysis of the neurological deficit evolution of patients (Graph 6). The neurologic deficit evaluation in the Frankel/ASIA scale at fracture (admission), placed 75 with total injury in A, 9 in B, 20 in C, 4 in D and 13 in A (Graph 7). The comparison of this evaluation with the one at the discharge and later with the follow up evaluation enabled the analysis of the neurological deficit evolution among the various severities of injury (Graph 8). Concerning the radiological evaluation, all patients underwent plain x-rays. Seventy-one examinations were complemented with computerized tomography and 50 with magnetic resonance. According to the MARGERL/GERTZBEIN (6) classification, most patients had C-1 type fractures in 72 cases and A-3 in 63 cases (Graph 12). In the analysis of the number of
  19. 19. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 19 levels fixed with the surgical procedure, we observed that 42 were fixed in 5 levels, 38 in 4, 30 in 6, 6 in 7 and 5 in 8, and two patients had fractures in two distant spine levels (Graph 13). The size of the rod is proportionally related with the number of levels fixed in most cases: there were 55 rods of 15 cm, 50 rods of 10 cm, 15 rods of 20 cm and only one rod of 5 cm, used in children and made according to the size required (Graph 14). The blood loss was registered by volume. We noticed that 93 patients had losses of less than 1,000 ml, 85 of them did not received postoperative transfusion, 36 patients received transfusion in volume less or equal to 1,000 ml of blood during the postoperative period (Graph 15). The average time of surgery ranged between 1 hour and 3 hours in 87 patients with prevalence between 2 hours and 3 hours in 49 cases. In 98 patients, the decompression of spinal canal was conducted as part of the procedure. Patients with no neurological deficit were excluded from this technique (18 cases), as well as 5 other cases in which the compression was not considered significant in the radiological evaluation. In 62 cases, the graft was taken from the iliac by conventional technique and, in 59 cases, only from the site of the surgery, including the spinous apophyses, part of the blade, facet and vertebral body removed at decompression and preparation of fusion. In 71 patients, we used double wires and, in 46 patients, the single wire was used. In four patients, flexible multifilament cables were used. All cases were x-rayed during outpatient evaluation. A new x-ray study was conducted in 43 patients, among the 93 patients who returned for a new evaluation after hospital discharge. In 93 of them, with anterior dislocation of the vertebra, we observed a correction from 37 percent to 16 percent of the dislocation. In the laterolateral dislocation, the reduction was decreased on average from 27 percent to 19 percent. The lateral inclination was corrected from 11 to 8 degrees. The correction and loss of angulation were 21 degrees before the procedure, 12 degrees immediately after the procedure and again 21 degrees on the late evaluation that was conducted, on average, 624 days after the second evaluation. In 56 patients, the time between the fracture and the admission was, at most, 14 days, in 28 patients, 329 days and in 23 patients, 44 days. Thirty-two procedures were conducted until the 6th day after hospital admission, 23 between 7 and 13 days and 26 between 14 and 20 days of hospital admission. We analyzed the time between the fracture and discharge. Among 100 patients with apparent neurologic deficit, in 68, the time between the surgery and the beginning of physical therapy was less than 14 days. For the other 32 patients, the time was longer than the period of 14 days. For the 18 patients who could deambulate, the average time of discharge for deambulation was between the 3rd and 5th postoperative day, i.e., half of the cases. Sixty-one
  20. 20. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 20 patients with neurologic deficit were rehabilitated within the 60 postoperative days and 94 patients returned for evaluation appointment and functional revaluation. The average MIF Scale evaluation on admission was 29 and at discharge 79. Only patients with brain-related injury had delays or low final grade. Twenty-one patients had traumatic brain-related injury, and one of them evolved to death due to late intracerebral frontal hematoma. Sixteen suffered distal fractures (superior or inferior limbs), 7 had abdominal injury, 3 with thoracic injury and 2 with pelvic injury. Two patients had fractures in two levels distant from the thoracolumbar spine. The complications identified before the surgery that justified its postponement, in addition to related traumas, such as brain, thoracic and abdominal/pelvic injuries were the following: urinary tract infection in 32 patients, bedsores in 20, venous thrombosis in 3 and pneumonia in 1. Occurrences identified after surgery and related to the rod and the wires were classified into early and late occurrences: EARLY OCCURRENCES – wrong level of the procedure in 1 case, superficial infection in 2 cases that received clinical treatment; suture dehiscence in 2 cases, local hematoma, despite the drain. in 2 cases, deep infection in 2 cases, one of them evolving to meningitis and death; LATE OCCURRENCES - bulging on the site in 3 patients, rod exchange due to local pain, with placement of more grafts in 2 cases, broken wire in 10 cases, 2 of them with multifilament wire, broken rod with no need of intervention, 1 case with previous angulation above 20 degrees, late removal of the rod for conducting DREZ in 2 cases. Concerning pain and spasticity, we observed that 2 patients had pain above the injury, related to joint pain, 7 had pain at the level of the injury and fracture site, which was related to instability, causing the evaluation of 2 cases in which the rod was replaced by a larger one and more bone graft was placed. Eight patients complained of intense pain below the injury, which resulted in clinical treatment and, in 2 cases, in conduction of DREZ. Two patients underwent pithing, for exaggerated spasticity with no drug control. After the surgery, and during the period of hospital stay, 9 patients had urinary infection, 7 developed bedsores (usually sacral or trochanteric bedsores), 1 had pneumonia, 1 had deep vein thrombosis and another one had myositis ossificans. Several urological complications were identified during the outpatient follow- up period: vesical calculi in 3 patients, demanding surgery, hydronephrosis in 2 and stenosis of urethra in 1. Eight patients reported penile erection dysfunction, with indication of prosthesis to one of them. Another patient enrolled in the program of fertilization and managed to be a parent. Likewise, a paraplegic patient of group became pregnant, with medical monitoring, giving birth to a healthy child.
  21. 21. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 21 Gender – 121 cases Age Group – 121 cases Women Men < 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 > 60 Graph 1 Graph 2 Fracture Deficit Causes – 121 cases Frankel/ASIA Scale – 121 cases Traffic Accident Fall Direct Trauma Graph 4 Graph 7 Deficit on Discharge Classification of fractures and dislocations Frankel/ASIA Scale – 121 cases Margerl/Gertzbein – 121 cases A B C D E Death Graph 8 Graph 12
  22. 22. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 22 Number of Fixed Spine Levels – 121 cases Blood Loss (ml) – 121 cases Graph 14 Graph 15 HORIZONTAL STATISTICAL ANALYSIS Does the time between fracture and surgery influence the final rehabilitation process of patient at discharge? In Graph 33, we observe that patients who underwent early surgery obtained a higher number of points on the FIM Scale at hospital discharge. This means that they took more advantage of time for their rehabilitation and, at discharge, they were better trained to perform their activities. We observed that the average classification in the FIM Scale, when analyzing patients who underwent surgery up to 31 days before (45 patients), was 57.6, while in those who underwent surgery more than 31 days before (52 patients), was 52.8 (x², p=0.010), which shows the significance of the difference. For this analysis, we excluded patients with no neurological deficit. We concluded that patients who underwent early surgery obtain better results in the rehabilitation program. Does the time between the fracture and the surgery influence the length of stay of the patient in the hospital for rehabilitation? In Graph 34, we noticed that the later the surgery, the longer is the length of stay of the patient in the hospital environment. We compared patients who underwent surgery up to 31 days before inclusively (45 patients), and those who underwent surgery more than 31 days before (59 patients), concluding that the average stay was 71.2 days in the first group, and 83 days in the second one. The difference was significant (x², p<0.026), which authorizes us to assert that: the shorter the time between the fracture and the surgery, the shorter is the length of hospital stay. For this analysis, we excluded the patients with no neurological deficit.
  23. 23. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 23 Average of Gain in FIM scores grouped by length of time between fracture and surgery Average of Gain in FIM Scores DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 >100 Graph 33 Length of stay grouped by length of time between fracture and surgery Length of Stay in Days DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 >100 Graph 34 Does the time between fracture and surgery influence the efficiency ratio (Functional Efficiency Measure gain divided by the length of hospital stay)? In Graph 35, we observed that there is a direct relationship between these two factors: the shorter the time between fracture and surgery, the better the efficiency ratio evaluation. We noticed that 43 patients were grouped as up to 31 days before inclusively, and 50 patients as more than 31 days before surgery. The analysis was significant with x², p<0.005). Does the time between the fracture and admission at rehabilitation hospital influence on treatment and rehabilitation program of the patient? In Graph 36, we noticed that the longer the time between the fracture and its admission, the lower is its evaluation in the FIM Scale at discharge. Graph 37 shows that patients admitted up to 10 days after the fracture feature shorter hospital length of stay. This ascends progressively between 11, 20 days, 21, and 30, of the fracture, indicating that the length of stay increases, reducing gradually later. In Graph 38, the efficiency ratio is high for patients admitted less than 10 days after fracture and decreases in the following groups.
  24. 24. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 24 By the Table 20, 30 patients were admitted less than 10 days inclusively and 63 more than 10 days. The comparison of efficiency rations of these two groups was significant (x², p<0.02), confirming that the shorter the time between fracture and patient admission, the shorter is the length of stay and the better the FIM Scale evaluation and the efficiency ratio. Efficiency Ratio (MIF Gain/Length of Stay) grouped by length of time between fracture and surgery Efficiency Ratio DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 >100 Graph 35 Average Gain in FIM scores grouped by length of time between fracture and surgery Average Gain in FIM Scores DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 > 60 Graph 36 Length of Stay grouped by length of time between fracture and surgery Length of Stay in Days DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 > 60 Graph 37
  25. 25. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 25 Efficiency Ratio (FIM Gain/Length of Stay) grouped by length of time between fracture and surgery Efficiency Ratio DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 >60 Graph 38 Does the waiting time of the patients for surgery, when they are already admitted in the institution where they will undergo rehabilitation after surgery, influence the rehabilitation program? According to Graph, 39 patients were divided into groups of 5 days, from the date of admission to surgery, noticing that 55 patients underwent surgery before the 15th day of admission. (Consider the analysis of other trauma- related spine injuries and preoperative complications.) In Graph 40, we may notice that the MIF Scale gain of hospital discharge was equal for all groups. This indicates that the patients who waited for surgery inside the rehabilitation institution were included in the rehabilitation program and could be rehabilitated, not wasting time, even waiting for surgery. Notice that when comparing those patients who underwent surgery in less than 15 days inclusively, to those who underwent surgery more than 15 days later, there was no significance (x², p<0.48). However, the length of stay of these patients was significantly increased, as demonstrated by Graph 41, in which the average of stay for patients who underwent surgery in less than 15 days of admission inclusively was 66 days, while those who underwent surgery more than 15 days later was 90.7 days, being the efficiency ratio x², p<0.000. According to Graph 42, the efficiency ratio decreases with the increased length of hospital stay. It is noticed that, when comparing 47 patients who underwent surgery with less than 15 days of hospital admission inclusively and 46 patients with more than 15 days, the difference in the efficiency ratio was highly significant (x², p<0.005). Patients waiting for surgical procedures of spine inside a rehabilitation institution do not waste time and participate in the rehabilitation program before and after the procedure. As the procedure is delayed, for the treatment of other trauma-related spine injuries, the length of hospital stay increases, thus reducing the efficiency ratio. (Consider the analysis of other spine trauma related injuries and preoperative complications.)
  26. 26. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 26 Number of cases grouped by length of time between admission and surgery Number of cases DAYS up to 05 06 to 10 11 to 15 16 to 20 21 to 25 26 to 30 31 to 35 36 to 40 41 to 45 >45 Graph 39 Efficiency Ratio (FIM Gain/Length of Stay) grouped by length of time between admission and surgery Efficiency Ratio DAYS up to 05 06 to 10 11 to 15 16 to 20 21 to 25 26 to 30 31 to 35 Graph 42 May the time between the fracture and the surgery be influenced by the presence of severe traumatic injuries of other segments? In Graph 43, a significant amount of traumatic injuries of other segments is evident in patients admitted in the acute phase. Influences are expected once the spinal fracture occurs in polytrauma patients. In Graph 44, patients who had and did not have other related injuries are compared. Cranioencephalic, thoracic, abdominal, pelvic and segment injuries are included here. It was evident that the average time between fracture and surgery in the group with trauma in other related organs decreased from 51 days to 36 days in the group that did not have other trauma-related injuries. The difference was significant, with p<0.05. The trauma related to other regions decreases the indication for the surgical procedure for thoracolumbar spine fracture. Number of cases grouped by length of time between fracture and surgery, separated between those who had or did not have other trauma-related injuries Number of Cases DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 > 60 Graph 43
  27. 27. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 27 Number of cases grouped by length of time between fracture and surgery, separated among those who had or did not have other trauma-related injuries Number of Cases DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 > 100 With trauma-related injuries No trauma-related injuries Graph 44 Is the type of fracture/dislocation related to recurring angulation in late evaluation? According to Graph 22, we notice the angulation on admission, after surgery and in the outpatient appointment. The difference was not as significant when conducted in group, while, in the paired analysis, the difference was significant between fractures A-2 and C-1 (p<0.05). The average of angulation loss of the fracture Type A-2 was 11 degrees and the average of angulation loss of fracture Type C-1 was 24 degrees. This loss occurred with the reangulation in 43 patients evaluated after discharge (third measurement) did not reflect in the individual evaluation of their Functional Independence. May the time between fracture and surgery be influenced by preoperative complications such as urinary tract infection, bedsores and venous thrombosis? In Graph 45, we may notice that, when comparing the groups with and without this type of complication, there was no difference. The average time of indication for surgery in both groups was 41 days, and there was no significant difference with p<0.42. Angulation Correction and Loss – 43 cases (Degrees) 1st Measurement 2nd Measurement 3rd Measurement Graph 22
  28. 28. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 28 Number of cases grouped by length of time between fracture and surgery, separated among those who had or did not have complications Number of Cases DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 >100 With complications (average time for surgery =41 days) No complications (average time for surgery + 41 days - There is no significant difference between average times for surgery (“t” with p.<0.42) Graph 45 DISCUSSION CONSERVATIVE TREATMENT OF THORACOLUMBAR FRACTURE/DISLOCATION The treatment of fracture/dislocation aims to preserve the residual function of the spinal cord and roots and maximize their recovery. It also aims to restore and preserve the alignment of spinal structures, obtain a consolidation free of pain and instability and prevent the occurrence of late neurologic deficit due to angulation, also enabling to mobilize the patient as early as possible in order to complement the rehabilitation. Within these principles, there is a real debate about whether the goals preconized may be reached with the conservative treatment or if there is the need for additional surgical treatment. Treatment with postural reduction and dynamic immobilization has been defended by several authors with great experience8. Laminectomy is absolutely contraindicated in these cases, due to the fact that it increases instability and deformity of the spine, with late damages9. Bed rest is recommended for 6 to 8 weeks, with use of vest for 16 weeks10. Patients with blast injury and no deficit, or with minor deficit, may be treated without surgery11, 12. Below there is an example of reabsorption of bone projection within the spinal canal after six months of injury, where the patient was treated without surgery (Summary of Case 4). The fact that those patients that associate severe traumas of other organs, such as skull, thorax and abdomen, may not be treated surgically during hospital stay, even when there is indication for surgery, draws attention in our casuistry. In this group, we observed extension in the period of rehabilitation. Those who have severe brain related injury could not participate in the rehabilitation program actively, undergoing only family practice. Patients with severe thoracic and abdomen injuries, which prevent the conduction of
  29. 29. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 29 a major surgical procedure, were treated conservatively within the GUTTMANN13´s principles. It was evidenced that the complications, which occurred within the hospital environment, did not extended the length of time of the rehabilitation program. Computer Tomography conducted after the injury. Computed Tomography conducted six months after injury. There was no surgery in this case. Summary of Case 4 - Male patient, 18 years old, running over victim when cycling. Evolved with lumbar pain presenting discreet dorsiflexion deficit of the left foot with hypoesthesia in S-1. No sphincter disorder. The computer tomography at admission showed the burst of L-1 with bone projection within the canal that was treated. The examination repeated six months after the accident showed absorption of anterior bone beam and progressive remodeling of the spinal canal. INDICATION FOR SURGERY The indication for surgery in the spinal cord injury has caused intense debates. Several experimental models have been developed over the years in an attempt to clarify the issue. These models provide rapid compression through bone displacement, traction, torsion, laceration and section, and also test the elasticity by causing a small spinal tension. Other models questioned the application of compressive forces, the kinetic energy involved, the displacement and impulse. The results were basically two classical models of spinal cord injury: a dynamic model and a static model. The dynamic model is usually caused by rapid compression, weight fall, application of clip or extradural balloon. The static model uses slow compression and constant speed, usually caused by weight or extradural balloon inflated slowly. Studies such as the one by TARLOV and KLINGER (17) used an extradural balloon located in the lumbar region to compress the cauda equina of dogs, causing partial compression by 5 minutes, obtaining recovery of neurologic deficit in 60 minutes after cessation of the experiment. The studies by DOLAN and TATOR (14), in addition to the one by GUHA and TATOR (15), placed a compression clip in the level of the first thoracic vertebrae. Weights of 2.3g and 178g were used for 3 to 240 minutes. The process concluded that the intensity
  30. 30. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 30 of the force applied and the compression time on the injuries considered light (between 2.3 and 16.9g) were important factors for the recovery of neurologic deficit. In experiments by NYSTROM and BERGLUND (16), in which weights of 20, 35 and 50g were applied on the thoracic spinal cord of rats, for 1 to 19 minutes, it was observed that the time length was not significant with 20g, but with weights of 35 and 50g the recovery varied with the time length of compression. TARLOV and KLINGER (17) proved that recovery varied depending on the force applied (size of the balloon) and the compression speed (minutes or hours). In summary, the dynamic experimental studies proved that the force of the injury is the main determining factor of the neurological deficit and the length of time may be significant for weights considered “light”. In addition, we should add that in static models, the length of time of the compression was also significant, however, the relevance to the acute spinal cord injury is questionable, once it is difficult to extrapolate it to the injury in humans. The conclusion that the neurologic deficit is defined by the initial trauma generated two different lines of indication for surgery in spinal cord injury. Not submitting patients to surgery is a position defended until these days by the British School12, which initially condemned the laminectomy in the acute phase, whose poor outcomes were related to greater instability. According to Guttmann, there is no indication for surgery, once the injury occurs at the moment of the impact and the decompression of medulla has no effect on recovery. Guttmann considered, in the occasion, that the operative morbidity and mortality superseded the possible benefits. Guttmann blocked, somehow, the development of surgical treatment with that excellent effects obtained through the rehabilitation of patients13. Opposing to the experience, there is indication for early surgery, internal fixation and immediate rehabilitation, positioning defended by the American and European Continent Schools, initially influenced by experimental studies of ALLEN BOHLLER (62), who planned the treatment of spinal cord injury by posterior pithing for drainage of the hematoma. At an early stage, Allen abandoned the research that already tended to demonstrate the existence of secondary injury and, thus, provided no guidance to those who, at the time, based on his initial studies, indicated the surgical treatment as an option. Over time, the two lines developed in different directions: the first one, with rehabilitation techniques and postural treatment of fractures and the second one, questioning the existence of the secondary spinal cord injury and the best moment to submit the patient to surgery, whether at an early or late stage. The latest experimental and clinical research suggests that the decompression in spinal cord injury may improve neurological recovery, demonstrating that time is a factor of paramount importance. DELAMARTER (18) applied a 50 percent compression
  31. 31. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 31 on the spine of the dog for a period of one week. The recovery was observed in those uncompressed within the first hour. Recovery is the reverse of the compressive force applied. It is difficult to transfer the data to the human beings. The force applied cannot be evaluated. We do not know if only traction is enough to align the canal, or whether we should conduct the total decompression of the canal to obtain the result desired. JOHNSSON (19) monitored 17 patients with decompression and stabilization of the thoracolumbar spine. The measure of the canal area postoperatively was 71 percent of normal, with an 86 percent improvement in monitoring. A similar finding was reported by LEVINE (20). However, WILLEN (21), in a study of the natural history of burst fracture between T-12/L-1, described that bone fragments that occupied more than 50 percent of the canal were not reabsorbed and, therefore, remained reducing and compressing the spinal cord and roots. WATERS (23) indicates that the recovery is more pronounced in the first 6 months after the injury. Twelve and 24 months after the injury, however, little improvement occurs. These are studies based on the American Spinal Injury Association6 standards and according to serial evaluation and a manual of the muscles chosen. Myometrial surveys seem to demonstrate continuous recovery after 1 year of injury. In quadriplegics, the possibility of functional recovery decreases with the increased distance below the level of injury. GRAZIANI (23) found 70 percent of recovery on the level below the injury, only 12 percent in the second level below the injury and 0 percent at the third level below the injury in quadriplegics. Muscles with partial injury recover better than those with total injury, in a ratio of 90 percent versus 43 percent. BRACKEN (24) NASCIS II information concluded that 6.7 percent of the patients admitted with total injuries became incomplete injuries. From those, only ¼ could recover the motor function. In contrast, 37 percent of the patients admitted into Frankel B improved. Half of them recovered some function. Fifty- three percent of patients admitted into Frankel C improved to a functional level. Young patients were more successful in the recovery than elderly patients. There are no randomized studies in human beings on the effects of decompression in neurological recovery. Publications on the subject are a mere collection of articles relating to contemporary or historical control groups, or even reports on cases with no control groups. KIWERSKI (25) examined 1,761 patients, 798 of whom did not undergo surgery. He reported that the groups were not similar: 20 percent of mortality in the group of patients who did not undergo surgery, with 8.6 percent in the group who underwent surgery. On complete injury, the mortality was 36 percent in the group of patients who did not undergo surgery, against 19 percent in the group who underwent surgery. The hospital stay was 27 weeks for the group of patients who did not undergo surgery and 17 for the group who underwent surgery. The
  32. 32. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 32 average length of stay in both groups was 9 to 12 weeks. It is worth mentioning that surgery is delayed for those with severe related-injury or complications resulting from traumatic injuries of other organs. BRUNETTE (26) showed that the traumatic cervical dislocation reduced by traction immediately after the injury and appropriate radiological control may result in significant neurological recovery. WEINSHEL (27) evaluated a comparative study between groups of patients only with arthrodesis and fixation and another one related decompression, not noticing substantial difference. BOSE29 analyzed patients with center cervical spinal syndrome and obtained sensitive improvement in the group who underwent surgery within the 20 initial days after the injury. KRENGEL29 evaluated decompression in incomplete thoracic paraplegia. The recovery obtained greater success in patients of the historical control group, with 68 percent of recovery in uncompressed and fixated patients, with a 44 percent drop in those who underwent only the fusion. HU30 evaluated the effect of decompression in incomplete lumbar injuries. The average improvement in the ASIA Scale for motor deficit was 10 points. Those patients who had fusion with no decompression improved 4.2 points (p>0.05), achieving significant statistical difference. Evidence from the literature that confirms decompression as efficient in the SCI (spinal cord injury) is present in studies of Level III, IV or V (C degree). The same recommendation is made for the removal of fragments of the canal. There are also two level-III studies that did not demonstrate benefits at decompression and removal of fragments. Within the protocol we used, all the patients underwent to surgery by using the same technique with decompression, fixation and arthrodesis. We were able to observe, however, that patients with total injury kept their injury (Frankel/ASIA = A), while those with partial injury tended to improve. This improvement was more evident in those patients with injury below or including the level of L1. We observe in Table 26-A that 85 percent of patients in C tend to migrate to D and E and that 55 percent of the patients classified in B tend to migrate to C or D. On final evaluation (Table 26-B), 70 percent of the patients migrated at least one level on the Frankel/ASIA Scale.
  33. 33. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 33 Chart 26-A Comparative study on the evolution of patients according to the neurologic deficit at admission and discharge Discharge A B C D E Admission 72 05 07 20 15 A 75 2 deaths 1B B 09 +1 A -5 B C 20 +4 B – 2 E 17 C D 04 +1 B +15 C E 13 +2 C Outcome – There was migration of 55 percent of the cases from B to C and D and 85 percent from C to D and E. Chart 26-B Comparative study on the evolution of patients according to the neurologic deficit at admission and outpatient evaluation Discharge A B C D E Admission 56 03 04 17 14 A 72 0 B 05 -1 B C 07 -2 C D 20 -3 D +2 C +1 B E 15 +3 D
  34. 34. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 34 WHEN SURGERY IS RECOMMENDED During the surgical study, the question of when surgery is recommended is not resolved. The use of a new classification of the types of fractures, as in the item above that deals with the indication for (early or late) surgery, does not answer this question either. We observed the existence of experimental studies that favor early surgery: TARLOV (13), DOLAN and TATOR (14), GUHA and TATOR (34) and also studies with clinical evidence that any recovery occurs when the injury occurred more than 24 hours before. The question is: what about those between 1 and 23 hours? There is also no definitive evidence for or against early surgery. None of the two schools could refute injury evidence. It is present in experimental models characterized as: late injury in the white and grey spinal matter, glutamate-related calcium- mediated injury, free radicals (lipid peroxidation) and ischemic injury. There is also, in the literature, clinical evidence supporting surgery. MAIMAN (33) evaluated 20 patients with thoracolumbar injuries that had late decompression through lateral cavity and noticed that 17 patients improved. WEINSHEL (27) examined 90 patients with cervical spinal cord injury, classified in Frankel A and B and noticed that 47 of them recovered the root function below the injury and 14 have recovered the spinal function also below the injury. We have to consider that, in thoracolumbar transition (most frequent location of these fractures), the injuries are a mixture of spinal cord and root injuries that have different clinical behaviors. There is also clinical evidence in the literature that does not support the surgery as the study by TATOR (34), which examined 208 patients with spinal cord injury and cauda equina, 116 (56 percent) of which underwent surgery with mortality of 6.1 percent, compared to 15.2 percent of patients who did not undergo surgery, being deep vein thrombosis the most frequent problem. Comparing the groups, there is no evidence of neurological recovery. FRANKEL (5) analyzed 612 patients with closed spinal cord injury. All were treated with postural reduction and only 4 needed surgery for spinal instability, which occurred lately. In this group, there were 2 percent of neurological worsening in patients during treatment. MARSHALL (35) conducted a prospective study with 283 patients with spinal cord injury, noticing patients worsening related to early surgery. WILLEN (8) stated there was no difference in the result whether the patient undergoes early or late surgery. Studies with clinical evidence supporting surgery: DUH (36) studies 187 patients with spinal cord injury, based on data from NASCIS II, being 56 through anterior approach, 247 through posterior approach and 38 patients with injuries that occurred less than 25 hours before and improvement of 17.8 percent, compared to the group which did not undergo surgery, in which there was 13.8 percent improvement. In this study, 105 patients underwent surgery more than 200 hours after injury, from which 16.4 percent improved. The author concluded
  35. 35. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 35 that the surgery is beneficial, regardless of the time of its conduction. There were differences in the analysis of the surgery effects, including misdeeds and even mortality. For WIMOT and HALL (37) and TATOR (34), surgery increases the complications. Both MARSHALL (36), who evaluated surgeries that occurred less than 5 days after injury, and LEVI38, who analyzed surgeries that occurred less than 24 hours after injury, adopt the same point of view. The study by WILBERGER (63) analyzes a group who underwent surgery less than 24 hours after injury, admitting that early surgery causes fewer complications. The conclusions that may be obtained from these studies are that laboratory tests enable the assurance that decompression may have positive aspects, however, they raise doubts as regards the moment to conduct such procedure. The positioning of GUTTMANN (12) concerning laminectomy was indeed valid, however, it was not consistent with the current methods of spine fixation. Those are techniques that may be performed safely, in specialized centers, at any time of the occurrence of spinal cord injury. Several small series of cases studied suggest the benefit of surgical decompression, however, in contrast, three major series, such as MARSHALL (35), TATOR (34) and DUH (36) failed to demonstrate the beneficial aspects. Over time, there have been modifications of the process. HEIDEN (40), for example, proved that patients with spinal injuries who underwent surgery in the first week after injury had 46 percent of complications and for those who underwent surgery after more than 1 week, the ratio dropped to 27 percent. MARSHALL (35) found 15 percent of neurological deterioration in patients who underwent surgery less than 5 days after injury. After this period, there was no deterioration. This allows us to assume that the evolution of the secondary injury, in some patients, may be confused or aggravated by surgical procedure, considered an additional injury in polytrauma patients. By analyzing the thoracolumbar region fractures, the Sociedade para Estudo da Escoliose (1992) showed 25 percent of complications in patients who underwent surgery and 3 percent in those who did not undergo surgery. DICKSON (41) evaluated 49 patients with thoracolumbar fractures and found the same recovery in a period between 8 and 35 days among those who underwent surgery less than 24 hours after injury. BENZEL (42) conducted anterior decompression in patients with more than 19 days after injury, not having found relation between recovery and the moment of the surgery. CLOHISY (43) monitored 20 patients with anterior decompression and compared half of them with decompression in less than 48 hours to the other half with an average of 60 days after the injury. In this series, patients with early decompression had better neurological recovery in comparison to those with late decompression.
  36. 36. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 36 BRUNETTE (26) has an interesting work that studies bilateral dislocation of facets and its reduction time with neurological recovery. The procedure relates the early surgical treatment with recovery. It is also possible to construe that the reduction of a bilateral dislocation of facets at cervical level withdraws the continuous traction and compression factor of the spin cord, preventing aggravation of the secondary injury. The analysis detailed at NASCIS II25 shows that from the 487 patients included in the study, only 295 underwent surgery. From those, 38 underwent surgical treatment less than 25 hours after injury and 105 more than 200 hours after injury. In our study, we concluded that surgery does not increase the risk of neurological worsening. The complications and hospital stay are reduced, however the effect about the neurological deficit recovery is inconclusive. Even among those who believe that surgery may improve the patient with spinal cord injury, there is some disagreement about the ideal moment to conduct it. WAGNER (44) is contrary to early surgery and MARSHALL (35) believes it may worsen the condition of the patient. Apologists of that modality of surgery bet on canal decompression and spinal immobilization as factors that enable early mobilization, thus avoiding prolonged bed rest with neurological improvement and early physiotherapy. MARSHALL (35) indicates caution, once in a multicenter study with 283 patients, from 134 patients who underwent surgery, 4 had the condition deteriorated after the procedure. They underwent surgery within the first 5 days after injury. HEIDEN (40) observed that those who underwent surgery in the first week had a higher number of pulmonary complications than those who underwent late surgery. Improvement was found in 1.5 to 5 percent of the cases of those who underwent surgery, however the time of surgery was not analyzed. ANDERSON and BOHLMAN (32) recommend late decompression in cervical injuries. Forty-nine percent of the 51 patients who underwent surgery between 1 month and 8 years of injury improved at least one neurological level. KATOH and MASRI (45) evaluated 53 patients with complete cervical spinal cord injury that were treated conventionally and from the 40 patients monitored for 12 months, 19 recovered. AEBI46 evaluated 100 patients with cervical injury and concluded that 1/3 of them improved neurologically and 75 percent had fractures that were reduced either manually or surgically up to 6 hours after injuries. LEVI38 examined 103 patients treated with anterior decompression retrospectively and no difference was observed in the neurological recovery of the patients who underwent surgery within 24 hours after surgery and those who underwent to surgery after more than 24 hours. The literature presents a mixture of studies of level III and V, conflicting with each other. Based on the evaluation of the surgical indications by DONOVAN (47), the idea that surgery improves the neurological outcome could not be confirmed, however, the evidence is not
  37. 37. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 37 as strong to the point of invalidating his indication. In selected patients, where there is spine cord and roots to be preserved, early decompression seems to have a theoretical potential for improvement. It is not a riskless surgery. The patient may occasionally deteriorate. In order to solve the question, more detailed studies are necessary. Thus, the moment of surgery is still controversial, requiring a randomized study for further clarification, including finding out whether the surgery is beneficial or not in the treatment of secondary injury. Even in the face of those facts, several authors are in favor of early surgery, aiming at neurological improvement with spine stabilization and reduction of complications related to prolonged immobilization in bed and early commencement of the patient rehabilitation, with resultant cost reduction. Those are refutable arguments, depending on the condition of service for the patient. In our study, we admitted most of the patients within the first two weeks after injury, and also most of them undergo surgery in the following week. The time of surgery depends on the severity of the trauma- related injuries. In a service aimed at rehabilitation, there seems to be no increase in the rehabilitation time of the patients that wait for surgery. This is our experience. Such conclusion is curious, once it shows that the ones who defend early surgery in emergency are somewhat correct. They aim, with this, to reduce the waiting time of the patient to be transferred to the rehabilitation center. On the other hand, the clinician responsible for patients is convinced that, with or without surgery, the moment of the procedure does not change the length of hospital stay and the end result of rehabilitation. Thus, we may be in favor of both sides in a recurrent discussion among experts. If the service should indicate the patient for rehabilitation in another department, and this transfer depends on the spine being stabilized or not, then the waiting time may influence the increased total time of hospital stay. In rare and exceptional cases, there is indication for emergency surgery in open dura mater injuries, progressing neurologic deficit caused by misalignment, great angulation or progressive angulation and pain related with severe spinal instability. With reference to the conduction of the surgery, there is disagreement in the literature. In patients with multiple injuries, there are authors who tend to conduct emergency surgery, once we know, in the early hours after injury, that the patient has more favorable conditions, which we call Window of Opportunity. This window occurs before the development of systemic complications. Patients with spinal cord injury, particularly those with thoracic, abdominal or high lesion, often develop respiratory complications (atelectasis and pneumonia) in the hours following spinal injury, which makes immediate surgery inconvenient. BRACKEN (24) demonstrated the beneficial effect of using Methylprednisolone in the early hours after injury and was criticized and discredited subsequently. YOUNG and
  38. 38. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 38 BRACKEN (48) defend the idea that the same therapeutic window should be used for surgery, to improve the prognosis of spinal cord injury recovery. The argument would be the observation of improvement in microcirculation and axonal compression. Therefore, the purpose of emergency surgery has the following advantages: 1- it would avoid systemic complications, stabilizing the spine at an early stage; 2- it would restore normal anatomophysiological conditions at the site of injury and early would enable the early transfer of the patient to the place of rehabilitation. WHICH APPROACH SHOULD BE USED FOR SURGERY – Before the various alternatives, posterior instrumentation and fusion related to decompression were selected for treatment of injuries, especially when the surgical approach occurs later than the 5th day after injury (which is more frequent in this casuistry), when only the alignment of the spine does not enable the expansion of the canal. There are several alternatives regarding the surgical route to be used in the treatment of thoracolumbar transition fractures: anterior decompression and instrumentation; posterior decompression and instrumentation and those methods combined. The most acceptable option is controversial. Mc AFEE and BOHLMAN (49) concluded that, with the anterior decompression of thoracolumbar spine, there was improvement of one level in the Frankel Scale in 88 percent of patients with incomplete neurological injury. KANEDA (50) obtained, through the same anterior route, an improvement of one level in 70 percent of patients. DICKSON and HARRINGTON (51) obtained improvement of level in the Frankel Scale in 75 percent of patients who underwent surgery by posterior approach. HARDAKER52 conducted bilateral pedicle trans decompression and instrumented with Harrington rods, obtaining improvement of one level in 85 percent of cases. EDWARDS (53) instrumented through posterior approach and all of his patients had neurological improvement. ESSES54 conducted a prospective study and compared two groups, with no difference between the anterior and posterior approaches. GERTZBEIN (55) did not notice statistical difference and 88 percent of patients who underwent surgery through anterior approach improved one level in the Frankel Scale, while 83 percent of those who underwent surgery through posterior approach also improved one level. In our study, we observed that 50 percent of patients with partial deficit (Frankel/ASIA B/C/D) migrated at least one level in the clinical evaluation at discharge. Among 46 patients, 23 improved. In the evaluation appointment after surgery, other 6 patients of this group showed upward migration in one level, increasing the improvement ratio to 70 percent. SHAFFREY and DANISA56 conducted a prospective study with 130 patients, from whom 49 underwent surgery, 27 through posterior approach, 16 through anterior approach, and 6 through the two routes. Among the items compared, the blood loss, the hospital stay, the cost of the procedure and the time of surgery were higher in the anterior approach.
  39. 39. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 39 However, the correction of kyphosis and the neurological improvement were not significantly different among the groups. In the posterolateral approach through facetectomy, the fenestration enables the removal of anterior bony projections and disc material often herniated to the inner part of the spinal canal. The fixation system consisting of a rectangle and sublaminar wires enables a rigid construction, which provides fixation and consolidation of arthrodesis. DOVE (64) should include abundant amount of bone graft on the entire region fixed and not on the level fractured. This leads to a lower stress on the system, reducing the indication for late surgery to withdraw the system due to fatigue or rupture. In patients with persistent compression of the spinal canal and with no improvement of the neurological deficit as expected, the anterolateral approach in a second moment may be chosen. If fusion through posterior approach has already occurred, there is no need for instrumentation, and only for decompression with bone graft. WHICH APPROACH SHOULD BE USED FOR SURGERY Before the various alternatives, posterior instrumentation and fusion related to decompression were selected for treatment of injuries, especially when the surgical approach occurs later than the 5th day after injury (which is more frequent in this casuistry), when only the alignment of the spine does not enable the expansion of the canal. There are several alternatives regarding the surgical route to be used in the treatment of thoracolumbar transition fractures: anterior decompression and instrumentation; posterior decompression and instrumentation and those methods combined. The most acceptable option is controversial. Mc AFEE and BOHLMAN (49) concluded that, with the anterior decompression of thoracolumbar spine, there was improvement of one level in the Frankel Scale in 88 percent of patients with incomplete neurological injury. KANEDA50 obtained, through the same anterior route, an improvement of one level in 70 percent of patients. DICKSON and HARRINGTON (51) obtained improvement of level in the Frankel Scale in 75 percent of patients who underwent surgery by posterior approach. HARDAKER52 conducted bilateral pedicle trans decompression and instrumented with Harrington rods, obtaining improvement of one level in 85 percent of cases. EDWARDS (53) instrumented through posterior approach and all of his patients had neurological improvement. ESSES54 conducted a prospective study and compared two groups, with no difference between the anterior and posterior approaches. GERTZBEIN (55) did not notice statistical difference and 88 percent of patients who underwent surgery through anterior approach improved one level in the Frankel Scale, while 83 percent of those who underwent surgery through posterior approach also improved one level. In our study, we observed that 50 percent of patients with partial deficit (Frankel/ASIA B/C/D) migrated at least one level in the clinical evaluation at discharge. Among
  40. 40. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 40 46 patients, 23 improved. In the e valuation appointment after surgery, other 6 patients of this group showed upward migration in one posterior approach, 16 through anterior approach, and 6 through the two routes. Among the items compared, the blood loss, the hospital stay, the cost of the procedure and the time of surgery were higher in the anterior approach. However, the correction of kyphosis and the neurological improvement were not significantly different among the groups. In the posterolateral approach through facetectomy, the fenestration enables the removal of anterior bony projections and disc material often herniated to the inner part of the spinal canal. The fixation system consisting of a rectangle and sublaminar wires enables a rigid construction, which provides fixation and consolidation of arthrodesis. DOVE (64) should include abundant amount of bone graft on the entire region fixed and not on the level fractured. This leads to a lower stress on the system, reducing the indication for late surgery to withdraw the system due to fatigue or rupture. In patients with persistent compression of the spinal canal and with no improvement of the neurological deficit as expected, the anterolateral approach in a second moment may be chosen. If fusion through posterior approach has already occurred, there is no need for instrumentation, and only for decompression with bone graft. COMPLICATIONS In the posterior and posterolateral approach, there may be dural injury in the preparation or placement of the instruments and, whenever possible, it should be repaired. The placement of instrumental may compress the spinal cord and/or roots, accentuating deficit and pain. Adequate training for the use of instrumentation and the preoperative use of the evoked, and motor and sensory potentials may be useful for the prevention of this type of complication. There may be bad reduction, hypertraction, hyperextension or rotation. We indicate the conduction of radiological control during surgery. The procedure is conducted with the prophylactic use of antibiotics. The patient preparation is important as well as special attention to skin conditions in the preoperative stage. Infection may mean the withdrawal of the instruments, which should be postponed to the maximum, i.e. until spinal fusion. Major bleeding is possible during the procedure. It is a complication that must and may be avoided by careful dissection, ligation or protection of vessels. The use of drains in the surgical area and a routine, one drain in the surgery site and another one in the side of graft donation, when applicable. In the anterior portion approach, there may be a number of problems: injuries of abdominal and thoracic organs, due to proximity to the spine, bleeding by laceration of the inferior vena cava, aorta or smaller arteries, neurological injury and liquoric fistula, in addition to infectious complications, with formation of pseudarthrosis. Special attention
  41. 41. Masini Treatment of Thoracolumbar…… Neurocirugía-Neurocirugía / Vol. 23 / 2014 41 should be given to dissection plans and hemostasis. The great vessels should be dissected, deviated or connected before being sectioned. Occasionally, there may be other distant complications, as in the pneumothorax due to trauma-related fracture of ribs, pulmonary embolism and urinary infection. Late complications may happen with the disruption of the system used for fixation, due to bending strength. The postoperative pain may be due to the deafferentation, when a few patients may require the conduction of DREZ (coagulation of posterior root entry). This means later approach, with removal of the entire system and conduction of a broader laminectomy. Such a procedure, if possible, should be conducted later, after the occurrence of the anterior fusion, once this may lead to instability. CONCLUSIONS Patients with severe neurologic deficit related to unstable thoracolumbar spine injuries are potential candidates for surgical procedures. The moment to conduct the surgical procedure should respect all clinical conditions of the patient. Individuals with injury related with skull, thorax and abdomen should have their surgery scheduled for the moment the general condition is clinically balanced. The time waiting for surgery does not influence the outcome with regard to neurological recovery and rehabilitation as demonstrated in this study. It only extends the length of hospital stay and reduces the hospital efficiency ratio which is a function based on the rehabilitation time. The method to be used should enable the concomitant decompression of neural elements with spinal fixation and arthrodesis. The decompression of neural elements should be considered whenever there is deficit and/or misalignment of the spinal canal. The fact that lumbar injuries show recovery potential five times higher than when compared with thoracic and cervical injuries justify this approach, since those are mixed spinal root injuries. The surgical stabilization of the spine occurs immediately. The method relieves pain and stabilizes the deformity, enabling the complementation of the rehabilitation program. Late evaluation enabled to detect that patients admitted with great dislocations and treated by using this method evolve with reangulation at the level of the injury and it does not influence the final outcome of treatment and rehabilitation. Preoperative clinical complications did not change the rehabilitation program of the patient, but influenced in deciding when to indicate the surgical procedure. The postoperative complications are similar to those of other methods, and are treatable. Safety, simplicity and economy are factors that contribute to surgeons continue using this method to treat thoracolumbar spine fractures and/or dislocations.
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