Eur Spine J (2017) 26:2682–2717 DOI 10.1007/s00586-017-5270-9
ABSTRACTS
Abstracts GEER 2017—San Sebastian, Spain
ORAL PRESENTATION 1 PREDICTIVE MODELS TO BE CONSIDERED IN SURGICAL DECISION-MAKING IN ADULT THORACOLUMBAR SCOLIOSIS Authors: 1Pizones Arce, Javier; 1Pe´rez Martı´n-Buitrago, Mar; 1 Sa´nchez Pe´rez-Grueso, F. Javier; 2Domingo Sa`bat, Montse; 2Vila Casademunt, Alba; 3Alanay, Ahmet; 4Obeid, Ibrahim; 5Acaroglu, Emre; 6Kleinstu¨ck, Frank; 7 Pellise Urquiza, Ferran; 8 European Spine Study Group, ESSG Workplaces: 1Hospital Universitario La Paz, Madrid, Spain; 2Vall Hebron Instititut De Recerca, Barcelona, Spain; 3Acibadem Hospital, Istanbul, Turkey; 4Chu Bordeaux, Bordeaux, France; 5Ankara Spine Centre, Ankara, Turkey; 6Schulthess Klinik, Zurich, Zurich, Switzerland; 7Hospital Universitario Vall d´Hebron, Barcelona, Spain; 8 European Spine Study Group, ESSG, Barcelona, Spain Introduction: To date, it is still unclear which is the ideal moment to surgically intervene patients with adult thoracolumbar scoliosis and who would obtain maximum clinical benefit with minimum risk of complications. The goal in this study is to obtain data to ease the decision-making process. Materials and methods: Retrospective analysis of data on patients with adult spinal deformity collected retrospectively from a multicenter database. Patients who underwent surgery due to thoracolumbar (TL) curves were initially identified. On the one hand, we chose as predictive variables those we considered more relevant for preoperative decision-making: age; magnitude of the coronal and/ or sagittal deformity (TL Cobb, lumbar mismatch (PI-LL), and SVA); and clinical symptoms (ODI and SRS-22 for evaluating function, pain, and image). On the other hand, the selection of the outcome variables was based on their capacity to quantify the surgery risks (blood loss, length of procedure, surgical aggressiveness-ADSCI-, complications) and benefits (SRS-22 for evaluating postoperative pain and image at 2 years). We created a predictive multivariate analysis with stepwise regression.
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Results: One hundred and seventy-five (175) patients met the inclusion criteria. Preoperative TL Cobb, SVA, and ODI predicted blood loss (R2 = 0.18). Preoperative TL Cobb and SVA predicted length of procedure (R2 = 13.7). Lumbar mismatch predicted surgical aggressiveness (R2 = 15.1). Preoperative pain predicted postoperative pain (R2 = 25.1). The initial image, ODI, and preoperative function predicted the final image (R2 = 29.9). Age, TL Cobb, and SVA predicted the complications (OR = 1). Conclusions: The risk of postoperative complications increases with age, but is not associated with the degree of surgical aggressiveness or to clinical outcome. Greater curve magnitude and sagittal mismatch correlates to longer length of procedure, more bleeding, and increased rate of complications, but no association with surgical aggressiveness or clinical outcome was determined. Higher lumbar mismatch correlates to greater surgical aggressiveness but not necessarily to more bleeding or complications. Preoperative clinical perception determines postoperative clinical perception regardless surgical parameters and complications. These predictive models provide systematic information based of the largest series of patients with adult thoracolumbar scoliosis published to date, which will be of help during the process of surgical decision-making.
2 CAN IMPEDANCE AUDIOMETRY PREDICT THE POSITION OF A PEDICLE SCREW IN A SIMPLE X-RAY DURING SCOLIOSIS SURGERY? ´ ngel; Authors: 1Mene´ndez Garcı´a, Miguel; 1Hidalgo Ovejero, A 1 Manrique Cuevas, Diego; 1Izco Cabezo´n, Toma´s; 2Sancho Gonzalez, Ignacio; 1Zabalza Hermoso de Mendoza, Norberto; 1Bermejo Arana, Irati Workplace: 1Complejo Hospitalario de Navarra, Navarra, Spain; Hospital Reina Sofı´a Tudela, Navarra, Spain
2
Objectives and introduction: The most precise way to know the placement of pedicle instrumentation in the management of deformity surgery is by using CT scans; however, simple radiological criteria can also be used to determine the position of the screw with reasonable specificity and sensitivity. In this study, we analyze the
Eur Spine J (2017) 26:2682–2717 relationship between the position of the screws as seen in simple X-rays and their neurophysiological impedance in scoliosis surgeries performed in our hospital. Materials and methods: Prospective randomized assessment of 383 screws in 25 scoliosis surgically treated in our center. Impedanciometry data of each screw were compared against the combination of misplacement criteria in simple radiology of pedicle instrumentation as per Kim and Lenke (Spine, 2005): (1) disruption of the normal line of progression of the tip of the screw; (2) lateral position of the tip of the screw in relation to the medial wall; (3) invasion of the mean line of the imaginary wall of each vertebral body. The Chi square test was used to analyze the potential association between neurophysiological criteria and simple X-rays. Cohen’s kappa coefficient was determined to assess similarities between these parameters. A sensitivity–specificity study was finally performed to assess the predictive ability of one parameter as compared with the others. Results: No significant association was observed (X2 = 2.12, p = 0.145); the misplacement RR in cases with impedance \8 mA and [8 mA was 1.66 (95% CI 0.84–3.27). Cohen’s kappa coefficient analysis suggests low agreement, k = 0.08 (p = 0.145). Our results show that neurophysiological values have low predictive value, as well as low sensitivity; on the other hand, they seem to have acceptable specificity and high negative predictive value. Discussion: Systematic use of CT scans is not justified in our environment for clinical research purposes, for which reason Kim’s criteria are used for determining the position of pedicle screws. A neurophysiological control provides further safety for their placement. According to our data, there is no relationship between impedanciometry and screw misplacement as per simple X-rays, although the data could be different if assessment is performed with CT scans.
3 THE VALUE OF TRANSCRANIAL MOTOR EVOKED POTENTIAL FOR INTRAOPERATIVE MONITORING OF SPINAL NERVE ROOTS DURING SPINAL SURGERY Authors: Alungulese AL1, Traba Lo´pez A1,2 Workplace: 1Department of Clinical Neurophysiology, Gregorio Maran˜o´n University Hospital, Madrid, Spain; 2Department of Neurology-Clinical Neurophysiology, HM Hospitals, Madrid, Spain Introduction and purpose: Paraplegia is the most severe complication of spinal surgery, but spinal nerve root injuries are much more frequent, being responsible for focal motor deficit and sensitive disturbances. Currently, there is a lack of defined criteria for the prediction of spinal nerve root deficits. Spontaneous and stimulustriggered electromyography is primarily used to monitor nerve root activity and proper placement of the screws. The purpose of this study is to investigate the value of transcranial motor evoked potential (TcMEP) for early detection of impending spinal nerve root injury and to establish cutoff warning criteria. Materials and methods: We present a retrospective study of 159 patients (72.13% women) with a mean age of 61.35 years, who underwent spinal surgery with TcMEP monitoring for degenerative pathology involving dorso-lumbar spine. The TcMEP were recorded from upper-limb and lower-limb muscles (quadriceps, tibialis anterior and abductor hallucis muscles). To be worthy of analyses, changes should include TcMEP amplitude decrease during surgical
2683 maneuvering. Different cutoff values of amplitude decrease were analyzed in order to determine the proper criterion to detect spinal nerve root injury. Results: The main aetiology was degenerative scoliosis (42.62%) affecting in the most of the cases the lumbar region (64.48%). Nine patients were excluded because the decrease of TcMEP was related to systemic causes. Spinal nerve root injury was observed in eight patients (4.37%): five cases affecting L5 level and three involving L2–L3–L4 levels. We analyzed cutoff warning criteria of 60, 70 and 80% of TcMEP amplitude decrease in order to determine the most reliable correlation with postoperative deficits. Using the criterion of a 60% decrease we obtained a sensitivity of 1 but a positive predictive value of 0.5, resulting in a high number of false positive (8 cases). Applying a stricter criterion, in which recordings site show a decrease of 70% we got one positive and one false negative case (sensitivity of 0.8 and specificity of 0.99). An 80% decrease of amplitude had a sensitivity of 0.37 and showed five false negative cases. Conclusion: Our study points out that the most reliable correlation of postoperative deficits related to spinal nerve root injury is with deterioration of amplitudes of 70% TcMEP as this cutoff value had the lowest number of false positive and false negative in our study.
4 CLINAL IMPACT OF ILIAC INSTRUMENTATION ON THE QUALITY OF LIFE OF ADULT PATIENTS WITH SPINAL DEFORMITY Authors: 1Pe´rez Martı´n-Buitrago, Mar; 1Pizones Arce, Javier; 1 Sa´nchez Pe´rez-Grueso, Francisco J.; 2Domingo Sa`bat, Montse; 2Vila Casademunt, Alba; 3Acaroglu, Emre; 4Obeid, Ibrahim; 5Kleinstu¨ck, Frank; 6Ahmet, Alanay; 7Pellise´ Urquiza, Ferran; 8European Spine Study Group, ESSG Workplaces: 1Hospital Universitario La Paz, Madrid, Spain; 2Vall Hebron Institut De Recerca, Barcelona, Spain; 3Ankara Spine Centre, Ankara, Turkey; 4CHU Bordeaux, Bordeaux, France; 5Schulthess Klinik, Zurich, Switzerland; 6Acebadem University Faculty Of Medicine, Istanbul, Turkey; 7Hospital Vall Hebron, Barcelona, Spain; 8 European Spine Study Group, ESSG, Barcelona, Spain Introduction and objectives: In some adult spinal deformities, fixation to the pelvis using iliac screws is required, which can affect certain day-to-day activities. The aim in this study is to assess these effects by analyzing the quality of life of patients with iliac screws in comparison to patients who had undergone instrumentation up to L5 or the sacrum (L5/S1/S2). Materials and methods: Retrospective analysis of information prospectively collected from an adult spinal deformity database. We included patients whose lowest instrumented vertebra (LIV) was L5 or below and with at least eight levels of arthrodesis. Patient’s condition preoperatively and at 6 months and 2 years after the surgery was assessed. Age, Cobb angle, coronal and sagittal imbalance, instrumented levels, and quality of life questionnaires (ODI, COMI, and the physical activity and pain components of the SRS-22 and the SF-36) were analyzed. Intergroup comparison was performed using the t-Student and Mann–Whitney U tests. Results: One hundred and twenty-nine (129) patients met the inclusion criteria. The sample was divided into two groups, ‘‘iliac YES’’: patients with iliac screws (N = 104) and ‘‘iliac NO’’: patients whose LIV was L5/S1/S2 (N = 24). Preoperatively both groups were homogeneous for all variables except for age, which showed to be
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higher in ‘‘iliac YES’’ (66 vs 56 years) (p = 0.008) and the Cobb angle, which was greater for ‘‘iliac NO’’ (45° vs 31.0°) (p = 0.019) (Table 1). The number of arthrodesis levels was higher for ‘‘iliac YES’’: mean = 12.6 (s = 3.4) in comparison to a mean of 10.9 (s = 3.0) for ‘‘iliac NO’’ (t = 2.28, p = 0.02). No statistically significant differences in any of the analyzed parameters were observed 6 months post-surgery. Two years after the surgery, no group differences were seen for any of the studied variables (p [ 0.2).
Conclusions: Starting from homogeneous and comparable groups, it was observed that iliac instrumentation was more frequent for longer arthrodesis and older patients. Pre-operative and follow-up scorings with the used quality of life questionnaires were similar for both groups. Thus, it is not possible to conclude that iliac instrumentation has a negative effect on patient’s quality of life with currently available tools.
Table 1 Preoperative Median Age Cobb CI SI ODI
2 years Interquartile range
p 0.009*
Iliacs YES
66 years
from 59.25 to 71.00
Iliacs NO
56 years
from 46.00 to 69.50
Iliacs YES
31.00°
from 18.00 to 48.00
Iliacs NO
45.00°
from 35.00 to 56.00
Iliacs YES
20.68 mm
from 9.28 to 34.62
Iliacs NO
12.84 mm
from 5.59 to 28.68
Iliacs YES Iliacs NO
68.30 mm 36.85 mm
from 23.47 to 110.37 from 0.00 to 88.58
0.244 0.958
Iliacs YES
49.00
from 38.00 to 64.00
Iliacs NO
50.00
from 41.00 to 61.00
SRS22 function
Iliacs YES
2.80
from 2.30 to 3.00
Iliacs NO
2.45
from 2.00 to 2.80
SRS22 pain
Iliacs YES
2.30
from 1.78 to 3.00
Iliacs NO
2.00
from 1.65 to 2.50
SRS22
Iliacs YES
2.58
from 2.05 to 3.00
Iliacs NO
2.52
from 2.03 to 2.95
Iliacs YES
32.45
from 27.83 to 37.87
Iliacs NO
31.53
from 25.52 to 37.88
Iliacs YES
30.75
from 25.01 to 36.49
Iliacs NO
32.66
from 27.39 to 40.32
SF36 RP
Iliacs YES
30.21
from 23.47 to 36.95
SF36 BP
Iliacs NO Iliacs YES
27.96 33.77
from 24.03 to 34.14 from 30.55 to 38.21
Iliacs NO
30.55
from 26.52 to 34.58
Iliacs YES
40.35
from 33.22 to 48.43
Iliacs NO
38.44
from 33.22 to 47.48
Iliacs YES
7.30
from 5.90 to 8.40
Iliacs NO
7.00
from 5.90 to 9.50
S36 PCS SF36 PF
SF36 GH COMI Number of levels
0.019* 0.086
Median
interquartile range
p
0.255
13.00°
from 7.25 to 22.5
19.00°
from 8.00 to 26.00
16.8 mm
from 6.40 to 30.83
15.2 mm
from 6.00 to 31.25
37.94 mm 34.5 mm
from 14.40 to 74.00 from 10.70 to 66.09
0.548 0.289
40.00
from 18.00 to 58.00
30.00
from 20.00 to 49.00
0.414
3.00
from 2.40 to 3.71
3.40
from 2.80 to 3.90
0.277
3.30
from 2.50 to 4.00
3.00
from 2.12 to 4.10
3.11
from 2.50 to 3.85
3.40
from 2.70 to 3.75
0.974 0.655 0.385
37.48
from 30.45 to 45.36
40.50
from 30.93 to 46.65
36.49
from 26.92 to 44.15
42.23
from 31.70 to 46.06
0.953
0.217 0.751 0.400 0.744 0.199
0.904
32.46
from 30.21 to 44.24
0.198
0.269
39.19 38.21
from 30.21 to 49.30 from 30.55 to 46.68
0.783
38.21
from 27.53 to 49.70
0.990 0.914
43.68
from 37.61 to 53.19
43.68
from 36.18 to 49.62
4.60
from 2.23 to 7.10
3.95
from 2.97 to 7.10
Iliacs YES
11
from 10.00 to 15.00
Iliacs NO
10
from 8.00 to 14.00
0.278 0.912 0.024*
Cobb Cobb angle, CI coronal imbalance, SI sagittal imbalance, quality of life questionnaires ODI, SRS22 function, SRS22 pain, SRS22 SRS22 subtotal, SF36 PCS physical component, SF36 PF physical activity, SF36 RP physical role, SF36 BP body pain, SF GH general health, COMI, number of levels number of arthrodesed levels * Statistically significant differences
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Table 1 continued
INFLUENCE OF SACROPELVIC FIXATION ON FUNCTIONAL LIMITATIONS IN PATIENTS WHO UNDERGO SURGERY DUE TO ADULT SPINAL DEFORMITY. EFFECT ON SRS-22 SUBDOMAINS Authors: 1Lombao Iglesias, Domingo; 1Blanco Hortas, Andres; 2 Ferna´ndez Gonza´lez, Manuel; 1Estany Gestal, Ana; 2Esteban Blanco, Marta; 1Bermu´dez Lo´pez, Marı´a Jose´; 2Betego´n Nicola´s, Jesu´s; 2 ´ ngel; 2Lozano Mun˜oz, Ana; 3Villar Pe´rez, Herna´ndez Encinas, Jose´ A Julio
Characteristic
Group 1
Group 2
p value
Mental health
2 (16.–2.6)
2.3 (1.9–2.5)
0.596
Continuous variables are expressed as medians and interquartile range Categorical variables are expressed as number of absolute cases and percentage p values calculated using the Mann–Whitney U test (continuous) and Fisher’s exact test (categorical) Table 2 Results in quality of life indexes Questionnaire
Group 1 (62)
Group 2 (15)
p-value
1
Workplaces: Hospital Universitario Lucus Augusti, Lugo, Spain; Complejo Asistencial Universitario de Leo´n (CAULE), Leo´n, Spain; 3 Hospital de Leo´n, Leo´n, Spain 2
Introduction: Sacropelvic fixation in adult spinal deformity (ASD) surgery is frequently associated to implant failure or pseudoarthrosis, raising doubts at where to end the instrumentation in the caudal segment. A better understanding of the functional limitations that patients might develop when the fixation includes the pelvis could be of help in preoperative planning. Objectives: Assess the functional limitations of patients who undergo ASD surgery when the distal fixation extends to the pelvis, as well as the effects on the subdomains of the SRS-22. Methods: Comparative cross-sectional study of two cohorts of patients who underwent ASD based on the extension of the distal fixation: Group 1: S1-PELVIS; Group 2: L3-L5. Clinical features were compared for both groups with the aid of the VAS, ODI, total value, and subdomains of the SRS-22. Results: From a prospective database of patients who had undergone surgery due to ASD, with a mean follow-up of 36 months (12 months minimum), the data of 77 patients (97% of the database) was available for the analysis. Both groups were comparable regarding age, gender, or mental health. Student’s t test, Mann–Whitney U test, or Fisher’s exact test were used for statistical analyses depending on the type of variable (continuous, categorical, or whether they were adjusted or not to normality) (Table 1). Patients with pelvic fixation (Group 1) showed less pain as per the VAS and greater impairment according to the ODI; however, the differences were not significant. For both groups of patients the worse scorings in the SRS-22 were for the function and pain subdomains; better scoring were seen for selfimage or mental health. Treatment satisfaction (SRS satisfaction) was high for both groups (Table 2). Conclusions: In patients who undergo ASD surgery, low lumbar and sacropelvic fixation seem to affect primarily pain and function; the impact is less on self-image or mental health. Although further studies should be carried out to confirm these preliminary data, pelvic fixation does not seem to significantly affect the function variable in patients who undergo ASD surgery and for this reason, it should not be considered as an essential factor in preoperative planning. Table 1 Baseline values for study groups Characteristic
Group 1
Group 2
p value
Age
70 (62–75)
60 (56–76)
0.652
Gender (M)
13 (20.9)
5 (33.3)
0.322
VAS*
4 (1.5–8)
6 (2.7–7)
0.602
ODI*
42 (23–60)
34 (30–46)
0.617
SRS22 function
2.9 (0.7)
2.9 (0.8)
0.935
SRS22 self-image
3.2 (0.8)
3.2 (0.6)
0.803
SRS22 pain
3 (1)
3.1 (0.9)
0.773
SRS22 satisfaction*
4 (3.5–4.5)
4.5 (4–4.8)
0.356
SRS22 mental health
3.5 (0.9)
3.2 (0.9)
0.385
SRS22 total
3.1 (0.7)
3.1 (0.7)
0.887
Values are presented as means and standard deviations. p values calculated using Student’s t test * Not normal variables in the groups: data expressed as medians and interquartile range. p value calculated using the Mann–Whitney U test
6 SENSITIVITY TOWARDS CONSERVATIVE TREATMENT CHANGES IN ADOLESCENTS WITH IDIOPATHIC SCOLIOSIS. PRELIMINARY STUDY Authors: Sa´nchez Raya, Judith; D’Agata, Elisabetta; Bago´ Granell, Joan; Matamalas Adrover, Antonia ´ Hebron, Barcelona, Spain Workplace: Hospital Universitario Vall D Introduction: Body image associated to trunk deformity is very important for adolescents who suffer idiopathic scoliosis (IS). The brace has shown to be effective for controlling the deformity. However, there is scarce literature regarding the impact the brace has on trunk morphology. Objectives: Assess trunk deformity morphological changes in patients with IS treated with a brace. Design: Case-series prospective observational study. Materials and methods: Study participants were included consecutively once diagnosed with IS, with indication to use a brace, and meeting the following criteria (C10 years; Risser B2; pre- or B1 year post-first menstrual period; primary curve between 25°–45°; no previous treatment). A relationship between the demographic data (age, gender) and spinal curve [radiological magnitude, angle of trunk rotation (ATR)] was done. All patients completed the Trunk Appearance Perception Scale (TAPS) and a clinical photograph of their back in standing position was taken. Several morphological parameters were calculated (shoulder, armpit, and waist height angle;
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waist asymmetric and right/left asymmetry by trunk, shoulder, and waist area) from the photograph. Results: Twenty-four (24) patients (21 female) who used a brace for one year were included in the study. Mean age was 12.2 (range 9–16) years. The initial mean Cobb angle was 35.3° (17°–47°) and the ATR was 8.9° (5°–21°). After 1 year, the mean Cobb angle improved to 32.6° (0°–56°) and the TAPS to 3.5 (2.3–4.7); however, the difference
was not significant. Similarly, no statistically significant differences were determined in the ATR or in the different morphological parameters assessed with the aid of the clinical photograph after one year of treatment. The different studied variables are shown in Table 1, whilst in Table 2 the calculated changes according to the considered variables are presented.
Table 1 Sample characteristics. Variations at 1 year Variable
Initial
Post-treatment (1 year)
Statistical significance (p)
Mean
CI
SD
Mean
CI
SD
17–47
8.2
32.6
0–56
12.7
0.62
3.5
Cobb (8)
35.3
TAPS
3.3
ATR (8)
8.9
5–21
3.6
9.2
SHA (8)
-0.7
-5.7 to 6.3
3.34
0.49*
0.68
0.45*
0–20
5.5
0.62*
-0.5
-7.5 to 7.3
3.32
0.60*
AHA (8)
-2.2
-7.3 to 3.4
2.9
-3.1
-10.8 to 4.4
3.19
0.25*
WHA (8)
1.4
-8.4 to 11.9
5.49
1.3
-10.3 to 12.5
6.3
0.80*
APC diff. (8) RArT
3.3 1.1
-0.3 to 0.5 0.7–1.4
24.8 0.15
1.7 1.1
-0.4 to 0.4 0.9–1.5
20.5 0.16
0.97* 0.30*
RArS
1.0
0.8–1.2
0.09
1.0
0.8–1.2
0.11
0.63*
RArW
1.2
0.8–1.6
0.20
1.2
0.9–2.0
0.27
0.46*
CI (confidence interval); SD (standard deviation); SHA (shoulder height angle); AHA (armpit height angle); WHA (waist height angle); APC diff. (right/left difference of the waist fold); RArT (right/left ratio of the trunk area); RArS (right/left ratio of the shoulder area); RArW (right/left ratio of the waist area) * Non-parametric Wilcoxon test
Table 2 Percentage of patients with changes in trunk deformity (TAPS/photograph) as a function of changes of skeletal deformity (Cobb) Cobb changes at 1 year Change
No change
Total
TAPS change at 1 year Change*
7 (53.8%)
6 (54.5%)
13 (54.2%)
No change
6 (46.2%)
5 (45.5%)
11 (45.8%)
SHA change at 1 year CAMBIO**
11 (84.6%)
4 (36.4%)
15 (62.5%)
No change
2 (15.4%)
7 (63.6%)
9 (37.9%)
AHA change at 1 year CAMBIO**
9 (69.2%)
4 (36.4%)
13 (54.2%)
No change
4 (30.8%)
7 (63.6%)
11 (45.8%)
Change**
9 (69.2%)
4 (36.4%)
13 (54.2%)
No change
4 (30.8%)
7 (63.6%)
11 (45.8%)
WHA change at 1 year
APC diff. change at 1 year Change*
10 (76.9%)
6 (54.5%)
16 (66.7%)
No change Total
3 (23.1%) 13
5 (45.5%) 11
8 (33.3%)
SHA (shoulder height angle); AHA (armpit height angle); WHA (waist height angle); APC diff. (right/left difference of the waist fold) * It is considered a change when the extent of the difference between the final measurement and the initial one is greater than half of the standard deviation of the analyzed variable ** It is considered a change when the extent of the difference between the final measurement and the initial one is greater to two times the error of the standard measurement of the analyzed variable
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Eur Spine J (2017) 26:2682–2717 Conclusions: Our results—with a small study sample—reveals that the use a brace for one year does not change the clinical deformity of the trunk or that perceived by the patient.
7 RISK-BENEFIT OF DEFINITIVE ARTHRODESIS IN PATIENTS WITH EARLY ONSET SCOLIOSIS TREATED WITH GROWTH FRIENDLY SYSTEMS Authors: Pizones Arce, Javier; Pe´rez Martı´n-Buitrago, Mar; Talavera, Gloria; Sa´nchez Marquez, Jose´ Miguel; Ferna´ndez-Baillo Gallego De La Sacristana, Nicomedes; Sa´nchez Pe´rez-Grueso, Francisco J Workplace: Hospital Universitario La Paz, Madrid, Spain Introduction: Management of early onset scoliosis (EOS) involves growth friendly systems until skeletal maturity, after which a final solution is suggested (graduation). The graduation can be performed via a final surgical fusion or by keeping the previous implants with no additional surgery. Decision criteria and risk-benefits derived from final fusion have not been yet established. Materials and methods: We prospectively analyzed a cohort of patients with EOS who had already undergone graduation. Demographic variables were included in the study; radiographic and surgical data of the growth preservation process were collected, as well as pre-intra-post-graduation information. A comparison of the results of the two final treatment options was done. Results: Thirty-two (32) patients were included in the study. Four withdrew from it. From the remaining participants, 13 underwent arthrodesis (AR) and 15 retained the implants (RE). Initial mean age was 7.4 ± 3 years and mean follow-up was 8.3 ± 2.9 years. Twenty-three (23) of the study subjects had growth rods, five VEPTR. Initial and end of follow-up radiographic values were statistically similar (p [ 0.05) for both groups. The differences for deciding one or other final treatment were: greater curve magnitude (AR = 63.28 ± 9.5 vs RE = 47.98 ± 15.2; p = 0.008), anterior imbalance-SVA- (AR = 19.5 mm ± 40 vs RE = -17.3 mm ± 35.5; p = 0.29), and a tendency towards coronal imbalance (AR = 28.8 mm ± 28.3 vs RE = 13.3 mm ± 11.5; p = 0.217). No influence of the other variables was observed. During final fusion 12/13 patients required multiple osteotomies (a mean SPO value of 5), one hemi-vertebrectomy, and three costoplasties. Mean length of the procedure was 291.5 ± 58 min; bleeding 946 ± 375 ml, and number of fused levels 13.7 ± 1.6. The primary curve was corrected in 19.78 ± 2.78 (31%); the secondary curve in 13.38 ± 6.38 (34% of correction); T1–S1 gained 31 ± 19.6 mm and T1–T12 9.3 ± 39.5 mm; kyphosis was reduced in 108 ± 10.48 (22% of the correction), and SVA was reduced 5.3 ± 30 mm; on the other hand, the imbalance increased in 2.3 ± 30.8 mm. At 1.97 ± 1.4 years post-surgery follow-up, only one superficial infection was detected and no major complications. Conclusions: Deciding graduation with a final fusion relied on an unacceptable or progressive deformity, an anterior imbalance, having a congenital origin, or a complication with the previous implants. Neuromuscular curves, a Cobb angle \508, and a coronal imbalance \20 mm retained the implant. The final fusion significantly corrected the coronal and sagittal deformity, with the trunk gaining height; no improvement in balance and at high surgical cost.
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8 DISCREPANCIES BETWEEN PROGRAMED AND OBSERVED DISTRACTION IN PATIENTS TREATED WITH ELECTROMAGNETIC GROWING RODS Authors: Farrington Rueda, David M.; Pozo Balado, Maria Del Mar; Martı´nez Salas, Jose Manuel; Lirola Criado, Jose´ Francisco Workplace: Hospital Universitario Virgen del Rocı´o, Sevilla, Spain Objectives and introduction: Magnetically-controlled growing rods (MGCR) allow performing frequent distractions without the need of additional surgery in early onset scoliosis (EOS). These distractions can be recorded by sonography, which reduces exposure to ionizing radiations. The aim of this study is to analyze the discrepancies between programmed distractions (PD) and observed distractions (OD) using sonography, and associated clinical factors. Materials and methods: A retrospective review of all children with a diagnosis of EOS treated with MCGR between March 2014 and January 2016 in our center was performed. PD and OD values for each distraction were registered and the difference between them calculated. Longitudinal comparisons involving multiple variables were performed with the Friedman test. Correlations between PD and OD, and clinical parameters and recorded demographic data (gender, age, weight, Cobb angle, and location of the rod in relation to the curve) were analyzed using Spearman’s test. A p value of 0.05 was considered statistically significant. Results: Seventeen patients (10 boys and 7 girls) with a 6 month minimum follow-up were included in the study. Distractions were performed every 2 months. Mean age at the time of surgery was 90.3 months. Total mean PD recorded at the External Remote Control was 15.9 mm for the right rod and 15.1 mm for the left one; total mean OD as measured by sonography was 16.5 mm for the right rod and 14.9 mm for the left one. The correlation between the PD and OD values was high for both rods (p \ 0.001). PD/OD ratio was 0.96 for the right rod and 1.01 for the left, with a significant increase of the PD/OD ratio over time only for the right one (p = 0.016). Finally, a negative correlation was determined between the PD/OD ratio and the Cobb angle preoperatively (p = 0.003) as well as at the end of the follow-up (p = 0.009). Conclusions: There are some discrepancies between the PD and OD values throughout the follow-up time, which seem to be linked to the Cobb angle. Patients with greater Cobb angles showed a reduced distraction capacity.
9 CAN A COMPLEX DEFORMITY CORRECTION WITH HALO TRACTION, POSTERIOR OSTEOTOMIES AND POSTERIOR FUSION, WITH AND WITHOUT RIB RESECTIONS, BE COMPARED TO SPINAL COLUMN RESECTION? Authors: 1Sacramento Dominguez, Cristina; 2Boachie Adjei, Oheneba; 2Ayamga, Jennifer; 2Wulff, Irene; 2Yirerong, Teresa; 2 Akoto, Harry; 3Jimenez Sosa, Alejandro; 4Pellise´ Urquiza, Ferran; 2 Focos, FOCOS Spine Research Group Workplaces: 1Hospital Ruber Internacional, Madrid, Spain; 2Focos Orthopedic Hospital, Accra, Ghana; 3Hospital Universitario De
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Eur Spine J (2017) 26:2682–2717
Canarias, Tenerife, Spain; 4Hospital Universitario Vall d´Hebron, Barcelona, Spain
10
Introduction: Posterior vertebral column resection osteotomy (PVCSO) is gaining popularity for correcting serious spine deformities. However, the procedure is technically very demanding and with potential risk of complications and significant neurological damage. Hypothesis: An ideal and safe correction is possible with halo-gravity traction (HGT) and posterior spine fusion (PSF) with posterior spine osteotomy (PSO), with or without costal osteotomies and without PVCSO. Design: Historical cohort study. Materials and methods: Demographic and surgical data from 72 patients were collected, all of which underwent consecutive surgery due to serious spinal deformity (Cobb angle [1008) and follow-up of at least 2 years. All study patients were put on HGT followed by final PSF, PSO, with or without costal osteotomy of the concavity and thoracoplasty. Conventional radiology measurements in coronal and sagittal planes were obtained preoperatively, post-traction, and at the end of follow-up. Evaluation of major and neurological postoperative complications was done. Results: Seventy-two (72) patients, 40 female/38 male. The etiology was congenital (21), idiopathic (45), neurofibromatosis (2), and neuromuscular (4). Mean age was 18 ± 4.6 years, HGT 103 ± 35 days; pre-operative coronal Cobb (131.58 ± 21.418) vs (92.18 ± 15.858) in HGT (a correction of 30.01%) and (72.88 ± 12.78) post-operatively (a correction of 47%); pre-operative kyphosis (134.78 ± 32.298) vs (97.18 ± 22.408) in HGT and (73.78 ± 21.338) post-operatively; fusion levels (14 ± 1); estimated blood loss (1730 ± 744 mL); PSO (5 ± 2); costal osteotomies in concavity (2 ± 2). Sixteen (16) patients had post-operative complications (22.2%); ten medical, one infection of wound, two associated with the implants, and three postoperative neurological deficits (all of which recovered during the follow-up). One patients died (stroke). Forty (40) intraoperative monitoring alerts (IMA) were communicated. Conclusions: HGT and one posterior fusion procedure with PSO with or without costal resection of the concavity and thoracoplasty, without PVCSO, leads to a satisfactory correction of complex rigid spine deformity with minimum neurological complications. These results are in line with other previously published results on similar deformities managed through PVCSO.
EARLY COMPLICATIONS IN PATIENTS WHO UNDERGO SURGERY FOR COMPLEX PEDIATRIC SPINAL DEFORMITY AND ARE TRANSFERRED TO THE PEDIATRIC INTENSIVE CARE UNIT. RETROSPECTIVE COHORT STUDY
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Authors: 1Martı´nez Gonza´lez, Carmen; 2Egea Ga´mez, Rosa Marı´a; 1 Certucha Barraga´n, Jose´; 1Gonza´lez Diaz, Rafael Workplaces: 1Hospital Infantil Nin˜o Jesu´s, Madrid, Spain; 2Hospital Universitario de Mo´stoles, Madrid, Spain Introduction: In deformity surgery, assessing surgical complications, as well as the outcome of the procedure, is a very common practice; however, immediate medical complications are frequently omitted in our research studies. In the present study, we aim to analyze the most frequent postoperative medical complications in corrective complex pediatric deformity surgeries. Materials and methods: Retrospective cohort study of patients who underwent surgery due to scoliosis and were transferred to the pediatric intensive care unit (PICU) between 2014 and 2016; 81 patients (43 idiopathic scoliosis, 24 neurological, 7 neuromuscular, 4 congenital, and 3 syndromic) were included in the study. Mean age was 15 years (2–19 years). We analyzed the various complications, their cause, and the treatment/treatment length to overcome the complications. Furthermore, we studied the management of postoperative pain and the differences between the various diagnostic groups. Results: The mean stay in the PICU was 3.71 days (3% of total hospital stay). The most frequent complications were hemodynamic alterations, seen in 26/81 study participants who required inotropic agents: dopamine in eight cases and dopamine + adrenaline in one case. Twenty-two (22) from the 81 study patients experienced some kind of renal disturbance (metabolic or lactic acidosis and SIADH), from which 14 required bicarbonate. Six cases of sepsis were identified (1 central line catheter), 3 surgical site infections, and 12 pneumonias. In 60 cases, morphine-derivatives were used for pain control, whilst for the remaining patients lower ladder analgesics—as per the WHO—were administered.
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65
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41
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Renal Metabolic SIADH Lactic Surgical Sepsis Catheter- Pneumonias TVP Catheter- Maximum alt. acidosis acidosis site infection related related nutritional infection thrombosis support
Age Days of Total HD Inotropes stay in length alt. the PICU of stay
3: Strongest morphine-derivative
3: Strongest morphine-derivative
1: Nolotil, paracetamol
3: Strongest morphine-derivative
3: Strongest morphine-derivative
1: Nolotil, paracetamol
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3: Strongest morphine-derivative
3: Strongest morphine-derivative
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3: Strongest morphine-derivative
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3: Strongest morphine-derivative
2: Tramadol
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3: Strongest morphine-derivative
2: Tramadol
3: Strongest morphine-derivative
Maximum level pain treatment
Eur Spine J (2017) 26:2682–2717 2689
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Renal Metabolic SIADH Lactic Surgical Sepsis Catheter- Pneumonias TVP Catheter- Maximum alt. acidosis acidosis site infection related related nutritional infection thrombosis support
Age Days of Total HD Inotropes stay in length alt. the PICU of stay
continued
3: Strongest morphine-derivative
3: Strongest morphine-derivative
1: Nolotil, paracetamol
1: Nolotil, paracetamol
3: Strongest morphine-derivative
3: Strongest morphine-derivative
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3: Strongest morphine-derivative
3: Strongest morphine-derivative
3: Strongest morphine-derivative
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3: Strongest morphine-derivative
3: Strongest morphine-derivative
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3: Strongest morphine-derivative
3: Strongest morphine-derivative
Maximum level pain treatment
2690 Eur Spine J (2017) 26:2682–2717
3: Strongest morphine-derivative
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3: Strongest morphine-derivative
2691 Conclusions: The most frequent complications were hemodynamic alterations, followed by renal and infectious difficulties. The complications occurred more often in neuromuscular patients. Being aware on the potential adverse outcomes after scoliosis surgery, allows improving the management of our patients, as well as prevent their inadequate control. Achieving a stabilization over the first 24 h and an effective control of pain facilitates patient progression.
Oral No
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No No
No 86
INCIDENCE OF MORPHOMETRIC VERTEBRAL FRACTURES IN A COHORT OF POSTMENOPAUSAL WOMEN. INFLUENCE OF MILD OR GRADE I DEFORMITIES ON THEIR DEVELOPMENT Authors: 1Casellas Basagan˜a, Mireia; 2Puigoriol Juvanteny, Emma; 2 Garcı´a Barrionuevo, Joan; 3Abanco´ Sors, Josep; 3Selga Jorba, Nu´ria; 1 Cruz Miranda, Daniel; 2Kanterewicz Binstock, Eduardo Workplaces: 1Hospital Althaia Manresa, Barcelona, Spain; 2Consorci Hospitalari De Vic, Barcelona, Spain Introduction: Knowledge on the prevalence and incidence of vertebral fractures (VF) is essential for osteoporosis studies. VF often go unnoticed, many of them being clinically silent. The relevance of mild vertebral deformities (MVD) is currently in discussion. Some authors do not consider them real VF, while others defend the idea that they are the initial phase of future VF. The aim in this work is to describe the relevance of MVD before the development of new VF in a cohort of postmenopausal women, assessed at baseline and after 4 years of follow-up. Materials and methods: The FRODOS cohort included 2968 postmenopausal subjects; a vertebral morphometry (vertebral fracture assessment-VFA) was performed to each participant in the two study phases (baseline and follow-up). This technique allows measuring the anterior, mean, and posterior heights of the vertebral bodies and compare them with reference values. MVD heights between -2 and -3 are considered deviations (SD) from the reference value and VF reductions greater to -3 SD. We present the results of 2493 female who completed the follow-up. Results: The results show that there are statistically significant differences pointing to VF prevalence and presence of MVD as risk factors for VF incidence. Considering the history of the fractures, 16.2% of morphometrically normal women had suffered some type of previous fracture, 23.7% with MVD without VF and 42.2% with VF (p \ 0.001). The analysis of VF in the group of women with prevalent VF, with or without prevalent MVD, revealed a 33.3% incidence in the subgroup of women with MVD in comparison to 19.7% in the subgroup without MVD (p = 0.126). When the incidence was assessed for the group of women without prevalent VF, 16.2% incidence was seen for the subgroup with MVD vs 3.8% for the subgroup without MVD (p \ 0.05). These results show that prevalent VF and prevalent MVD are risk factors for VF incidence. VFA can be a useful tool for the diagnosis of VF. Being aware of these risk factors and their progression can help prevent them.
8
No
No 1 18
No 2 6
Oral No Yes
No No
No No
No No
No No
No No
No No
No No No
No Yes
No 86
11
No
Oral 1 6
No Yes 1 18
No
Renal Metabolic SIADH Lactic Surgical Sepsis Catheter- Pneumonias TVP Catheter- Maximum alt. acidosis acidosis site infection related related nutritional infection thrombosis support
11
Age Days of Total HD Inotropes stay in length alt. the PICU of stay
continued
Maximum level pain treatment
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12 BALLOON KYPHOPLASTY SAFETY AND RESULTS IN COMPARISON TO TITANIUM IMPLANT IN THE TREATMENT OF VERTEBRAL COMPRESSION FRACTURES: RESULTS OF A CLINICAL TRIAL 36 MONTHS AFTER SURGERY Authors: Herna´ndez Ramajo, Ruben; Ardura Arago´n, Francisco; Crespo San Juan, Jesu´s; Arin˜o Palao, Blanca; Noriega Gonzalez, David Cesar Workplace: Hospital Clinico Universitario, Valladolid, Spain Objectives: Compare clinical-radiological results of two kyphoplasty techniques in the management of osteoporotic vertebral fractures with a postoperative follow-up of 36 months. Materials and methods: 30 patients were randomly assigned to one of two possible study groups: balloon kyphoplasty (BKP) (n = 15) or kyphoplasty with titanium implant (n = 15) and the following clinical parameters were then assessed: VAS, Oswestry, EQ-VAS, preoperative analgesic use, and 5 days, 1, 3, 6, and 12 months after the surgery. X-rays were taken in standing position 48 h before the surgery, and 5 days, 6, 12, and 36 months after the surgery. Independent radiologists from the University of Filderstadt (Germany) performed the radiological analysis using the ACES software (FDA validated). Results: The length of the procedure was shorter for the group of study subjects who underwent kyphoplasty with titanium implant (23 vs 32 min, p \ 0.001). VAS reduction was statistically significant for both groups at 12 months (94 vs 82%), with no significant intergroup differences; similar results were obtained for the ODI (94 vs 90%). Radiological results were statistically higher for the group with the titanium implant either at medium level or anterior and posterior. Significant improvement in decrease of the vertebral, Cobb, and Gardner angles was observed and maintained for 36 months for the group with titanium implant vs the BKP group (p = 0.012). Similarly, there was an improvement of angular parameters between follow-up months 12 and 36 in the group with the titanium implant. There were three patient losses (two diseased and one for whom X-ray images were not available). A radiological underlying fracture with no clinical significance was identified in one of the participants in the BKP group. Conclusions: This randomized clinical trial shows that both study techniques are safe and efficient for the symptomatic control of vertebral compression fractures, although the intervertebral titanium has a better capacity for reducing the vertebral body and the kyphosis, remaining stable for 36 months.
13 IMPACT OF VERTEBRAL FRACTURES ON OUTCOME IN POLYTRAUMATIZED PATIENTS Authors: 1Vicente Goma-Camps, Matias; 1Gonza´lez Tartie`re, Pilar; 1 Ramı´rez Valencia, Manuel; 1Matamalas Adrover, Antonia; 1Riveiro Vilaboa, Marilyn; 1Monforte Alemany, Ramo´n; 2Garcı´a De Frutos, Ana; 1Bago´ Granell, Joan; 1Pellise´ Urquiza, Ferran Workplaces: 1Hospital Universitario Vall D’Hebro´n, Barcelona, Spain; 2Hospital Universitario Vall D’Hebron, Institut Universitari Dexeus, Barcelona, Spain
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Eur Spine J (2017) 26:2682–2717 Objectives and introduction: Few studies in the literature have evaluated the impact of vertebral fractures (VF) in polytraumatized patients. In this study, we aim to establish the impact of VF (with no spinal cord injury (SCI)) on medium-/long-term quality of life, pain, and mental health in these patients. Materials and methods: Retrospective review of polytraumatized patients admitted in our center between 2010 and 2015 and crosssectional study of medium-/long-term quality of life and psychological status. Inclusion criteria:[18 years, Trauma Index Severity Score (TISS) C16. Exclusion criteria: Glasgow Outcome Scale Extended (GOSE) B3 at inclusion, patients with SCI. Results: 85 patients from 177 agreed to participate in the study, 32 completed the questionnaires (mean age was 50.3; 78. 1% male). Twenty-one (21) patients had some VF, 70% classified as AO, A1, and A2. Traffic accidents were the most common cause of trauma with one subject from the VF group who attempted to self-harm. Mean hospital stay was 57.6 days (28.09 ICU), during which 46.9% had some major complication. Patients with VF had a significantly higher number of lesions at admission (7.6 vs 4.7). 39.5% of study participants were admitted with serious TCE (Table 1). No differences between the scales of injury severity were observed, except for the Head Abbreviated Injury Scale (AIS) (VF 1.8; no VF 3.1) (Table 2). Mean time between occurrence of the trauma and completion of the questionnaires was 44.6 months (14–80). A larger percentage of patients with VF had some problems (72.2%) or extreme problem (16.7%) in the pain/discomfort dimension of the EQ5D (OR = 12), as well as worse scoring in global quality of life Table 1 Descriptive sample Variable
Total (n = 32)
Without vertebral fracture (n = 11)
With vertebral fracture (n = 21)
Mean age
50.3 (16.5)
52.64 (18.72)
49.14 (15.61)
Male (%)
78.1
81.8
76.2
CCI (SD)
0.1 (0.44)
0.2 (0.64)
0.1 (0.3)
Hospital stay (days) Estancia en UCI (dı´as)
57.6 (39.07)
56.73 (48.74)
58.19 (34.31)
28.09 (28.9)
32.09 (46.3)
26 (14.68)
Traffic accident
78.1
90.9
71.4
Fall from height
18.8
9.1
23.8
Autolysis
3.1
12
4.8
Cause of injury (%)
Vertebral fractures
1.47 (1.62)
0
2.24 (1.51)
Multi-level vertebral fracture (%)
43.8
0
94.4*
Fracture location (%) C1–C2
19
C3–C7
9.5
19 9.5
T1–T5
14.3
14.3
T6–T11
23.8
23.8
T12–L2
14.3
14.3
L3–L5
14.3
14.3
S1–S5
4.8
4.8
A1 & A2
70
70
A3 & A4
10
10
B
15
15
C
5
5
AO Classification (%)
Injuries (SD)
6.6 (2.75)
4.72 (2)
7.6 (2.5)*
Serious TCE (%)
39.5
54.5
33.4
Major complications (%)
46.9
27.3
57.1
CCI Charlson Comorbidity Index, SD standard deviation * Significant difference between groups (p \ 0.05)
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Hospital Virgen De La Salud, Toledo, Spain; 4Fundacio´n Jimenez Diaz, Unidad De Patologı´a De Columna, Madrid, Spain
Table 2 Scales of severity of trauma Variable
Total (n = 32)
Without vertebral fracture (n = 11)
With vertebral fracture (n = 21)
Ventilation (%)
67.9
60
72.2
Ventilation (days)
10.8 (10.84)
6.5 (9.8)
14.4 (11.3)
ISS
23.3 (7.13)
25 (9.64)
22.4 (5.48)
AIS
8.2 (2.14)
8.3 (2.54)
8.2 (1.9)
AIS head
2.3 (1.54)
3.1 (1.59)
1.8 (1.36)*
AIS face
0.8 (1.16)
0.8 (1.06)
0.8 (1.23)
AIS neck
0.26 (0.8)
0.6 (1.34)
0.1 (0.53)
AIS thorax
2.1(1.2)
2.6 (0.51)
1.9 (1.39)
AIS abdomen
1.6 (1.79)
1.8 (1.8)
1.5 (1.83)
AIS spine
1.2 (1.1)
0
1.4 (1.24)*
AIS Upper extremity
0.7 (0.62)
0.6 (1.34)
0.8 (1.22)
AIS Lower extremity
1.5 (1.41)
1.4 (0.13)
1.5 (1.55)
AIS Unspecific
0.7 (0.62)
0.6 (0.51)
0.6 (0.67)
APACHE TTS
14.1 (5.9) 5.5 (4.8)
14.81 (5.68) 6.87 (3.13)
13.08 (6.24) 5 (5.31)
GCS
11.25 (4.5)
9.7 (5.06)
12 (4.14)
Injury Severity Score (ISS); Abbreviated Injury Scale (AIS); Acute Physiology and Chronic Health Evaluation II (APACHE II); Glasgow Coma Scale (GCS) * Significant difference between groups (p \ 0.05) (EQ-5D index in VF = 9.5; no VF = 0.9) at medium-/long-term. This group of patients had a worse scoring in the posttraumatic stress disorder checklist (PCL for VF = 40.5; no VF = 27). Conclusions: VF associated to multitrauma increase the risk of having pain and discomfort by 12—even years after the occurrence of the injury—in comparison to individuals who undergo a trauma of similar severity, but with no VF. This seems to affect overall quality of life. Furthermore, these patients experience more post-traumatic stress symptoms.
14 ANTERIOR CERVICAL ARTHRODESIS RESULTING FROM DEGENERATIVE DISC DISEASE. PROSPECTIVE STUDY OF LONG-TERM CLINICAL IMPLICATIONS OF TANTALUM INTERBODY IMPLANT SINKING AND CHANGES IN THE SAGITTAL PLANE Authors: 1Tome´ Bermejo, Fe´lix; 2Cervera Irimia, Javier; 3Moreno ´ ngel R; 4A ´ lvarez Galovich, Luis; Pe´rez, Javier; 4Pin˜era Parrilla, A 4 Mengis Palleck, Charles L.; 4Gallego Bustos, Jesu´s; 4Garzo´n Marquez, Francisco M.; 4Rodrı´guez Arguisjuela, Marı´a G
Objectives: The sinking of the interbody implant is one of the most frequent complications in anterior cervical arthrodesis (ACA): Despite of this, there are no studies in which a direct relationship between the sinking of the implant and lower fusion rates or unsatisfactory clinical outcomes is shown. In this study, we aim to assess long-term results of ACA with tantalum implant and correlate the radiological findings with the clinical outcome, with special emphasis on the influence of implant sinking. Methods: Multicenter observational study of results prospectively collected from 56 consecutive patients who underwent one/two levels of ACA with tantalum implant. Results: Mean follow-up was 4.63 years. Final fusion rate, 96.42%. The insertion of the implant lead to a significant increase in the height of the interbody space (HIS) immediately after the surgery at all operated levels. Despite a gradual loss of height during follow-up, the HIS at the end of the follow-up was significantly greater than before the intervention (p \ 0.0001). During follow-up, the HIS of the anterior and posterior columns loss 54.76 and 74.83% of the initially increased height, respectively, and a 72% increase of the anteroposterior differential height. We were able to confirm the effective sinking of the implant ([3 mm) in 15 disc spaces (26.78%). Immediate postoperative HIS was significantly greater among patients who showed final effective sinking; however, no differences in the HIS at the end of the follow-up were determined between patients with/ without sinking (p [ 0.05). No further sinking was seen in patients with C3 years of follow-up (75%) after the second year. Regarding lordosis, segmental Cobb, the VAS questionnaires, and the Neck Disability Index, no differences were found between patients with/ without sinking at the final follow-up. Conclusions: The use of a tantalum implant led to an immediate increase of interbody space height; despite a gradual loss of the height during follow-up, it remained significantly greater than before surgery. A dynamic setting of the tantalum implant within the vertebral body is expected until the consolidation of the arthrodesis, which includes some sinking with no effect on long-term clinical outcome. The dynamic setting of the implant during follow-up, particularly in the posterior spine, has a positive effect on cervical lordosis and it well may be the result of adaptive segmental changes.
Initial increase Preop-Postop*, p
Total increase Preop-Final*, p
Differential Postop-Final*, p
Interbody space height columna anterior (mm)
3.5 (2.4, 4.5), 0.000
1.5 (0.1, 3.0), 0.033
-2.0 (-2.9, -0.9), 0.000
Interbody space height columna mean (mm)
2.8 (1.9, 3.7), 0.000
1.0 (-0.4, 2.4), 0.398
-2.8 (-3.7, -1.9), 0.000
Interbody space height columna posterior (mm)
2.2 (1.3, 3.0), 0.000
0.5 (-0.5, 1.5), 1.000
-1.6 (-2.6, -0.7), 0.000
Cobb C1–C7 (cervical lordosis)
-1.78 (-8.3, 5.0), 1.000
10.18 (5.2, 11.78 (4.3, 14.9), 0.000 19.1), 0.000
Cobb angle
7.08 (4.1, 9.8), 0.000
5.68 (2.2, 9.0), -1.48 (-3.5, 0.000 0.7), 0.542
Interspinous distance segmento (mm)
4.2 (-1.4, 4.6), 3.4 (2.8, 3.6), 1.000 0.000
0.8 (-0.2, 2.4), 0.062
* (95% CI)
Post-hoc DLS significance
Workplaces: 1Hospital Universitario Fundacio´n Jime´nez Dı´az, Madrid, Spain; 2Hospital General De Villalba, Madrid, Spain;
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15 CORRELATION OF THE SAGITTAL CERVICAL PLANE WITH SPINOPELVIC PARAMETERS Authors: 1Gallego Bustos, Jesu´s; 1Garzo´n Marquez, Francisco M.; 2 ´ ngel Ramo´n; 1Rodrı´guez Moya Dı´az, Ana Belen; 2Pin˜era Parrilla, A 3 Arguisjuela, Marı´a G.; Tome´ Bermejo, Fe´lix; 1Mengis Palleck, Charles L.; 2Garcı´a-Seisdedos Pe´rez-Tabernero, Fernando; 1Sanz ´ lvarez Galovich, Luis Aguilera, Sylvia; 1A Workplaces: 1Fundacio´n Jimenez Dı´az, Unidad de Patologı´a de Columna, Madrid, Spain; 2Hospital Fundacio´n Jime´nez Dı´az, Madrid, Spain; 3Hospital General de Villalba, Madrid, Spain Introduction: Distortion correction surgery in young adults and adolescents leads to changes of spinopelvic parameters and this alters cervical sagittal parameters. Thus, it seems logical to believe that the modifications in these spinopelvic parameters because of age can cause changes in cervical alignment linked to horizontal gaze. In this study, we will analyze global sagittal alignment in patients older than 70 years and correlate the alterations of the different spinopelvic parameters with the cervical sagittal plane. Materials and methods: Prospective study with 294 patients to whom AP and lateral teleradiographies of the spine were performed, as well as functional assessment based on VAS and NDI. Different measurements of spinopelvic parameters (lordosis (arch in the lower back), thoracic kyphosis, pelvic incidence, pelvic tilt, sacral slope, and deviation of SVA) and different cervical parameters (SSA, C-7 Slope, C2–C7, O-C2 angle, and SCA) were carried out. Epidemiological parameters and the number and location of the vertebral fractures were also recorded. A comparison by cohort group against the different parameters was done (alterations of thoracic kyphosis, SVA alterations, etc.). Results: Mean age of study patients was 76.7 years. SP values were CD 55.7 (SD 17.66), PI 54.25 (SD 13.17), PT 22.93 (SD 9.26), SS
31.95(SD 9.35), LL 31.33 (SD 44.48), SVA 46.4 (SD 41.1), and cervical values were SSA 90.51 (SD 12.94), C7 Slope 32.37 (SD 12.38), C2–7 20.52 (SD 13.49), Occ-C2 20.93 (SD 10.24), SCA 69.51 (SD 10.76). No relationship between changes of the different spinopelvic parameters and cervical alignment was found in the analysis of the cohorts. A high cervical lordosis in comparison to population groups was surprisingly observed. No change occurred in the lordosis even with an increase of thoracic kyphosis or SVA unbalance. Conclusions: Aged patients show greater cervical lordosis in comparison to the younger population. The curves are rigid and are not subjected to the changes of other variations of the global sagittal plane.
16 ADJUSTMENT OF THE CERVICAL SEGMENT IN T10 TO ILIAC ARTHRODESIS. RADIOLOGICAL AND FUNCTIONAL ASSESSMENT Authors: 1Da´vila Ferna´ndez, Fernando; 1Ferren˜o Marquez, David; 1 Dauder Gallego, Cristina; 1Peces Garcı´a, Enrique; 1Mena Roso´n, Araceli; 1Losada Vin˜as, Jose´ Isaac; 1Carrillo De Albornoz, Rodrigo; 2 Gonza´lez Dı´az, Rafael Workplace: 1Hospital Universitario Fundacio´n de Alcorco´n, Madrid, Spain; 2Hospital Infantil Universitario Nin˜o Jesu´s, Madrid, Spain Introduction: The relationships between cervical and lumbar segments remain poorly understood. Research on degenerative adult scoliosis (DAS) focuses on adaptive capacity of non-fused segments. Studying the cervical sagittal balance after a T10 to iliac fusion will allow gaining knowledge about the biomechanics of the spine. Objectives: Describe variations of sagittal balance radiological parameters after DAS surgery. Analyze adaptive changes of the cervical segment post-T10 to iliac fusion and functional results.
Table 1 Spinopelvic parameters of the sample
n=30 ángulo Cobb IP EP PS CO-C2 c1-c7 C1-C2 C2-C7 Pendiente C7 T1-T12 L1-S1 SVA SSA TPA
PRE 27.7 (10.7 - 31.7) 57.55 (51.28 - 63.78) 30.05 (24.15 - 34.03) 30.85 (24.35 - 35.18) 19.3 (12.5 - 23.6) 43.7 (38.75 - 49.48) 29.6 (22.93 - 31.9) 13.55 (8.6 - 23.73) 21 (17.4 - 26.93) 35.9 (22.83 - 43.58) 38.55 (28.25 - 50.05) 55.2 (22 - 123.75) 112 (97.3 - 123.55) 23.25 (19.53 - 40.6)
POST 4.9 (2.33 - 10.1) 62.1 (53.65 - 69.73) 34.35 (28.25 - 40.55) 31.05 (23.88 - 36.88) 15 (8.2 - 24.3) 43.1 (39 - 52.4) 26.1 (23.5 - 32) 18.4 (9 - 26.5) 23 (16.35 - 31.03) 36.8 (29.53 - 45.98) 41.7 (32.83 - 47.5) 70.05 (48.51 - 101.16) 108 (99.9 - 113.8) 31.7 (23.1 - 35.1)
P-VALOR (Wilcoxon test) <0.001* 0,107 0,023* 0,776 0,04* 0,51 0,755 0,339 0,347 0,094 0,194 0,675 0,135 0,299
Cambio absoluto (pre-post) 20.75 (7.9 - 25.3) -2.05 (-10.48 - 3.78) -5.65 (-12.35 - 2.78) 0.75 (-6.75 - 4.23) 3.7 (-2.5 - 9.5) -0.2 (-12.2 - 5.75) -0.1 (-9.3 - 7.3) -1.7 (-9.6 - 3.35) -1.55 (-8.6 - 3.73) -3.6 (-12.23 - 4.48) -4.85 (-13.6 - 8.75) -15.31 (-50.09 - 42.21) 7 (-6.8 - 13.2) -2.55 (-9.95 - 5.03)
Median (interquartile range) Angle Cobb Cobb angle, P-VALOR p value, Cambio absoluto (pre-post) absolute change (pre-post), C7 slope C7 slope * p \ 0.05
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Materials and methods: Analytic retrospective cohort study. Inclusion criteria: patients with DAS who underwent T10 to iliac arthrodesis. Exclusion criteria: Parkinson. Previous lumbar arthrodesis. Unavailable teleradiography. Pre- and postsurgical epidemiological variables and radiological parameters: pelvic incidence (PI), pelvic extension (PE), sacral slope (SS). C0–C2 angle, cervical lordosis (CL), C1–C2, C2–C7 angle, C7 slope, thoracic kyphosis (CT), low back lordosis (LL), sagittal vertical axis (SVA). The validated Neck Disability Index (NDI) was completed after the surgery. Analyses were performed with the aid of the SPSS 21Ò program using the Wilcoxon test and Spearman’s correlation coefficient. Comparisons of NDI scores were done as per SVA \6 or C6 cm. An index value [0.4 was considered moderate correlation, whilst for an index [0.6 the correlation was considered good. A p value of 0.05 was taken as statistically significant. Results: Sample size: 30 patients (27 female, 3 male). Median age was 66.41 years (58.1–74.9). Preoperative correlation analysis: The C7 slope showed good association with CL and C2–C7. Postoperative: The C7 slope showed good association with CL and CT. Regarding changes, the C7 slope showed moderate association with the SVA and the CL. In cases in which the SVA remained below 6 cm, an association with the C7 slope and the CL was found. NDI scoring had a median of 25% (17.5–32.5), showing a moderate association with the C7 slope, the CL, and the CT. No correlation between the global sagittal balance and the NDI scale was determined. Conclusions: T10 to iliac fusion provides good results in the correction of the coronal plane. There is a relationship between the C7 slope and cervical, lumbar, and global balance. In patients in which the sagittal plane is not corrected, cervical parameters remain altered. In our series, proximal junctional kyphosis leads to unexpected increase of SVA values, not affecting cervical function.
17 IMPORTANCE OF THE OCCIPITOCERVICAL REGION IN PATIENTS WITH ANKYLOSING SPONDYLITIS. ANALYSIS OF A COHORT OF 86 CERVICAL FRACTURES IN PATIENTS WITH ANKYLOSING SPONDYLITIS WHO UNDERWENT SURGICAL TREATMENT 1
2
3
Authors: Covaro, Augusto; Manabe, Nodoka; Robinson, Yohan Workplaces: 1Institut Dexeus, Icatme, Barcelona, Spain; 2Yokohama, Japan; 3Uppsala Akademiska, Uppsala, Sweden Study design: Retrospective analysis of prospectively collected data. Objectives: Ankylosing spondylitis (AS) affects the axial skeleton and can cause progressive ankylosis of all the vertebral segments. The effect of high cervical ankylosis in these patients is not documented. The aim of this study is to describe the radiological characteristics of the occipitocervical joint in patients with AS who had undergone surgery due to cervical fracture and correlate it with its clinical course. Methods: Assessment of patients with AS who underwent treatment of a cervical vertebral fracture in a single institution between 2007 and 2014; the follow-up of these patients was done prospectively through the SWESPINE register. The integrity of the CO–C1–C2 joints was determined by performing a new measurement to define the angle between the C0–C1 and C1–C2 joints in the coronal plane of the CT scans (we named the X angle), aiming to describe the integrity/degeneration of the occipital–cervical region. The tools for
measuring quality of life and impairment were EQ5D and ODI, respectively. Results: 86 patients with AS who underwent surgical treatment of a cervical fracture had complete facet ankylosis between C3 and T1. Mean age was 69.2 years (SD 11.7). The level at which fractures occurred more frequently was C5–C6. In 24 patients, the C0–C1 joint was fused, in 15 patients the C1–C2, and 11 patients had total C0–T1 cervical ankylosis. Inter-observer Pearson’s r for the X angle measurement was 0.94. The X angle was 125° (SD 12) in patients with no C0–C1–C2 (AB type) fusion and 136° (SD 14) in fused patients (Ctype) (p \ 0.001). No differences in quality of life and impairment were observed at 2 years between both groups: an EQ5D index of 0.54 and 0.55 (p = 0.5), an ODI of 26.4 and 24 (p = 0.35), respectively. Conclusions: The X angle is a reliable way for C0–C1–C2 joint integrity in patients with AS. Total cervical ankylosis, including the C0–C1–C2 segments is not associated with worse quality of life and impairment in these patients.
18 (ELIGIBLE FOR BEST ORAL PRESENTATION) INFORMATION AND COMMUNICATION TECHNOLOGIES-SUPPORTED COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF CHRONIC LOW BACK PAIN: RANDOMIZED CLINICAL TRIAL Authors: 1Dome´nech Ferna´ndez, Julio; 2Pen˜alver Barrios, Lourdes; 3 del Rı´o Gonza´lez, Eva; 3Garcı´a Palacios, Azucena; 3Herrero, Rocı´o; 4 ´ lvarez Llanas, Ezzedine, Aida; 3Botella, Cristina; 2Schmitt, Julia; 5A Alejandro; 5Llombart Blanco, Rafael; 3Byears, Rosa Workplaces: 1Arnau De Vilanova, Universidad Cardenal Herrera Ceu, Valencia, Spain; 2Servicio de Rehabilitacio´n, H Arnau de Vilanova, Valencia, Spain; 3Facultad De Psicologı´a, Universidad Jaime I, Castello´n, Spain; 4Servicio de Rehabilitacio´n Hospital Marina Alta, Alicante, Spain; 5Servicio De Cirugı´a Ortope´dica H Arnau de Vilanova, Valencia, Spain Introduction: Researchers from Nordic countries have shown the effectiveness of cognitive-behavioral therapy (CBT) for low back pain; however, this has not been assessed in Spain. The reported effectiveness is mild or moderate. One way to increase adherence and the therapeutic effects is the self-management with the aid of Information and Communication Technologies (ICTs) Objectives: Assess (1) effectiveness of CBT in our environment comparing it with the rehabilitation treatment; (2) effectiveness of CBT when accompanied with ICTs (internet and mobile phone), in comparison to only CBT and to the rehabilitation treatment. Methods: Randomized three-arm, single blind, and parallel-group clinical trial. Two hundred (200) patients with chronic low back pain were randomly assigned to one of three possible study groups: the control group (n: 65) received back sessions from a school, the CBT group (n: 72) received group sessions (n: 63), and the CBT + ICT group (n: 63) received the treatment with telephonic support and an online program. The three groups received the same rehabilitation treatment. Pain, impairment, quality of life, comorbidities, catastrophizing, fear-avoidance beliefs, anxiety, depression, pain coping strategies, and satisfaction with the treatment were assessed with the aid of validated questionnaires.
123
2696 Results: There was an immediate significant and clinically relevant improvement of pain and impairment in the three groups at 3, 6, and 12 months. A decrease in maladaptive catastrophizing and fearavoidance beliefs was observed in patients who received CBT. Patients in groups CBT + TIC and CBT showed significant reduction of pain, increase in the quality of life, and greater satisfaction with the treatment in comparison with isolated rehabilitation. Differences in pain, impairment, and quality of life were not clinically relevant between the CBT groups with and without the support of the ICTs. Conclusions: CBT leads to clinical improvement in patients with chronic low back pain, although the effect was modest. Contrarily to what was expected, internet and mobile use does not increase the effectiveness of the CBT on chronic low back pain, producing an effect that is similar to that of face-to-face sessions. Registry ClinicalTrials.org NCT01802671 Funded by the Health Research Fund (FIS). National Institute of Health Carlos III, Ministry of Economy and Competitiveness.
19 (ELIGIBLE FOR BEST ORAL PRESENTATION) IMPACT OF POSTOPERATIVE INFECTION IN ADULT SPINAL DEFORMITY SURGERY Authors: 1Haddad, Sleiman; 2Nun˜ez Pereira, Susana; 3Vila Casademunt, Alba; 3Domingo Sa`bat, Montse; 4Acaroglu, Emre; 5 Alanay, Ahmet; 6Kleinstu¨ck, Frank; 7Sa´nchez Pe´rez-Grueso, Francisco J.; 8Obeid, Ibrahim; 1Pellise´ Urquiza, Ferran; 9European Spine Study Group, ESSG Workplaces: 1Hospital Universitari Vall d´Hebron, Barcelona, Spain; St. Franziskus Hospital Ko¨ln, Cologne, Germany; 3Vall Hebron Institut de Recerca, Barcelona, Spain; 4Ankara Spine Centre, Ankara, Turkey; 5Acibadem Hospital, Istanbul, Turkey; 6Schulthess Klinik, Zurich, Zurich, Switzerland; 7Hospital Universitario La Paz, Madrid, Spain; 8Chu Bordeaux, Bordeaux, France; 9European Spine Study Group, ESSG, Barcelona, Spain 2
Purpose: The impact of deep Surgical Site Infection (SSI) on surgical outcomes after Adult Deformity Surgery (ASD) is still unclear. We aimed to study the morbidity of SSI in ASD and its impact on deformity correction and functional outcome Methods: Prospective multicenter matched-cohort study including consecutively enrolled ASD patients. Patients developing SSI were matched to similar controls in terms of age, gender, ASA, primary or revision, extent of fusion and use of tricolumnar osteotomies. Preoperative parameters, surgical variables and complications were recorded. Deformity parameters and HRQoL scores were obtained preoperatively and at 6, 12 and 24 months. Independent t-test and Fischer Exact test were used for comparisons. Results: 331 surgical ASD patients with more than 2 years of followup were identified. 20 (6,4%) sustained a SSI and 60 controls were accordingly matched. No differences were observed between groups in preoperative radiological and HRQoL variables confirming comparable groups. SSI patients had longer hospital stay and more mechanical complications including PJK. Infection was associated with more unrelated complications and revisions. Deformity correction was maintained equally at the different time intervals. One death was related to SSI. SSI patients had worse overall HRQoL status at 1-year and were less likely to experience improvement. However, no significant differences were recorded thereafter. Conclusion: SSI significantly affects the first postoperative year after ASD surgery. It is associated with more complications, unrelated
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Continuous variables
Cases Mean
Controls Mean
p value
BMI
27.15
26.76
0.773
Age (years)
53.25
51.68
0.743
Length of the surgery (min)
347.6
350.08
0.947
Area of the arthrodesis
12.05
10.65
0.138
Number of de osteotomies
0.35
0.32
0.815
Blood loss (ml)
1651.56
1983.58
0.32
Alogenic transfusion (volume)
636.35
497.22
0.388
Alogenic transfusion (units)
2.15
1.77
0.505
Autologous transfusion (volume)
156
257.67
0.352
Autologous transfusion (units)
0.37
0.66
0.177
Stay in the ICU (h)
94.6
62.44
0.606
Hospital stay (days)
28.25
12.35
0.019
Preoperative radiological variables
Mean
Mean
p value
SVA (mm)
56.456
69.906
0.535
PI
54.98
52.85
0.536
LL
-42.83
-40.25
0.687
PI-LL
12.15
12.6
0.95
SS
33.95
31.1
0.384
PT
21
21.7
0.827
Global tilt
27.71
31.76
0.403
Major coronal Cobb
40.77
36.85
0.596
Preoperative quality of life scores
Mean
Mean
p value
Back pain
6.56
6.42
0.826
Radicular pain
3.93
4.21
0.765
COMI
6.99
6.44
0.523
ODI
47.02
44.37
0.645
SF 36 MCS
41.36
41.12
0.946
SF 36 PCS
35.24
34.14
0.664
SRS22 function
2.88
2.85
0.926
SRS22 mental
2.95
3.05
0.675
SRS22 pain
2.49
2.55
0.812
SRS22 satisfaction
2.96
2.46
0.199
SRS22 self image
2.43
2.17
0.253
SRS22 subtotal
2.69
2.66
0.883
Categorical variables
Cases
Control
p value
Female
60%
60%
1
Male
40%
40%
Alcohol
5%
3%
1
Anemia
0%
8%
0.324
Arthritis
0%
5%
0.569
TVP
5%
5%
1
Cancer
15%
7%
0.358
Depression
5%
27%
0.057
Diabetes
10%
12%
1
Heart disease
15%
5%
0.162
Hypertension
30%
25%
0.77
Kidney disease
0%
2%
1
Liver disease
10%
3%
0.259
Pulmonary disease
10%
8%
1
Osteoporosis
5%
12%
0.672
Peripheral artery disease
5%
2%
0.44
Psychiatric disease
0%
3%
1
Gastric disease
15%
22%
0.749
Tobacco user
32%
17%
0.194
Osteotomy
30%
30%
1
Need of ICU
85%
88%
0.705
Eur Spine J (2017) 26:2682–2717
2697
continued Categorical variables
Cases
Control
p value
Checkup surgery
30%
30%
1
ASA I
35%
35%
1
Asa II
35%
35%
ASA III
30%
30%
revisions and worst quality of life. However it´s negative impact seems to be diluted by the second postoperative year as differences in HRQoL scores between the two groups decrease. Keywords: Adult spinal deformity, Scoliosis, Infection, Complication, Results
20 (ELIGIBLE FOR BEST ORAL PRESENTATION)
relationships’’) showed higher saturations in Spanish and Turkish in comparison to French and German. The analysis of a ‘‘shorter’’ version of the remaining 16 questions, showed good adjustment for the baseline data (RMSEA = 0.04, CFI = 0.92). Conclusions: The four-factor structure suggested by the designers of the instrument showed a correct adjustment. The SR22 questionnaire appears to be a valid instrument for assessing AS. Introducing certain modifications to the instrument should be considered to improve its psychometric properties.
21 (ELIGIBLE FOR BEST ORAL PRESENTATION) ANALYSIS OF SPINE FACET JOINT CARTILAGE DEGENERATION MECHANISMS. COMPARISON TO THOSE OF LARGE JOINTS
FACTOR ANALYSIS OF THE SRS22 INSTRUMENT IN PATIENTS WITH ADULT SCOLIOSIS
Authors: 1Pino Mı´nguez, Jesu´s; 2Villar Liste, Rosa; 3Dı´ez Ulloa, M. Alberto; 3Otero Ferna´ndez, Marı´a; 1Pernal Duran, Carlos; 3Jorge Mora, Alberto Agustı´n; 2Gualillo, Oreste
Authors: 1Mannion, Anne F.; 2Elfering, Achim; 3Bago´ Granell, Juan; 3Pellise´ Urquiza, Ferran; 4Vila Casademunt, Alba; 4Domingo Sa`bat, Montse; 5Sa´nchez Pe´rez-Grueso, Francisco J.; 6Obeid, Ibrahim; 7Acaroglu, Emre; 8Alanay, Ahmet; 1Kleinstu¨ck, Frank
Workplaces: 1COT Hospital Clinico Univ. de Santiago de Compostela, A Corun˜a, Spain; 2Laboratorio Neirid, Instituto de Investigacio´n Idis, Santiago de Compostela, A Corun˜a, Spain; 3 Complejo Hospitalario Universitario de Santiago, La Corun˜a, Spain
Workplaces: 1Schulthess Klinik, Zurich, Switzerland; 2Universidad de Berna, Berna, Switzerland; 3Hospital Universitario Vall d’Hebron, Barcelona, Spain; 4Vall Hebron Institut de Recerca, Barcelona, Spain; 5 Hospital Universitario La Paz, Madrid, Spain; 6Chu Bordeaux Pellegrin Hospital, Bordeaux, France; 7Ankara Spine Center, Ankara, Turkey; 8Acibadem University School of Medicine, Istanbul, Turkey Introduction: The SR22 questionnaire was designed for adolescent patients with idiopathic scoliosis although it is currently being used for assessing patients with adult scoliosis (AS). There are no studies that confirm the structure of four factors in AS (pain, function, body image, and mental health). The aim in this study is to determine if the Spanish, French, German, and Turkish versions of the SRS22 show the same structure as the original instrument regarding the four factors, and if variation of the structure occur throughout the follow-up period. Methods: Eight hundred and eighty (880) patients with AS (297 surgical, 583 non-surgical) recruited for the ESSG database completed the SR22 questionnaire once included in the study and at 12 months of follow-up. A unifactorial factorial analysis (FA) and a confirmatory FA analysis were done. The differences observed in the saturation of the items between initial and follow-up data were analyzed. Additionally, differences between the data in Spanish (n = 409), Turkish (n = 221), French (n = 66), and German (n = 184) were also evaluated. Results: The factorial structure of the SRS22 does not adjust to a unifactorial solution, but it does to the suggested four-factor solution (RMSEA = 0.04, CFI 0.87). This four-factor model is similar in the four languages and for the initial and follow-up data. Saturation of item 15 (function ‘‘economic difficulties ‘‘) was generally low in all the languages. Other three points (item 11 ‘‘pain medication use’’, item 17 ‘‘days away from work’’, and item 14 ‘‘personal
Introduction: Two types of enzymes are primarily involved in articular cartilage degradation, the MMPs and the ADAMTS; they destroy aggrecans and Type II collagen. Various Interleukins—IL-1 alpha among them—participate in the activation of these enzymes. Objectives: The aim of this study is to analyze the IL-1, MMPS, and ADAMTS involved in cartilage degradation of large joints, intervene in the degradation of the facet cartilage. Materials and methods: MMPS-13 and ADAMTs-5 mRNA expression—from facet and femoral head cartilages—were examined with the aid of RT-qPCR. Samples were obtained from 30 patients affected by degenerative scoliosis and 30 patients with coxarthrosis; group mean age were 67.3 years and 66.1, respectively. Western blot was used to assess IL-1 alpha mechanism of action. Results: The data obtained in this study show that IL-1 alpha activates MMPS-13 and ADAMTS-5 in facet cartilage and the femoral head with their levels being similar except for a slight increase of MMMPS in femoral head cartilages. Conclusions: Recently, several studies have linked pro-inflammatory cytokines, e.g., IL-1 alpha, with facet cartilage degeneration, its influence on low back pain, radicular, and facet instability. The relevance of IL-1 alpha in the inflammatory processes involved in the degradation of large articular joints has been shown. Facet joints, as well as the hip, are synovial joints; however the hip is an enarthrosistype joint and the facet an arthrodial one, both subjected to different mechanical solicitations. In this study, we have shown that ADAMTS-5 IL-1 alpha-induced expression is similar in the facet cartilage of patients with adult scoliosis in comparison to patients with coxarthrosis. However, greater increase of MMPS-13 was seen in the coxarthrosis group. These data suggest that IL-1 alpha is an important factor for the enzymatic inducement of facet degeneration, as in a large joint such as the hip.
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2698
22 (ELIGIBLE FOR BEST ORAL PRESENTATION) EVIDENCE OF ALTERED BRAIN WHITE MATTER IN ADOLESCENT IDIOPATHIC SCOLIOSIS: A DIFFUSION MAGNETIC RESONANCE IMAGING AND CONNECTOME APPROACH STUDY Authors: 1de Luis Garcı´a, Rodrigo; 2Herna´ndez Ramajo, Ruben; 1 ´ scar; 3Calabia del Campo, Alberola Lo´pez, Carlos; 1Pen˜a Nogales, O Juan; 2Ardura Arago´n, Francisco; 2Noriega Gonzalez, David Cesar Workplaces: 1Laboratorio Procesado de Image Universidad de Valladolid, Valladolid, Spain; 2Hospital Clinico Univeristario, Valladolid, Spain; 3Servicio de Radiologia. Hcuv, Valladolid, Spain Objectives: Explore the possible relationship between adolescent idiopathic scoliosis and potential variations in brain connectivity by comparing parameters obtained with diffusion magnetic resonance imaging among healthy controls and patients with idiopathic scoliosis. Methods: 18 HC (8 female and 10 male, 12.33 ± 2.43 years) and 22 IS (17 female and five male, 14.73 ± 3.03 years) were included in the study. T1-weighted anatomical sequences and diffusion-weighted sequences in a 3T NMR (for diffusion-weighted sequences 32 gradient directions, b = 1000 s/mm2, voxel size 1.66 9 1.66 9 2 mm, and a matrix size of 144 9 144 with 140 cuts covering the totality of the brain and the cervical are was used) were obtained. For data analysis, a connectivity matrix was constructed including 84 cortical and subcortical regions, with the aid of Freesurfer, FSL, and MRTrix and generating 2,000,000 tractography lines for each subject. Fractional anisotropy (FA) was used as the connective descriptive parameter. From the 3570 connections, those with at least 500 tractography lines in all subjects were used for a later statistical analysis. The statistical analyses was done using a general linear model; the influence of age, gender, and HC/IS condition on the obtained connectivity was studied. Results: From the 3570 initial connections, 159 surpassed the previously described threshold and an analysis was done using a general linear model. Considering all these connections globally, we observed that the HC/IS condition is significant (p = 3.8 10-6) when adjusted by age and gender. Regarding individual analysis of the connections and applying multiple testing correction via false discovery rate (FDR), significant differences were found between medial-frontalcaudal cortex (left hemisphere) connections and the superior-frontal cortex (left hemisphere) ones, the connection of the left cingulate gyrus isthmus with itself, and the connection of the right cerebellar cortex with itself. Conclusions: The analysis of the data suggests possible connectivity impairments in the white matter of the brain in patients with adolescent idiopathic scoliosis. However, these are only preliminary results and further studies are required to confirm these alterations and their nature.
23 MULTICENTRIC MULTIDISCIPLINARY STUDY ON NEUROPATHIC PAIN KNOWLEDGE AND TREATMENT PATTERNS BY VARIOUS SPANISH SPECIALISTS
Eur Spine J (2017) 26:2682–2717 Authors: 1Tome´ Bermejo, Fe´lix; 2Sanz Aya´n, Marı´a Paz; 3Guille´n Astete, Carlos; 4Madariaga Mun˜oz, Marı´a; 5Duce Tello, Susana; 6 Mun˜oz Martı´n, Andre´s; 1Prieto Mun˜oz, Isabel; 7del Avellanal Calzadilla, Martı´n Workplaces: 1Hospital Universitario Fundacio´n Jime´nez Dı´az, Madrid, Spain; 2Hospital Doce de Octubre, Madrid, Spain; 3Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 4Hospital Quiro´n, Madrid, Spain; 5Centro De Salud Orcasitas, Madrid, Spain; 6Hospital Gregorio Maran˜o´n, Madrid, Spain; 7Hospital La Moraleja, Consultores en Dolor, Madrid, Spain Objectives: Spinal stenosis, diabetic neuropathy, complex regional pain syndrome, and nerve root disorders (sciatica/brachialgia) are some of the most common neuropathic pain (NP) manifestations; despite their frequency, few studies have been performed to evaluate the prescription pattern for their treatment in routine clinical practice. The aim of this study is to evaluate the degree of knowledge on NP by the different specialists who treat this type of medical disorders, as well as their treatment preferences. Materials and methods: 239 specialists who regularly treat patients with NP. The study had four stages: selection of the topics; preparation of the questionnaire; completion of the questionnaire; statistical analysis. The assessment questionnaire includes 11 questions; they were distributed during the scientific activities to which the members of the scientific committee went; 231 specialists completed the questionnaire. Results: Fifteen (15) specialties were included; the most frequent were oncology (35.9%), family medicine (20.8%), and traumatology (10.8%). 44.6% of the specialists communicated not having specific training on NP. On a scale from 1 to 10, the median -self-assessed- knowledge on NP was 7 and satisfaction regarding pharmaceutical management 6. Significant differences regarding self-assessed NP knowledge and satisfaction on pharmaceutical management between specialties were determined (p = 0.004 and p = 0.003, respectively). The most commonly used pharmacological agent for the treatment of moderate-intense NP were antiepileptics (91.3%, n = 211), major opioids (76.2%, n = 176), and antidepressants (69.3%, n = 160). The most frequently used opioid based on its effectiveness/tolerability was tapentadol (30.3%/ 29.0%, respectively), followed by oxycodone (28.1%/26.8%, respectively), and tramadol (16.0%/18.2%, respectively). There were significant differences regarding the use of opioids between specialists. Conclusions: For the first time we present the results of a study on the knowledge and management of NP by different specialists. The training of physicians who handle this type of patients is insufficient, particularly in certain specialties. The low degree of follow-up of clinical guidelines should draw the attention of scientific societies. In most guidelines, the use of opioids in NP seems to be the last-line treatment option, while the trend between specialists who deal more frequently with this type of cases is to use them on a regular basis. Use frequency of different types of drugs versus specific training on neuropathic pain by study participants. Fisher’s exact test.
Drugs
Training on NP, % (n)
Bilateral significance (Fisher)
Antiepileptics
88.3% (91)
94.4% (119)
p = 0.147
Major opioids
67.0% (69)
83.3% (105)
p = 0.005*
Antidepressants
58.3% (60)
78.6% (99)
p = 0.001*
Minor opioids
59.2% (61)
61.9% (78)
p = 0.686
Anti-inflammatories
54.4% (56)
53.2% (67)
p = 0.894
Paracetamol
39.8% (41)
31.7% (40)
p = 0.214
Metamizole
38.8% (40)
32.5% (41)
p = 0.334
* Significant difference
123
No training on NP, % (n)
Eur Spine J (2017) 26:2682–2717
2699 Conclusions: The results of this study show high agreement in the treatment of certain LDD (isthmic spondylolisthesis), but great variability in the remaining cases. A lack of agreement in the literature is the cause of this intra-national and inter-national variability.
24 VARIABILITY OF LUMBAR DEGENERATIVE DISEASE TREATMENT GUIDELINES
25
´ lvarez Galovich, Luis; 2Debono, Bertrand; 3Kerever, Authors: 1A Sebastien; 4Guiots, Ben; 5Eicker, Svenollison; 2Hamel, Olivier; 1 ´ ngel Ramo´n; 6Tome´ Bermejo, Fe´lix; 7Duart Pin˜era Parrilla, A Clemente, Javier Melchor Workplaces: 1Fundacio´n Jimenez Dı´az, Unidad de Patologı´a de Columna, Madrid, Spain; 2Clinique des Ce´dres, Toulouse, France; 3 Cress, Epidemiology and Statistics Center, Sorbonne, Paris, France; 4 South Denver Neurosurgery, Colorado, United States of America; 5 Universita¨tsklinikum Hamburgeppendorf, Hamburg, Germany; 6 Hospital General De Villalba, Madrid, Spain; 7Hospital Fundacio´n Jime´nez Dı´az, Madrid, Spain Introduction: Because of a lack of consensus regarding treatment regimens, there is currently a wide variation of surgical indications (based on geographical reasons, training, or specialty) for Lumbar Degenerative Disease (LDD). The goal of this study is to analyze this variability amongst specialists (neurosurgeons and traumatologists) from four countries, and five different LDD scenarios. Materials and methods: An on-line survey was performed to 102 surgeons (52 traumatologists and 50 neurosurgeons) on the treatment of five different pathologies: multilevel stenosis, monosegmental stenosis, spondylolisthesis due to spondylolysis, foraminal stenosis due to spondylolysis, and degenerative scoliosis. For each case, there was predetermined treatment options. The variability for each country was calculated based on the Qualitative Variation Index (QVI = 0: no variability and 1: maximum variability). To determine up to which point the observed agreement was higher to the randomly expected, the Fleiss kappa test was used (-1: little agreement, 1: very good agreement); this allows obtaining the level of agreement between participants of the same specialty, same country, or same age. Results: The QVI for the five cases had a mean of 0.64. Arthrodesis in isthmic spondylolisthesis was the treatment with the highest agreement (QVI \0.63). In cases of lumbar stenosis, American surgeons had a more conservative attitude (only decompression) (multilevel QVI = 0.47 and monosegmental QVI = 0.32) in comparison with European countries, who had a more heterogeneous (QVI [70) and more aggressive attitude. Degenerative scoliosis showed high variability (QVI [0.8). However, the most heterogeneous attitude was for isthmic lysis (QVI range between 0.48 and 0.76), with a 37% anterior route proposal in France and 19.2% in the United States of America. The agreement index was low between neurosurgeons (kappa = 0.04) and traumatologists (kappa = 0.13). The same lack of agreement was observed for countries (kappa [0.13) and different age groups (kappa [0.1).
ARE MODIC CHANGES IN PATIENTS WITH CHRONIC LOW BACK PAIN INDICATIVE OF A WORSE CLINICAL COURSE AND GREATER CHANCE OF REQUIRING SURGERY? PROGRESS AT 10 YEARS Authors: 1Romero Mun˜oz, Luis Marı´a; 1Barriga Martı´n, Andre´s; 2 Martı´nez Gonza´lez, Carmen; 3Segura, Antonio Workplaces: 1Hospital Nacional de Paraple´jicos, Toledo, Spain; 2 Hospital Infantil Nin˜o Jesu´s, Madrid, Spain; 3Servicio de Investigacio´n del Instituto de Ciencias de la Salud Talavera de la Reina, Toledo, Spain Objectives: Establish the long-term (10 years) predictive value of Modic changes in the course of lumbar pain and the need of surgical treatment. Materials and methods: Observational longitudinal prospective cohort study. Comparison of progression at 10 years of two groups of patients with chronic lumbar pain. Group A with Modic changes in RM and group B with no changes in Modic. Exclusion criteria: neoplasia, inflammatory or infectious diseases, or previous surgery. Assessment was done with the aid of the Visual Analogue Scale for low lumbar and radicular pain and the Oswestry Disability Questionnaire. The need of surgical or medical treatment and occupational disability during study period was analyzed. For the statistical analyses, the Mann–Whitney U test and logistic regression were applied. Results: 70 patients, 24 male, and 46 female, with a mean age of 56.5 years (35 in each group) were included in the study. The group with Modic changes was divided in types 1, 2, or 3. Data of the groups are shown in Table 1. No statistically significant differences in the intensity of lumbar pain, degree of impairment, or need of medical or surgical treatment (p [ 0.05) were found in patients with Modic changes types 1, 2, or 3 between the baseline assessment and 10 years after. No statistically significant differences between patients with changes/without changes in Modic regarding greater intensity of lumbar pain, degree of impairment, or need of medical or surgical treatment at 10 years of follow-up (p [ 0.05) were determined. Conclusions: There is no relationship between Modic changes in RM and greater intensity of lumbar pain, impairment because of lumbar pain, or need of medical or surgical treatment at 10 years of follow-
Table 1 VAS for low back VAS for leg Oswestry VAS for low back VAS for leg Oswestry Surgery Analgesia Disability Changes is Modic Group A n: 35
6
5
32
5
5
26
6%
65%
26.5%
Modic 1(12)
6
4.6
28
4
5.5
28
0%
67%
17%
Modic 2 (21)
6
4.6
33
5
4
26
10%
65%
33%
Modic 3 (2)
7
7.5
40
2.5
2.5
9
0%
50%
50%
5.4
34
4.9
4.5
32
9%
66%
46%
No changes in Modic 6.7 GROUP B n: 35 10 years ago
Current
123
2700
Eur Spine J (2017) 26:2682–2717
up. Modic changes cannot be considered by themselves a sign of bad prognosis, nor an indication for surgery.
26 RELATIONSHIP BETWEEN SLEEP QUALITY AND THE COURSE OF NON-SPECIFIC LUMBAGO ´ lvarez Galovich, Luis; 2Kovacs, Francisco M.; 3Seco, Authors: 1A Jesu´s; 4Royuela, Ana; 5Gonza´lez Rubio, Yolanda Workplaces: 1Fundacio´n Jimenez Dı´az, Unidad de Patologı´a de Columna, Madrid, Spain; 2Red Espan˜ola de Investigadores en Dolencias de la Espalda (REIDE), Unidad de la Espalda Kovacs Hospital Universitario Moncloa, Madrid, Spain; 3Instituto de Biomedicina (IBIOMED), Leo´n, Spain; 4Hospital Ramo´n y Cajal, Madrid, Spain; 5Fundacion Jimenez Diaz, Madrid, Spain Introduction: Non-specific low back pain can cause sleep disorders and poor quality of sleep (QS) can disrupt the integration of pain and make it worse. In fact, poor QS worsens the course of cervicalgia, existing a correlation between QS and the presence and intensity of low back pain. However, ‘‘association’’ does not mean ‘‘causality’’; low back pain and QS can be coetaneously influenced by other factors, such as psychological ones. The aim of this study is to determine if the QS affects the prognosis of low back pain; should this be the case, the management of sleep may help improve low back pain. Materials and methods: A prospective study was performed in 11 centers of various specialties; 461 patients with sub-acute or chronic low back pain were included with three months follow-up. Demographic data, current low back pain and that of the previous three months (with the aid of the VAS), functional impairment (Roland Morris Disability Questionnaire-RMQ-), catastrophism (CSQ), depression (Beck Depression Inventory), QS (Pittsburgh Sleep Quality Index, which includes the use of hypnotics), comorbidities, and received treatment were collected. The following logistic regression models were used, adjusting for possible confusion factors; improvement of low back pain and impairment as per baseline QS, improvement of the QS as per low back pain and baseline
Table 1 Correlation between baseline values for lumbar pain, functional impairment, catastrophism, depression, and quality of sleep (QS) Pain
Pain during the previous 3 months
Impairment
Catastrophism
Depression
Pain Pain during the previous 3 months
0.596
Impairment
0.658
Catastrophism
0.535
0.584
0.549
Depression
0.452
0.466
0.513
0.573
Quality of sleep
0.346
0.330
0.445
0.457
0.547
0.464
Pain: Initial intensity of low back pain as per a visual analogue scale (VAS) Pain during previous 3 months: Mean intensity of low back pain during the three months before the beginning of the study (VAS) Impairment: Initial scoring of the Roland–Morris questionnaire Catastrophism: Initial scoring of the Coping Strategy Questionnaire Depression: Initial scoring of the Beck Depression Inventory Quality of sleep: Initial scoring of the Pittsburgh Sleep Quality Index
123
impairment, and the association between the course of QS and that of low back pain and impairment. Results: 27.3% of the patients had chronic pain ([90 days of duration), with mean VAS and RMQ values of 4. A correlation (r = 0.330–0.658) between low back pain, impairment, catastrophism, depression, and QS initial scores was determined. The models showed an association between initial impairment and the course of the QS (OR [95% CI] = 1.05 [1.00; 1.10]), the course of QS and low back pain (4.34 [2.21; 8.51]), and that of QS and impairment (4.60 [2.29; 9.27]). No association between the initial intensity of low back pain and the course of QS (1.09 [0.98; 1.20]) was observed, nor between the initial QS and the course of low back pain (0.99 [0.94; 1.06]) or impairment (0.99 [0.93; 1.05]). Conclusions: There is a correlation between QS, low back pain, and impairment, however, unlike what occurs with cervicalgia, the QS does not have an impact on the course of low back pain. Having a disrupted QS does not affect the course of DL.
27 IS THERE A CORRELATION BETWEEN THE TWO MAIN CALCULATION METHODS FOR MINIMAL CLINICALLY IMPORTANT DIFFERENCES? Authors: 1Blanco Hortas, Andre´s; 1Estany Gestal, Ana; 1Lombao Iglesias, Domingo; 2Ferna´ndez Gonza´lez, Manuel; 3Esteban Blanco, Marta; 3Betego´n Nicola´s, Jesu´s; 1Bermu´dez Lo´pez, Marı´a Jose´; 3 ´ ngel; 3Lozano Mun˜oz, Ana; 3Villar Pe´rez, Herna´ndez Encinas, Jose´ A Julio Workplaces: 1Hospital Universitario Lucus Augusti, Lugo, Spain; Complejo Asistencial Universitario de Leo´n (CAULE), Unidad de Columna-Traumatologı´a, Leo´n, Spain; 3Complejo Asistencial Universitario de Leo´n (CAULE), Leo´n, Spain
2
Introduction: Patients with spinal deformity suffer more pain and disability in comparison to the general population. Quality of life questionnaires help quantify this suffering and assess—by calculating minimal clinically important differences (MCID)—if the improvement of the quality of life after the surgery is significant for the patient. Although different techniques for calculating this parameter have been described, no agreement has been reached on which is the most appropriate method for each case. Objectives: Determine the level of agreement between two MCID calculation methods, as well as the percentage of subjects who reach the MCID in every case. Methods: Comparative retrospective study in adult patients who underwent spinal deformity surgery with a minimum of four instrumented levels and over a year of follow-up. The quality of life tests applied preoperatively and at the end of the follow-up were the VAS and the SRS-22. MCID were assessed by: (1) distribution-based method (for which the mean standard error was calculated) and (2) an anchor-based method of (question 4 of the SRS-22); the MCID was calculated by analyzing the ROC curves. The kappa agreement index was used to compare the percentages of patients who reached the MCID through both study methods. Results: Seventy-nine (79) patients (75.9% female) were included in the study; the mean age was 70 years (59–75), BMI was 28.73 (±5.834), median of instrumented levels was 8 (6–13), and length of the procedure was 390 min (330–525). MCID reached in both methods are shown in Table 1. Relevant differences between the percentages of subjects who reached the MCID with each of the methods were found for SRS-22 function, mental health, and self-
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2701
image. The level of agreement between the methods was moderate for the VAS, and function and mental health subdomains of the SRS-22 Conclusions: The moderate level of agreement for half of the items lead us to believe that the calculation methods are not interchangeable. We believe further studies are require to determine the method of choice for every situation or reach an agreement of which method is better for comparing results.
Table 1 MCID values Subdomain
MCID based)
(distribution- MCID based)
SRS22_pain
0.878
0.6
SRS22_function
0.891
0.2
SRS22_self-image
0.609
0.8
SRS22_mental health
0.705
1.45
SRS22_total
0.425
0.67
VAS
2.884
3
(anchor-
Distribution-based method through SEM
Materials and methods: The study sample consisted of 30 subjects, 20 sick and 10 healthy; affected participants had different sagittal imbalance values measured via C7 plumb line through radiological, clinically static, and dynamic approaches. Static and dynamic analyses of the selected patients were performed. The static analysis included radiographic measurements (telemetry in standing position) of the various sagittal balance and spinopelvic parameters. The dynamic analysis was done in a walking corridor equipped with cameras with infrared sensors. Data were included in an inverse kinematics dynamic model. A correlation between spinopelvic and spinal sagittal balance parameters was made for each patient with gait disturbances and the results compared against the normal patter in the healthy individuals. From these tests, a movement profile was obtained for each patient, as well as the flexo/extension and/or abduction ranges of hips and knees. Results: An increase of sagittal imbalance leads to an increase in the average hip flexion–extension, as well as an increase of its abduction during gait. This correlation was observed in a statistically significant (p \ 0.05) way. Furthermore, a statistically significant (p \ 0.05) correlation was also found between the degree of affectation in our patients greater flexion of the knees. Conclusions: During gait, patients with positive balance sagittal show a greater hip flexion–extension and abduction range and greater flexion of the knees.
Anchoring performed through item 4 of the SR22 questionnaire
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Table 2 Percentage of patients who reach the MCID Subdomain
MCID MCID Kappa (distribution-based) (anchor-based) index
SRS22_pain
52.4
64.3
0.759
SRS22_function
35.7
80.9
0.472
SRS22_self-image
71.4
59.5
0.741
SRS22_mental health 76.2
54.7
0.549
SRS22_total
78.5
64.3
0.659
VAS
66.6
55.5
0.476
MCID data expressed as percentages Distribution-based method through SEM Anchoring performed through item 4 of the SR22 questionnaire
28 CHANGES IN ARTICULAR RANGE OF MOTION OF LOWER LIMBS DURING GAIT IN PATIENTS WITH SPINAL SAGITTAL BALANCE DISORDERS Authors: 1Miguez, Paula; 2Idelsohn Zielonka, Sebastian; 2Koch, Martı´n; 3Lo´pez Alcover, Alejandro; 1del Arco Churruca, Alejandro; 1 Salo Bru, Guillem Workplaces: 1Hospital del Mar, Barcelona, Spain; 2Eurecat CTM Centre Tecnologic, Barcelona, Spain; 3Parc de Salut Mar, Barcelona, Spain Objectives and introduction: Spinal sagittal imbalance determines the static standing posture and gait of patients who suffer this condition. Very few studies have analyzed gait abnormalities in subjects with sagittal imbalance. Objectives: to determine how sagittal imbalance influences biomechanics of walking, particularly focusing on articular mobility and ranges of the lower limbs (hip and knee).
ANALYSIS OF STRENGTH, MUSCULAR WORK, AND ENERGY EXPENDITURE DURING GAIT IN PATIENTS WITH SPINAL SAGITTAL BALANCE DISORDERS Authors: 1Miguez, Paula; 2Idelsohn Zielonka, Sebastian; 2Koch, Martı´n; 3Lo´pez Alcover, Alejandro; 1Molina Ros, Antonio; 1Salo´ Bru, Guillem Workplaces: 1Hospital del Mar, Barcelona, Spain; 2Eurecat CTM Centre Tecnologic, Barcelona, Spain; 3Parc de Salut Mar, Barcelona, Spain Objectives and introduction: Spinal sagittal imbalance determines the static standing posture and gait of patients who suffer this condition. To date, there are no studies analyzing the changes this imbalance causes on lower limb muscles while the patient is walking. Objectives: Determine how sagittal imbalance affects muscle energy expenditure, strength, and work, measured in different groups of muscles of the lower limbs involved in gait. Materials and methods: The study sample consisted of 30 subjects, 20 sick and 10 healthy; affected participants had different sagittal imbalance values measured via C7 plum line through radiological, clinically static, and dynamic approaches. Dynamic analysis was done in a walking corridor equipped with cameras with infrared sensors. Data were included in an inverse kinematics dynamic model (the ANYBODY SIM software), through which a platform was created for configuring the geometric parameters adjusted to each patient based on their radiological parameters. By using inverse dynamic methods, it is then possible to know the effort needed in each of the muscle groups for generating a gait pattern for each subject. We measured the strength, muscular work, and energy expenditure of the oblique, psoas major, quadriceps, anterior tibial muscle, gastrocnemius, and hamstring muscles. Results: A significant correlation was seen (p \ 0.05) between muscular work/energy expenditure and gait speed/variations of the sagittal profile; thus, with increased unbalance a slowing down of gait
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occurred. Furthermore, and with a statistically significant (p \ 0.05) correlation, with greater sagittal imbalance more tension was imposed on the psoas major, hamstring, gastrocnemius, and the anterior tibial muscles. However, no significant correlation was found with the quadriceps muscles (maybe because sample size was too small). Conclusions: In patients with positive sagittal balance a slowing down of gait and a greater overload in the muscles of the lower limbs occurs at the level of the psoas major, anterior tibial muscle, gastrocnemius, and hamstring muscles; the observed differences were statistically significant (p \ 0.05).
17.6 ± 12.8 mm (p = 0.000); pelvic tilt 20.58 ± 10.18; global tilt 22.88 ± 14.68; lumbar mismatch (PI-LL) 12.68 ± 158; (p = 0.000), and SVA 31.7 ± 37.5 mm, (p = 0.004). COMI 4; ODI 28.6; SF-36 MCS 45.7, SF-36 PCS 42; SRS-22 function 3.5; mental 3.4; pain 3.5; image 3.5; subtotal 3.5 (all p = 0.000). Conclusions: TLS surgery in adults at two years leads to a 60% coronal correction and improves anterior and lumbar imbalances. It also improves function, pain, and image above the minimal clinically important difference, but with a high rate of complications (57%)— most of them major—and 24% need of revision surgery.
30
31
SURGICAL RESULTS AT TWO YEARS OF A PROSPECTIVE COHORT OF PATIENTS WITH ADULT THORACOLUMBAR SCOLIOSIS
THROMBOPROPHYLAXIS IN ADOLESCENTS AND ADULTS WHO UNDERGO ELECTIVE SPINE SURGERY. SYSTEMATIC LITERATURE REVIEW
Authors: 1Pe´rez Martı´n-Buitrago, Mar; 1Pizones Arce, Javier; 1 Sa´nchez Pe´rez-Grueso, Francisco J.; 2Domingo Sa`bat, Montse; 2Vila Casademunt, Alba; 3Alanay, Ahmet; 4Obeid, Ibrahim; 5Acaroglu, Emre; 6Kleinstu¨ck, Frank; 7Pellise´ Urquiza, Ferra´n; 8ESSG, European Spine Study Group
Authors: 1Colomina, Marı´a J.; 2Bago´ Granell, Juan; 3Urrutia, Gerard; 3Nishishinya, Marı´a Betina; 4Pellise´ Urquiza, Ferra´n
Workplaces: 1Hospital Universitario La Paz, Madrid, Spain; 2Vall d´Hebron Instititut de Recerca, Barcelona, Spain; 3Acibadem Hospital, Istanbul, Turkey; 4Chu Bordeaux, Bordeaux, France; 5Ankara Spine Centre, Ankara, Turkey; 6Schulthess Klinik, Zurich, Zurich, Switzerland; 7Hospital Vall Hebron, Barcelona, Spain; 8European Spine Study Group, ESSG, Barcelona, Spain Introduction: The surgical treatment of adult spinal deformity in general has been analyzed and published. However, studies specifically dealing with thoracolumbar scoliosis (TLS) are scarce, even though it is very prevalent in this population segment. Materials and methods: Retrospective analysis of data collected prospectively from an adult spinal deformity multicenter database. The patients who underwent surgery of primary thoracolumbar-lumbar curves (TL) were identified. Primary thoracic curves, revision surgeries, and patients who underwent partial surgery of the deformity were excluded from the study. Results: One hundred and seventy-five (175) patients who underwent surgery were included. Preoperative data: mean age was 52.4 ± 19.2 years. Preoperative Cobb of TL was 45.48 ± 21.18, with apical translation of 33.7 ± 19.1 mm, and compensatory thoracic curve of 36.18 ± 238. T2–T12 kyphosis 37.78 ± 198; lordosis -45.28 ± 20.98. Pelvic incidence 558 ± 13.28, pelvic tilt 21.48 ± 10.98, global tilt 24.78 ± 178, lumbar mismatch (PI-LL) 17.28 ± 20.28, and SVA 41.4 ± 51.6 mm. COMI 6.2; ODI 39.8; SF36 MCS 43.5, SF-36 PCS 35.4; SRS-22 function 3.07; mental 3.2; pain 2.7; image 2.5; subtotal 2.86. The number of fused levels was 10.9 ± 3.5, with a blood loss of 1522 ± 1190 ml, length of procedure 303 ± 128 min, stay in the hospital 11 ± 9.3 days; 76 patients underwent osteotomies; in 61 interbody cages were used; 77 were instrumented to the pelvis. One hundred and one (101) patients suffered complications (49 minor, 52 major). Forty-three (43) patients had to undergo revision surgery during these 2 years. Postoperative data at 2 years: TL Cobb was 17.98 ± 15.58 (a correction of 60%, p = 0.000), compensatory thoracic curve of 18.48 ± 15.78 (49%, p = 0.000). T2–T12 kyphosis increased to 44.18 ± 16.18 (p = 0.000); lordosis -48.58. Lumbar apical translation
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Workplaces: 1Hospital Universitario Bellvitge, Barcelona, Spain; 2 Hospital de Traumatologia Vall d´Hebron, Barcelona, Spain; 3Centro Cochrane Iberoamericano. Servei d’Epidemiologia Clı´nica i Salut Pu´blica. Institut d’Investigacio´ Biome`dica. Hospital Sant Pau, Barcelona, Spain; 4Hospital Universitario Vall d´Hebron, Barcelona, Spain Objectives: Venous thromboembolism (VTE) is a serious complication during the postoperative period in spinal surgery. Currently there is no agreement on the ideal thromboprophylaxis (TBX) in this type of surgery. Here, we aim to perform a systematic review of the literature to assess the effectiveness of mechanical and chemical TBX in the prevention of complications in elective spine surgery in adults and adolescents. Methods: A sensitive search strategy was designed and executed in Medline and Embase, which included information up to March 2016. Studies in adults and adolescents ([10 years) who underwent elective spinal surgery because of deformity or degenerative pathology between C1 and S1 were included; the evaluated interventions included perioperative mechanical TBX (compression socks or intermittent pneumatic compression devices) and/or chemical TBX (heparin, AAS, ACO, etc.). Results: 1567 citations were identified; 137 articles for complete reading were included in the study; finally, 26 studies were included in the systematic review study: six randomized clinical trials and 20 cohort studies and/or cases and controls. From the included studies, five (3 ECA and 2 observational studies) assessed pharmacological interventions, 13 analyzed mechanical interventions (3 ECA and 10 observational studies), and eight observational studies analyzed mixed interventions. It was not possible to perform a quantitative data meta-analysis because of the low quality of the included studies. Conclusions: The high variability of interventions, population, result measurements and methods, as well as the lack of detailed information on relevant topics, limited a precise assessment of the quality of the evidence, as well as the interpretation of the results. There is no clear advantage of mechanical thromboprophylaxis over pharmacological, nor of a specific way of intervention. High quality studies and better guidelines for the presentation of the reports in this field are still necessary.
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32 OBJECTIVE-GUIDED FLUID THERAPY REDUCES TRANSFUSION RATE IN ADOLESCENT IDIOPATHIC SCOLIOSIS SURGERY Authors: Mane´n Berga, Ferran; Vilalta Vidal, Imma; Prieto Gundin, Alejandra; Dome´nech Fernandez, Pedro; Rodrı´guez Olaverri, Juan Carlos Workplace: Hospital Sant Joan de De´u, Barcelona, Spain Objectives and introduction: There are no published studies on the impact of objective-guided fluid therapy in AIS surgery. The goal in this study is to compare a series using the traditional methodology (central venous pressure and theoretical loss calculation) with another in which the administration of fluids is guided using the percentage of stroke volume variation (%SVV). Materials and methods: Retrospective study with 36 consecutive patients who underwent posterior spinal fixation between May 2015 and September 2016. Data from the electronic clinical history were collected. Patients were separated into two groups. Subjects in Group I (18 patients) received fluid therapy as per the criterion of the responsible anesthesiologist, using central venous pressure and theoretical loss calculation. Subjects from Group II (18 patients) were administered an infusion based on theoretical basal needs and heart expenditure was monitored with the aid of a Most-Care (Vygon, Valencia) monitor, giving a 10 ml/kg bolus from Plasmalyte when the stroke volume variation was above 14%. Results: Study groups were comparable with respect to age (15 ± 1.9 vs 15 ± 2 years), weight (59.7 ± 12 vs 54.7 ± 13.8 kg), height (161 ± 7.8 vs 161.4 ± 7.6 cm), and fixed levels (11.8 ± 1.7 vs 11.7 ± 2). The amount of give fluid was higher in Group I (3812 ± 677 ml vs 2251 ± 521 ml, p \ 0.05). 16 and 5 patients from Group I and Group II, respectively, received transfusion during the surgery (p \ 0.05). During hospital stay all patients in Group I (100%) were transfused, while in Group II it was only 55.6% (10/18) (p \ 0.05). Total amount of administered concentrates was 47 for Group I and 18 for Group II (p \ 0.05). There was no was no kidney damage in any of the patients. Hospital stay was similar in both groups (8.9 ± 2.8 vs 7.8 ± 0.8 days). High hemoglobin counts were greater in subjects from Group I (10.6 ± 1.2 vs 9.4 ± 1.1 g/L). Conclusions: Objective-guided fluid therapy in adolescent idiopathic scoliosis surgery with non-invasive heart expenditure control reduces the rate of patients who receive transfusion in AIS surgery in comparison to traditional management.
33 BLEEDING AND TRANSFUSION PATTERNS IN IDIOPATHIC SCOLIOSIS WITH LOW-DOSE TRANEXAMIC ACID USE: PROSPECTIVE STUDY 1
2
1
Authors: Fuentes Caparros, Simo´n; Echerei, Zahra; Gavila´n ´ ngel; 1Rodrı´guez Martı´nez, Isidro Antonio; 1Marı´n Luja´n, Miguel A de Tembleque Aguilar, Federico; 1Gonza´lez Barrios, Ildefonso
Introduction and objectives: Prophylactic use of tranexamic acid for blood loss and allotransfusion in spine surgery are currently under discussion. The Spanish Agency for Medicine and Health Products only describes their use in child cardiac surgery. The aim here is to study bleeding and transfusion patterns found with the use of low doses of tranexamic acid (ATDB, loading dose of 10 mg/kg and maintenance dose of 1 mg/kg/h), as well as the allotransfusion recommendation in force (Seville document 2), in patients who undergo adolescent idiopathic scoliosis (AIS) surgery. Materials and methods: Prospective study of a consecutive series of 31 patients who underwent AIS surgery by screw-based posterior correction instrumentation between June 2015 and September 2016 in our center and who received prophylactic ATDB. We assessed the relationship between demographic, clinical, and surgical variables with respect to bleeding. We analyzed the course of perioperative analytical values and their association with transfusion indications. Data were processed and analyzed with the aid of SPSS (v.20.0). Results: A mean decrease of 5.32 g/dl (-4.79, -5.85) in hemoglobin and 15.28% (-13.76, -16.80) of the hematocrit (95% CI) was determined in comparison to preoperative values; a continuous and clinically significant decrease during the first 2 days after the surgery. A statistical relationship was found between blood loss (953 ± 353 ml) and the fused levels (p = 0.025), degree of preoperative curvature (p = 0.006) and duration of the surgery (p = 0.009). Twenty-four (24) patients (77.4% 95% CI) underwent transfusion. Significant differences were seen between the group that received transfusion vs the one that did not regarding immediate postoperative mean BMI (19.82 vs 23.7; p = 0.015), hemoglobin, and hematocrit (11.65 vs 10.43 g/dl; p = 0.038 and 37.23 vs 31.07%; p \ 0.001). The bivariate analysis showed that Hb counts \11 g/dl at the end of the surgery is associated to a greater risk of requiring transfusion postoperatively (OR = 9.5 95% CI; p = 0.012). Conclusions: (1) The use of ATBD has only shown to be effective for maintaining hemoglobin and hematocrit levels far from the range were transfusion is needed at the time of the surgery. (2) Immediate postoperative hemoglobin counts bellow 11 g/dl were associated to the need of allotransfusion during progress. Table 1 Comparison between patients who underwent transfusion during the postoperative period against those who did not receive transfusion Transfused (n = 24)
Not transfused p (n = 7)
BMI (kg/m2)
19.88 (±3.4)
23.71 (±3.87)
0.017*
Bleeding (ml)
945 (±389)
977 (±212)
0.840
Recovered blood (ml)
125 (±83)
407 (±142)
0.001*
Duration of the surgery (min)
325 (±83)
297 (±60)
0.408
Preoperative Hb (g/dl)
13.72 (±0.96)
14.40 (±1.37)
0.145
Immediate postoperative 10.43 (±1.16) Hb (g/dl)
11.65 (±1.89)
0.038*
Preoperative Hb (%)
42.35 (±3.54)
0.335
37.23 (±3.54)
0.001*
40.9 (±3.13)
Immediate postoperative 31.07 (±3.12) Hb (%)
Workplaces: 1Unidad de Columna, Hospital Universitario Reina Sofı´a, Co´rdoba, Spain; 2Facultad de Medicina, Universidad de Co´rdoba, Co´rdoba, Spain
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35
LONG-TERM EVOLUTIVE STUDY OF POSTOPERATIVE SHOULDER ASSYMETRY IN PATIENTS WITH LENKE 1A AIS. EFFECT OF VERTEBRAL DEROTATION, CORONAL CORRECTION, AND SKELETAL MATURITY
DOES PROXIMAL ANCHORING WITH HOOKS PROTECT ADOLESCENT IDIOPATHIC SCOLIOSIS PATIENTS FROM PROXIMAL JUNCTIONAL KYPHOSIS IN THE MEDIUMTERM?
Authors: 1Garcı´a Gonza´lez, Vicente; 2Burgos Flores, Jesu´s; 3Barrios Pitarque, Carlos; 2Anton Rodrigalvarez, Luis Miguel; 4Hevia Sierra, Eduardo; 5Sanpera Trigueros, Ignacio; 5Piza´ Vallespir, Gabriel; 6 Castro Torre, Miguel
Authors: 1Go´mez Rice, Alejandro; 2Rioseco, Felipe; 2Pizones Arce, Javier; 1Sa´nchez-Mariscal Dı´az, Felisa; 2Sa´nchez Ma´rquez, Jose´ Miguel; 1Zun˜iga Go´mez, Lorenzo; 2Pe´rez Martı´n-Buitrago, Mar; 2 Ferna´ndez-Baillo Gallego de la Sacristana, Nicomedes; 2Sa´nchez Pe´rez-Grueso, Francisco J.; 1Izquierdo Nun˜ez, Enrique
Workplaces: 1Hospital Mancha Centro. Alca´zar de San Juan, Ciudad Real, Spain; 2Hospital Ramo´n y Cajal, Madrid, Madrid, Spain; 3 Universidad Cato´lica de Valencia, Valencia, Spain; 4Hospital Central la Fraternidad-Muprespa, Madrid, Spain; 5Hospital Universitari son Espases, Palma de Mallorca, Spain; 6Hospital Materno Infantil Teresa Herrera, La Corun˜a, Spain Introduction and objectives: In this study, we aim to assess the influence of preoperative degree coronal plane correction, degree of periapical derotation, and degree of skeletal maturity on the raising of the shoulder of the concavity in patients who undergo AIS due to a Lenke type 1A spinal deformity. Materials and methods: Retrospective study of 30 non-consecutive cases of Lenke type 1A spinal deformity AIS who underwent surgery with the ‘‘all screws’’ technique and a minimum two-year follow-up. Demographic parameters were described, as well as the preoperative Risser degree. Vertebral rotation was assessed with the Perdriolle scale and the modified Upasani procedure with 4°. Preoperative, postoperative, and at 3, 6, 12, and 24 months degrees of primary curve Cobb angle; two groups were defined, [80 and \80%. Statistical analyses were done using Pearson’s correlation coefficient. Results: Thirty (30) girls (mean age 13 years) had right curves with Cobb´s angle of 55.98 (468–728****) and coronal T8–T9 apex. Thirteen (13) cases in Risser 0/1. Left shoulder lower (M: 17 mm). Preoperative rotation of 238 according to Perdriolle. Immediately after the surgery, a mean correction of 48.28 (85.25%) in the primary curve was seen, with 18 cases showing a correction of [808 and derotation mean of 7.78 according to Perdriolle. Postoperative measurements showed a significant relationship between the raising of the left shoulder and the degree of vertebral rotation (r = -0.495, p = 0.05). A correlation (r = 0.568, p = 0.01) between the magnitude of correction of the primary curve and la raising of the left shoulder was observed. A spontaneous correction of the raising of the left shoulder is seen immediately after the surgery during the first 6 months (18.1–10.5 mm in [80%; 7.7–6.6 mm in \80%). Immediately after the surgery, patients with Risser 0/1 showed a greater raising of the left shoulder in comparison to the Risser 2/5 (p \ 0.05). Similar corrections were observed for both groups at 24 months postoperative. Conclusions: The strong derotation of the periapical vertebras, the coronal correction of the primary curve in [808, and preoperative Risser 0 and 1 have been statistically linked to a higher postoperative rising of the left shoulder. Partial correction of the asymmetry of the shoulder is seen during the first six month after the surgery and maintained for 24 months.
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Workplaces: 1Hospital Universitario de Getafe, Madrid, Spain; Hospital Universitario La Paz, Madrid, Spain
2
Introduction: The use of hooks as a protective measure against proximal junctional kyphosis (PJK) has been suggested as an alternative to screws in adolescent idiopathic scoliosis (AIS). To date, there are no short-/long-term studies that assess this effect. Materials and methods: Retrospective study in AIS with thoracic curves (Lenke 1–4), sole posterior approach, proximal instrumentation to T6, and minimum 5-year radiological follow-up. Proximal anchoring with screws vs hooks (transverse-facet). Pre-, post-operative, and finales X-ray sagittal profile images were analyzed: proximal junctional angle (PJA), T1–T5 kyphosis, T5–T12 and spino-sacral angle (SSA); number of check-up surgeries secondary to PJK and complications. PJK was considered as the PJA between the lower proximal instrumented vertebral plate and the upper plate of two proximal vertebras C108 and a difference with the previous PJA C108. Results: 164 patients were assessed, from which 50 met the inclusion criteria; 27 had hooks as proximal instrumentation and 23 had screws. Follow-up was 78.5 months (60–240); 46 were female and four male. Age at the time of the surgery was 14 years (11–18). The accompanying table presents the median values and ranges. No significant differences between both study groups were detected regarding T1– T5 kyphosis, T5–12, preoperative SSA, postoperative PJA, nor final PJA. Patients in the ‘‘hooks’’ group showed greater postsurgical T5– T12 kyphosis in comparison with the patients from the ‘‘screws’’ group: 188 (7–37) vs 108 (2–22) (p = 0.000). Five patients (10%) had PJK (3 from ‘‘screws’’ group, 2 from the ‘‘hooks’’ group; no statistically significant correlation). Final PJA was 158 (14–28). None of the patient required check-up surgery due to PJK. Preoperative frontal Cobb of the primary curve was significantly lower in patients with PJK: 508 (45–52) vs 59.758 (47–87) (p \ 0.05). Eight patients had to undergo check-up surgery (7 from the ‘‘hooks’’ group’’, 1 from ‘‘screws’’ group; p \ 0.05). Three patients from the ‘‘hooks’’ group required surgery due to proximal anchoring problems. Conclusions: No protective factor of hook vs screws in PJK as proximal anchoring for AIS can be derived from the results of this study. The hooks shaped a better postoperative thoracic kyphosis, although it led to an increases number of check-up surgeries in comparison to proximal anchoring with screws. There were no clinical consequences due to reinterventions post-PJK in our series of patients.
Eur Spine J (2017) 26:2682–2717
Preoperative
2705
Postoperative Final
Pain group
No pain group
p
T1–T5 kyphosis
10.58 (2–37)
14.58 (2–36)
158 (2–36)
T5–T12 kyphosis
188 (3–47)
16.58 (2–37)
158 (2–38)
Subtotal
3.08
3.97
0.0001
Proximal junctional angle
68 (0–23)
78 (0–20)
98 (0–28)
Function
3.45
4.33
0.0001
Pain
2.64
4.38
0.0001
Spinal sacral angle
1388 (120–160)
1358 (121–164)
1358 (119–164)
Image
2.67
3.14
0.002
588 (45–87)
208 (2–42)
218 (2–40)
Mental
3.52
4.04
0.0001
Subtotal
4.11
4.35
0.015
Function
4.25
4.50
0.004
Pain
4.15
4.56
0.003
Image
4.07
4.09
n.s.
Mental
3.98
4.20
n.s.
4.58
4.69
n.s.
Subtotal
1.03
0.37
0.001
Function
0.79
0.22
0.0001
Pain
1.50
0.18
0.0001
Image
1.39
0.95
0.016
Mental
0.46
0.16
0.05
Primary Cobb curve
The table presents preoperative, postoperative, and final mea values (range)
36 POST-SURGICAL CHANGES IN THE PAIN SUBDOMAIN OF THE SRS22 SCALE IN PATIENTS WITH IDIOPATHIC SCOLIOSIS Authors: 1Van˜o Pujol, Anna; 2Bago´ Granell, Juan; 2Matamalas Adrover, Antonia; 3D’Agata, Elisa; 4Sa´nchez Pe´rez-Grueso, Francisco J.; 4Pellise´ Urquiza, Ferran Workplaces: 1Hospital Universitari Josep Trueta, Girona, Spain; 2 Hospital Universitario Vall d’Hebron, Barcelona, Spain; 3Institut de Recerca Vall d’Hebron, Barcelona, Spain; 4Hospital Universitario La Paz, Madrid, Spain Objectives and introduction: The effect a surgical procedure has on pain perception in patients with idiopathic scoliosis (IS) has not been thoroughly studied. The aim of this study is to analyze and compare the quality of life between two groups of patients diagnosed with IS who underwent surgery and experienced different levels of pain before the surgery. Materials and methods: One hundred and nine (109) patients (mean age of 18 years) (85.3% female) diagnosed with IS, and who underwent surgical treatment through posterior instrumented fusion were included. Mean follow-up was 20.5 months. Thirty-nine (39) patients (35.8%) were included in the non-acceptable pain group (Pain Group, pain subdomain of the SRS22 scale \3.8) and 70 patients (64.2%) in the acceptable pain group (No Pain Group, pain subdomain of the SRS22 scale C3.8). The statistical analysis included an inter-group comparison of preoperative, postoperative, and mean change data after the surgery. Results: Data are presented in the table below. In the No Pain group, 21% of the subjects showed worsening of the pain and only in 25.7% it improved above a minimal clinically important difference (MCID); in the Pain group, only 7.6% of the subjects communicated worsening of the pain, while in 92.3% an improvement above the MCID was seen. Conclusions: Patients with non-acceptable preoperative pain had worse scorings in all measurements and total score in comparison with the No Pain group. The Pain group showed greater improvement after surgical treatment in all subdomains of the SRS22 scale, but identical satisfaction with the treatment. In this group, a larger percentage of patients improved above the MCID of the pain scale. However, during follow-up both groups leveled up only in mental health and body image subdomains. On the contrary, the No Pain group showed better scoring in pain, function, and total score subdomains.
Preoperative SRS22
Follow up SRS22
Satisfaction D SRS22
37 DOES THE SURGEON’S EXPERIENCE AFFECT THE INCIDENCE OF SURGICAL SITE INFECTION FOLLOWING MAJOR SPINAL INSTRUMENTATION SURGERY? PROSPECTIVE COHORT STUDY Authors: 1Rodrı´guez Caravaca, Gil; 1del Moral Luque, Juan Antonio; 1Losada Vin˜as, Jose´ Isaac; 1Carrillo de Albornoz, Rodrigo; 3 Gonza´lez Menocal, Alfonso; 2Villar del Campo, Ma Concepcio´n; 3 Gonza´lez Dı´az, Rafael Workplaces: 1Hospital Universitario Fundacio´n Alcorco´n, Madrid, Spain; 2Centro de Salud los Ca´rmenes, Madrid, Spain; 3Hospital Infantil Nin˜o Jesu´s, Madrid, Spain Introduction and objectives: Spinal fusion is a surgery with the higher infection incidence amongst orthopedic surgeries, e.g., hip and knee arthroplasty. The surgeon´s experience and the surgical technique are important risk factors for surgical site infection (SSI) in this type of surgery. Our aim is to study the influence of surgeon´s experience and technique on the incidence of SSI in major instrumented spinal surgery. Materials and methods: Prospective cohort study. All patients who underwent spinal fusion in our hospital between January 1, 2012 and November 30, 2016 were included in this study. Qualitative variables are described by their distribution frequency and quantitative variables by the mean and standard deviation. Incidence of SSI was studied, after a maximum period of incubation of de 90 days. The rate of infection per surgeon was calculated and the various rates compared between them with the aid of the Odds ratio and 95% confidence interval. Differences were considered statistically significant for p values \0.05.
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Table Effect of surgeon’s experience on the incidence of surgery site infection and mean stay (n = 812) Surgeon
Incidence (%)
95% CI
p
Mean stay
Standard deviation
6.9
2.1
p
Surgeon 1 2.1
0.7–3.5
Surgeon 2 4.1
3.8–4.3
[0.05
9.4
3.3
\0.05
Surgeon 3 4.3
4.0–4.7
[0.05
8.5
3.1
\0.05
Results: Eight hundred and twelve (812) interventions were included throughout the study period. Most patients were female (54.1%) (p \ 0.05). Mean age of the patients was 57 years (SD = 15.3). Adequacy to antibiotic prophylaxis was of 82%. Preoperative preparation was adequate in 96% of the patients. Accumulated global incidence was 3.4% (95% CI 2.2–4.6). Accumulated infection incidence per surgeon was 2.1% (n = 341; 95% CI 0.7–3.5) for surgeon 1; 4.1% (n = 267; 95% CI 3.8–4.3) for surgeon 2, and 4.3% (n = 234; 95% CI 4.0–4.7) for surgeon 3 (p = 0.14). Mean hospital stay was 6.9 days for patients who underwent surgery with surgeon 1; 9.4 days for those with surgeon 2 (p \ 0.05), and 8.5 days for those with surgeon 3 (p \ 0.05). Conclusions: The incidence of surgical site infection in spinal surgery was low. Adequacy to antibiotic prophylaxis and preoperative preparation were high. Differences in the infection rates and mean hospital stay were associated to the surgeon who performed the intervention.
Spain, and 2.05 compared to the NHSN/CDC in the United States of America. The following were shown to be predictive factors of SSI: diabetes mellitus (OR 2.81; 95% CI 1.18–6.72, p \ 0.05), COPD (OR 5.16; 95% CI 2.04–13.08; p \ 0.05), duration of surgery above the 75 percentile (OR 5.39; 95% CI 1.77–110.84; p \ 0.05), and dirty surgery (OR 14.01; 95% CI 1.01–28.88; p \ 0.05). Conclusions: Our rate of SSI in spinal fusion surgery was lower than that Madrid and Spain, but higher than the American rate. The following were the independent risk factors for SSI: diabetes mellitus, COPD, duration of surgery above the 75 percentile, and dirty surgery. Knowing about these risk factors will allow reducing the rate of infections in spine surgery. Table 1 Multivariate analysis of the risk factors of spinal fusion SSI Risk factors
OR
95% CI
p value
Obesity
1.44
0.58–3.56
0.43
Diabetes mellitus
2.81
1.18–6.72
0.02
COPD
5.16
2.04–13.08
0.00
Inappropriate antibiotic prophylaxis
0.58
0.24–1.42
0.24
Appropriate preoperative preparation 1.99 0.56–7.11 Dirty surgery 14.01 1.01–28.88 Duration of surgery [75th percentile 5.39
0.29 0.04
1.77–110.84 0.01
38 39 RISK FACTORS FOR SURGICAL SITE INFECTION FOLLOWING SPINAL SURGERY: PROSPECTIVE COHORT STUDY Authors: 1del Moral Luque, Juan Antonio; 2Gonza´lez Dı´az, Rafael; 1 Losada Vin˜as, Jose´ Isaac; 1Gonza´lez Menocal, Alfonso; 3Villar del Campo, Ma Concepcio´n; 1Rodrı´guez Caravaca, Gil Workplaces: 1Hospital Universitario Fundacio´n Alcorco´n, Madrid, Spain; 2Hospital Infantil Nin˜o Jesu´s, Madrid, Spain.;3Centro de Salud los Ca´rmenes, Madrid, Spain Introduction and objectives: The rate of infection in spine surgery is very high compared to other orthopaedic procedures, e.g., hip and knee arthroplasty. Surgical site infection (SSI) is one of the most frequent complications, and studying its risk factors can help reduce the incidence of infection, its morbimortality, and the associated increased health care costs. The aim of the study is to analyze the risk factors associated to SSI incidence in spinal fusion and compare this incidence with the rates in Madrid, Spain, and United States of America. Materials and methods: Prospective cohort study. All patients who underwent spinal fusion in a tertiary hospital between July 1, 2007 and June 30, 2016 were included in the study. Incidence of SSI was studied, after a maximum period of incubation of de 90 days. Infection rate was calculated and the association between risk factors and SSI incidence assessed using univariate and multivariate analysis. Results: One thousand five hundred and fourteen (1,514) interventions were included in the study; 813 in female (53.7%) and 701 in male (46.3%). Mean age of the patients was 56 years (SD = 15.5). SSI incidence was 3.8% (n = 57). Standardized rate of infection in our hospital was 0.58 compared to that of Madrid, 0.76 compared to
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BIOMECHANICAL STUDY OF THE SACRAL REPLACEMENT PART AS A MODEL FOR SPINOPELVIC RECONSTRUCTION FOLLOWING TOTAL SACRECTOMY Authors: Morales Codina, Ana Marı´a; Martı´n Benlloch, Juan Antonio Workplace: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Objectives and introduction: The aim of this study is to assess the biomechanical properties of a novel spinopelvic reconstruction system following total sacrectomy: a sacral solid porous titanium replacement part manufactured through a rapid prototyping technic (EBM, electron beam melting). Materials and methods: Three studies were carried out: with finite element methods (FEM), fatigue with a polyamide model, and in cadaver. The following models were compared in the FEM study: (1) two connected rods in L, L3–L5 pedicle screws, and two bilateral iliac screws; (2) Model 1 with no L3 fixation; (3) two connected rods in L, two screws to the L5 body and L3–L5 pedicle screws; (4) Model 3 with no L3 fixation; (5) sacral replacement part connected to the L5 body with two screws and two bilateral iliac screws, pedicle screws in L4–L5, and two vertical rods that connects them to the part; (6) Model 5 with a trans-iliac fixation rod. The L5 (mm) vertical drop, the Von Mises stress (Nm), and stress distribution were assessed. In the other studies, Model 5 was evaluated, checking the existence of errors in the instrumentation.
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Results: The results of the FEM study are shown in Table 1. The areas of maximum stress were located in the connection between L5 and the pelvis in all the models. No errors were detected in the fatigue with a polyamide model studies nor in cadaver. Conclusions: Significant reductions of tension and vertical displacements were achieved with the sacral replacement part as well as the lowest values published to date; this indicates that the assembly is rigid and stable, preventing the collapse of the spine on the pelvis. With the tensions obtained with the replacement part—112 MPa— there is no risk of breaking when exposed to static loads nor fatigue behavior of the implants, as opposed to the other assessed and published models. Once implanted, the replacement part could show good behavior by reconstructing the anterior spine, preventing overloads in the spine or pelvis, increasing fusion rates, potentially reducing the number of check-up surgeries due to instrumental breaking down, and allowing early mobilization of the patient. Table 1 Parameters measured in the models by FEM MODELS 1
2
3
4
5
with the VAS at 6M (p = 0.023). Differences in motor function were determined between preoperative values and at 1Y (p = 0.000) and between 1M and 6M (p = 0.004). There were differences between preoperative vesical and intestinal functions and at 1M (p = 0.000), and intestinal function between 6M and 1Y (p = 0.008) and preoperatively and 1Y (p = 0.004). Normal motor function at 1Y was associated to S1 root indemnity (p = 0.006) and intestinal function to S2 (p = 0.029). A relationship between Fourney’s classification and motor function at 6M (p = 0.042), vesical function throughout the whole follow-up (p \ 0.05), and intestinal function at 1M (p = 0.014) and 1Y (p = 0.001) was determined. Conclusions: En bloc sacrectomy led to a decrease in the VAS, reaching its baseline value after a month. Its value at 6 months was associated to spinopelvic reconstruction. The prevailing types of pain were neurogenic and axial. This did not entail deterioration of longterm motor or intestinal function; on the other hand, there was deterioration of vesical function, which reached baseline levels at 6 months and intestinal at 1Y. A linear association was determined for motor, vesical, and intestinal functions with Fourney’s classification, i.e., with integrity of the sacral roots and not with the degree of bone resection, emphasizing the relevance of maintaining the S1 roots for motor function and S2 for intestinal function.
6
Vertical displacement -5.08 -5.15 -1.69 -1.7 -0.13 -0.13 of L5 (mm)
41
Maximum Von Mises 1179 1182 787 786 112 112 stress (MPa) Rigidity (Nm/mm) 232.1 292.7 465.7 462.4 861.5 861.5
ENNEKING CRITERIA, WBB, AND PRIMARY OSSEOUS TUMORS OF THE CERVICAL SPINE Authors: 1Fiore Staffieri, Nestor; 2Ferna´ndez, Claudio; 3Romano Dittlar, Osvaldo; 4Castagno, Aldo; 5Mengotti, Alejandro; 3Lambre, Jorge
40 ASSESSMENT OF FUNCTIONAL OUTCOME FOLLOWING EN BLOC SACRECTOMY 1
2
Authors: Morales Codina, Ana Marı´a; Martı´n Benlloch, Juan Antonio; 3Valverde Belda, Diego; 4Mun˜oz Donat, Sonia; 5Aguirre Garcı´a, Rafael Workplace: 1Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Objectives and introduction: En bloc sacrectomy leads to a functional deterioration with a negative impact of the quality of life of the patient. The objectives of this study is to analyze the functional results (pain, motor, vesical, and intestinal function) in patients who undergo an en bloc sacrectomy. Materials and methods: Retrospective descriptive study on 23 subjects who underwent en bloc sacrectomy. The following variables were collected: the classifications of Fourney, Li, and Zhang, resection of roots, soft tissues, and sacroiliac joint, spinopelvic reconstruction, limitus osteotomy. Preoperatively and postoperatively [at 1 month (1M), 6 months (6 M), 1 year (1Y), and 2 years (2Y)], the following variables were assessed using the modified Biagini scale: the VAS and type of pain, motor, vesical, and intestinal function. Results: Differences in VAS preoperatively and at 1M (p = 0.002) and 1Y (p = 0.023) were seen. 56.5% of the participant had axial and neurogenic pain at 1Y. Spinopelvic reconstruction was associated
Workplaces: 1Raquis, Buenos Aires, Argentina; 2Hospital de Nin˜os Sor Marı´a Ludovica de la Plata, Buenos Aires, Argentina; 3Hospital El Cruce Florencio Varela, Buenos Aires, Argentina; 4Clı´nica San Camilo, Buenos Aires, Argentina; 5Hospital San Roque de Gonnet, Buenos Aires, Argentina Introduction and objectives: Primary tumors of the cervical spine are relatively infrequent. The biological behavior according to the Enneking classification and the horizontal distribution as per Weinstein, Boriani, and Biagini (WBB) are of help when deciding on which treatment to use. The aim of this study is to assess the characteristics and extension of primary bone tumors of the cervical spine. Assess the agreement between the treatment suggested following Enneking’s criteria and the one used. Materials and methods: Retrospective assessment of cervical spine tumors managed in various centers. Age, gender, clinical features, biopsy, line, extension (WBB), biological behavior (Enneking), type of treatment, results, and complications were analyzed. Results: Thirty-three (33) patients were assessed with a mean age of 27 years (6 months to 68 years), 21 male. The more affected level was CIII (8 subjects). The following clinical features were described: cervicalgia in 29, radiculopathy in 10, medullary compression in four. Needle biopsy was done to 17 subjects. In 23 patients the cell line was benign: osteoid osteoma, histiocytosis, osteochondroma, and hemangioma in four, QOA three, TCG and osteoblastoma in two (G1 6, G2 9, G3 8); in ten patients the cell line was malign: osteosarcoma three, plasmacytoma two, chondrosarcoma, malignant fibrous histiocytoma, hemangiopericytoma, Ewing, and lymphoma in one (IA 1, IB 6, and III 3). In 12 patients, and because of its extension, the tumor was not confined to a single sector, anterior, lateral, or posterior. Only in ten, the tumor was located in zones B and/or C. In 17, tumor extension
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2708 compromised zone D (WBB). The following treatments were applied: non-surgical in seven, intralesional surgery in 20, and en bloc resection in six. Seven patients experienced complications (6 deaths: 3 IS and 3 EIII). Tumor embolization was performed in four cases, vertebral artery embolization in three and ligation of the vertebral artery in three. Regarding the ideal treatment vs possible treatment, agreement was determined for ten patients (30%). Conclusions: One-third of the tumors were not located in one specific zone, only ten were located in the B and/or C zones and in 17 the extension of the tumor compromised the D zone (WBB). In 30% of the patients, it was possible to apply the ideal treatment (Enneking).
42 BIBLIOMETRIC ANALYSIS OF THE 100 MOST CITED INTERNATIONAL IDIOPATHIC SCOLIOSIS ARTICLES Authors: Gambin Botella, Joel; Alfonso Beltra´n, Joaquı´n; Barrios Pitarque, Carlos Workplace: Universidad Cato´lica de Valencia, Valencia, Spain Introduction and objectives: The scientific literature on idiopathic scoliosis is in constant development. Despite this, many etiological factors, of natural history, and regarding treatment response remain in discussion. To date, no study has used bibliometric analysis to collect the most influential articles about this condition. The aim of this work is to analyze the characteristics of the 100 most cited articles from the international literature on idiopathic scoliosis. Materials and methods: The Web of Science property of Thomson Reuters was analyzed by introducing the term ‘‘idiopathic scoliosis’’ in the title. Once collected the 100 more cited articles, we examined the information as per the number and density of citations, authors, institutions, country of origin, journal, and year of publication. Furthermore, each paper was classified regarding the type of article, study topic, and the level of the evidence. Results: The 100 most cited articles add up 13,749 citations. The first ten articles represented 24.6% of all the citations. Mean citation per article was 137.5 (ranging between 612 and 80). The most-cited article from our sample was published in 2001 by Lenke et al. in which a new classification system for IS was proposed. The treatment of idiopathic scoliosis is the most studied topic (n = 48), particularly its surgery (n = 38). Most studies come from the United States of America (n = 62) and have been published in Spine (n = 56). Fortynine of the studies were published between 2000 and 2008. Most articles present evidence level III (n = 33) o IV (n = 38). Level I articles have an average citation density of 10.6, whilst the general average is 7.57 (p \ 0.01). Conclusions: The articles related with the radiological classification of IS occupy the two first places regarding citations. However, treatment of IS is the area that generates more articles. The poor level
123
Eur Spine J (2017) 26:2682–2717 of the scientific evidence in the clinical articles caught our attention. In this bibliometric analysis, we collected 100 articles essential for future studies on idiopathic scoliosis.
43 PARAVERTEBRAL BOTULINUM TOXIN TO STOP THE PROGRESSION OF SCOLIOSIS IN PINEALECTOMIZED CHICKEN ´ lvaro; 2Riquelme Garcı´a, O ´ scar; Authors: 1Gonza´lez Miranda, A 3 del Can˜izo Lo´pez, Juan Francisco; 3Garcı´a Barreno, Pedro Workplaces: 1Hospital Universitario la Paz, Madrid, Spain; 2Hospital General Universitario Gregorio Maran˜o´n, Madrid, Spain; 3Facultad de Medicina de la Universidad Complutense, Madrid, Spain Introduction and objectives: Severe and progressive idiopathic scoliosis has no satisfactory treatment since high rates of morbidity and mortality are associated. Developing procedures that help slowdown, even partially, the progression of the scoliosis during the development of a child, could have a positive effect on the child’s growth and delay the definitive treatment of the deformity once musculoskeletal maturity is reached. The main objective of this study is the assessment of botulinum toxin influence, injected unilaterally in the paravertebral muscles of the deformity’s concave side, in the scoliosis curve progression in pinealectomized chickens. Materials and methods: Fifty-two (52) Broiler female chickens were used in the study. The animals underwent a surgical pinealectomy at the age of 48–72 h to generate progressive scoliosis. The course of the deformity was compared between a control group and an intervention group assigned to paravertebral injection of botulinum toxin at the concavity of the curve electromyographycally guided, at 2 weeks of age. Serial radiographic studies were performed every 2 weeks until the animals were sacrificed eight weeks later, as well as anatomopathological analysis of the pinealectomies to confirm the procedure. Cobb angle method was used to measure spine deformation. The analysis of normal distribution of the values for each group was done using the Shapiro–Wilk test and data comparison through parametric tests, using the t-Student test. Results: Five animals died (one in the control group and four in the intervention group). A mean deformity of 39.92° was seen in the control group (n = 25) at the end of the study while in the intervention group this value was 18.84° (n = 22). The difference was statistically significant (p \ 0.05). Conclusions: The administration of botulinum toxin to paraspinal muscles at the concavity of the curve of the scoliosis slows down the progression of the deformity in pinealectomized chicken.
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2709
Table 1 Animal data from the study: control group (pinealectomy)
Control group (pinealectomy)
Animal no.
Survival
Weigh gr (48 h)
Weigh gr (2 weeks)
Weigh gr (4 weeks)
Weigh gr (6 weeks)
Weigh gr (8 weeks)
Curve
Cobb angle (8)
1
Yes
50
226
759
1677
2241
Right
32.2
2
Yes
43
204
1116
2185
2783
Right
35.4
3
Yes
43
265
967
1813
2508
Left
25.8
4
Exitus
41
–
–
–
–
–
–
5
Yes
45
267
745
1484
2403
Left
39.2
9
Yes
49
254
997
1928
2574
Right
17.8
10 14
Yes Yes
38 54
319 307
873 941
1647 1784
2797 2610
Right Right
41.3 32.4
17
Yes
62
330
801
1650
2375
Left
19.8
23
Yes
47
283
930
1925
2634
Right
35.6
24
Yes
52
287
932
1560
1798
Left
29.3
25
Yes
59
314
1064
2023
2424
Right
31
26
Yes
54
286
763
1566
2168
Right
37.5
28
Yes
43
242
792
1535
2454
Right
47.7
29
Yes
48
258
632
1501
2087
Left
34.1
30
Yes
52
384
868
1669
2960
Right
33.8
33
Yes
44
256
714
1430
1969
Right
31.9
34
Yes
43
234
802
1805
2088
Right
44.1
36
Yes
48
258
797
1696
2102
Left
30
37
Yes
55
298
772
1738
2265
Left
30.4
41
Yes
51
253
1020
2010
2987
Right
34
42 44
Yes Yes
49 42
312 294
761 712
1446 1358
2422 1765
Right Left
23.9 34.8
45
Yes
40
312
1035
1563
2660
Left
37.2
46
Yes
53
203
812
1648
2087
Left
27.1
49
Yes
50
301
817
1389
1812
Right
36.8
Results are presented in terms of survival, weight evolution, laterality and magnitude of the curve according to the Cobb angle method
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2710
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Table 2 Animal data from the study: intervention group (pinealectomy and botulinum toxin) Intervention group (pinealectomy + botulinum toxin)
6
Exitus
56
–
–
–
–
–
–
7
Yes
46
217
943
1753
2423
Left
23.1
8
Yes
51
341
842
1480
2105
Right
15.2
11
Yes
46
321
1038
1874
2642
Right
13.5
12
Yes
47
360
909
1632
2204
Right
13.7
13
Yes
45
313
1036
2006
2867
Right
12.2
15
Yes
53
266
999
2130
2865
Right
14.2
16
Exitus
53
–
–
–
–
–
–
18
Exitus
52
–
–
–
–
–
–
19
Yes
44
201
941
1512
2366
Right
28.6
20
Yes
47
297
928
1321
1822
Right
18.8
21
Yes
42
275
1050
2012
2749
Left
16.4
22
Yes
39
78
318
608
870
Right
24.1
27
Exitus
45
193
861
1915
–
Left
–
31 32
Yes Yes
56 52
253 233
714 801
1719 1682
2402 2140
Left Right
29.9 12.1
35
Yes
51
242
733
1960
2669
Right
14.6
38
Yes
49
231
757
1564
2007
Right
13.8
39
Yes
58
379
1268
2470
3102
Left
31.2
40
Yes
46
259
462
798
1683
Left
14.9
43
Yes
42
197
579
965
1798
Right
22.4
47
Yes
56
273
530
1112
1763
Left
10.8
48
Yes
44
275
941
1742
2438
Right
19.8
50
Yes
54
281
941
1841
2713
Right
21.5
51
Yes
45
263
644
1276
2130
Right
17.9
52
Yes
47
237
1009
1820
2696
Right
25.8
Results are presented in terms of survival, weight evolution, laterality and magnitude of the curve according to the Cobb angle method
44 ADVANCES IN CELLULAR THERAPIES: CLINICAL TRIAL ON LUMBAR DEGENERATIVE DISEASE Authors: 1Ardura Arago´n, Francisco; 1Noriega Gonza´lez, David Cesar; 1Herna´ndez Ramajo, Ruben; 1Crespo San Juan, Jesu´s; 1Alı´a Ortega, Julia´n; 2Garcı´a Sancho, Javier; 2Sa´nchez Garcı´a, Ana Workplaces: 1Hospital Clinico Universitario de Valladolid, Valladolid, Spain; 2Universidad de Valladolid. Facultad de Medicina. IBGM, Valladolid, Spain Objectives and introduction: Degenerative disc disease (DDD) is a frequent cause of severe low back pain. It has become a public health problem with great economic impact on the quality of life of the patients. Chronic cases frequently require surgery that can lead to mechanical problems and speed up the degeneration of the adjacent segments. The treatment with autologous Mesenchymal Stromal Cells (MSCs) has shown to be possible and safe; there is strong evidence on their possible clinical effectiveness. Allogenic MSC are more convenient from a logistic perspective in comparison with the autologous ones. The aim of this study is to confirm the clinical and radiological safety of allogenic MSCs in the treatment of DDD.
123
Materials and methods: Randomized controlled clinical trial. Twenty-four (24) patients with chronic low back pain, diagnosed with lumbar DDD, who had not responded to a conventional treatment, were included in the study. Study subjects were randomly assigned to one of two possible groups. The control group received a placebo that consisted of an anesthetic infiltration applied to the paraspinal muscles. The case group was given an intradiscal injection with 25 million allogenic MSC obtained from the bone marrow, in each treated disc. Clinical follow-up lasted 1 year and included scales pain, impairment and quality of life, scales. Disc quality was assessed through magnetic resonance. Results: We assessed the effectiveness and safety of this treatment, as well as its clinical efficacy. Patients treated with MSC showed rapid and significant improvement of pain and functionality in comparison to the controls. This improvement seems to be limited to a group of responders that included 40% of the cohort. Disc degeneration, quantified with Pfirrmann’s scale, improved in the group de patients who underwent treatment with MSC and worsened in the control group. Conclusions: MSC therapy can be a valid alternative for the treatment of DDD, being much simpler from a logistical perspective in comparison to autologous treatments. The procedure is safe, easy, does not require surgical intervention, provides symptomatic relief, and significantly improves disc quality.
Eur Spine J (2017) 26:2682–2717
45 OSSEOINTEGRATION ON TITANIUM SURFACES MODIFIED WITH ULTRASHORT PERIODIC PULSES (LIPSS) Authors: 1Jorge Mora, Alberto; 2Nieto Garcı´a, Daniel; 3Rodolfo Go´mez, Vaamonde; 4Pino Minguez, Jesu´s Workplaces: 1Hospital Clı´nico, La Corun˜a, Spain; 2Facultad de Fı´sicas, Departamento de Fı´sica Aplicada, La Corun˜a, Spain; 3 Fundacio´n Ramo´n Domı´nguez, La Corun˜a, Spain; 4COT, Hospital Clinico Univ de Santiago de Compostela, A Corun˜a, Spain Introduction: Advances in biomaterial sciences have accompanied advances in orthopaedic surgery and traumatology; this has allowed reproducing multiple procedures with satisfactory results, e.g., spine arthrodesis. Because of general population aging, it is necessary to develop new materials to improve osseointegration in time and quality. Laser surface treatment to create laser-induced periodic surface structures (LIPSS) is a new and promising mechanism. Recently, it has been shown that by using LIPSS it is possible to change the orientation of the extracellular matrix and favor the anisotropic adhesion of osteoblasts, which up to know was inconceivable and only occurred in life bone. In this work, we aim to study the differentiation of mesenchymal cells to osteoblasts on titanium LIPSS. Materials and methods: An in vitro experimental study was designed. We created four type V titanium discs of the AMS and mechanically polished them. A laser treatment was applied on two of these discs, creating a LIPSS. The created surface and the polished one were categorized. The discs were then sterilized; subsequently human mesenchymal cells were let to grow on them; cells were obtained from patients who underwent elective iliac crest surgery in our service. Adhesion, osteoblast differentiation, and swelling of the mesenchymal cells was assessed at 5, 10, 15, and 20 days with the aid of the TRAIL, alkaline phosphatase, TNF-alpha, and osteocalcin assays. Results: Treatment with ultrashort laser pulses generates a periodic reproducible structure. Our results show a behavior of all studied parameters that is statistically superior when using the LIPSS in comparison to polished surfaces. Conclusions: The creation/use of titanium LIPSS favors the in vitro differentiation of mesenchymal cells to osteoblasts in comparison to smooth surfaces. Being an industrially standardized cheap process that can be applied to almost any structure, it can be of great benefit in osseointegration of titanium components in the bone, e.g., pedicle screws, interbody devices, etc.
2711 Introduction: The etiology of intervertebral disc degeneration is multifactorial, i.e., genetic, metabolic, and mechanical factors, amongst others. One of these factors are the cellular ones. Understanding the physiopathology of disc degeneration seems crucial for addressing this important health problem. A contribution for this understanding is to study native cell population in the disc, and particularly the cells involved in repairing the lesion in the disc. The aim of this study is to compare mesenchymal stem cells (MSC) obtained from degenerated lumbar and cervical discs and determine possible differences based on biomechanical factors with influence on disc degeneration. Materials and methods: Experimental comparative study between MSC isolated from degenerated lumbar and cervical intervertebral discs and a sample of MSC obtained from the bone marrow from the same subjects. A comparison of morphological, immunophenotypic, and of differentiation characteristics was done. Results: Fourteen (14) patients underwent surgery due to cervical disease and 16 due to lumbar pathology. In all cases, it was possible to isolate and expand MSC from the intervertebral discs and the bone marrow; the morphology of the cells from the intervertebral disc was slightly different (their size was somewhat smaller). All the cells from the intervertebral discs met the immunophenotypic criteria of a MSC: positive for CD90, CD73, CD105, CD166, and CD106, and negative for CD45, CD34, CD14, CD19, as well as to the HLA-DR antigen. In all cases, differentiation to osteoblasts was achieved; differentiation to adipocytes was only achieved with the cells from the intervertebral disc at cervical level and differentiation to chondrocytes from lumbar intervertebral cells. Conclusions: The presence of MSCs in degenerated discs supports the use of cell therapy for the management of this pathology. Furthermore, the finding of alterations, in particular differentiation difficulties, may be the cause of the low repair capacity of the disc tissue when there is a lesion.
47 IMPORTANCE OF SURGICAL TIMING IN THE TREATMENT OF THE CAUDA EQUINA SYNDROME: SINGLE-CENTER EXPERIENCE WITH 147 CASES Authors: Haddad, Sleiman; Venkatesan, Muralidharan; Nasto, Luigi Aurelio; Tsegaye, Magnum Workplaces: Queens Medical Center, Nottingham, UK
46 COMPARATIVE STUDY OF HUMAN MESENCHYMAL STEM CELLS FROM INTERVERTEBRAL CERVICAL/LUMBAR DEGENERATIVE DISCS. MORPHOLOGICAL AND IMMUNOPHENOTYPIC ANALYSIS Authors: 1Marque´s Parrilla, Carlos; 1Blanco Blanco, Juan Francisco; 1Pescador Herna´ndez, David; 2Gonza´lez Dı´az, Rafael; 3 Lo´pez Gonza´lez, Diego; 1Pe´rez Bermejo, Diego Workplaces: 1Complejo Asistencial Universitario de Salamanca, Salamanca, Spain; 2Hospital Infantil Universitario Nin˜o Jesu´s, Madrid, Spain; 3Fundacio´n Hospital Alcorco´n, Madrid, Spain
Introduction: Cauda equina syndrome (CES) is a rare but complex condition mainly due to diagnostic challenges and medico-legal litigations. Surgical delay has been advocated to have a significant bearing on functional recovery, although this has been supported with small studies. The aim of this study is to expose the experience of a regional reference center with of CES and analyse the effect that surgical timing has on final recovery. Methods: single centre retrospective study of consecutive patients treated surgically for CES due to lumbar disc herniation between January 2012 and December 2015. The diagnosis was confirmed preoperatively in a multidisciplinary meeting whenever possible. Preoperative demographic and clinical data, post-mictional residue, and magnetic resonance imaging were assessed. Surgical data, postoperative complications, and pre and postoperative clinical outcomes were also recorded. These included: low back pain, sciatica, bladder or bowel symptoms, perianal paresthesia, and sexual dyfunction.
123
2712 Final results and complications were analysed according to surgical timing (3 groups: \24, 24–48 and [48 h). Results: 147 patients were included in the study: 81 female and 67 male, mean age 40.6 years, mean follow-up 16 months. The most common symptom was low back pain (95%), followed by sciatica (91%), perianal paresthesia (70%), micturition disturbance (73%), and sexual dysfunction (13%). 50% of herniated discs occurred at the L4/L5 level. 51% had more than 75% canal occlusion. 71% had surgery with 24 h of presentation, 13% between 24 and 48 h, and in only 16% the surgery was performed [48 h. Fourteen (14) patients had a dural tear. There was significant improvement of all parameters after the surgery, except for sexual function. Patients who underwent surgery \24 h (71%) had more intraoperative complications (p = 0.02) and dural lesions (p = 0.04), but a higher proportion of patients experiences improvement of their lumbar pain and micturition function. No statistically relevant differences were determined between groups. Conclusions: CES can result in permanent damage, particularly sexual dysfunction. Patients who undergo surgery over the first 24 h seem to benefit more from the surgery although they experience more complications.
Eur Spine J (2017) 26:2682–2717 Two patients (4.8%) required check-up surgery. Global functional course was towards an improvement of over 50% in all functional parameters, remaining stable over time. No differences were seen in functional progression between patients with no degenerative changes and those who did have them (Table 1). Conclusions: Instrumented spinal arthrodesis in aged patients is associated to a very high incidence of radiological degenerative changes in the adjacent segments. However, these changes have no clinical implications.
PRE ODI
Year 1
With no Mean 60.7837838 26.975 changes SD
SD
´ lvarez Galovich, Luis; 3Pin˜era Authors: 1Lo´pez Herrado´n, Ana; 2A ´ ngel Ramo´n; 4Tome´ Bermejo, Fe´lix; 2Garzo´n Ma´rquez, Parrilla, A Francisco M.; 2Rodrı´guez Arguisjuela, Marı´a G.; 2Sanz Aguilera, Sylvia; 2Mengis Palleck, Charles L.; 2Gallego Bustos, Jesu´s; 3Duart Clemente, Javier Melchor Workplaces: 1Instituto de Investigacio´n Sanitaria Fundacio´n Jime´nez Dı´az, Madrid, Spain; 2Fundacio´n Jime´nez Dı´az, Unidad de Patologı´a de Columna, Madrid, Spain; 3Hospital Fundacio´n Jime´nez Dı´az, Madrid, Spain; 4Hospital General de Villalba, Madrid, Spain Introduction: The treatment of low back degeneration pathology in aged patients causes a dilemma. Sometimes, decompressive laminectomy is suggested as the sole treatment to avoid the possible development of degenerative disc disease of the secondary adjacent segment due to the use of rigid instrumentation, despite the potential instability. However, to date there are no conclusive data on the relationship between the use—in aged patients—of short instrumentation and the presence of changes in the adjacent segment. The aim of this study is to assess the long-term course and analyzed the effect on the patient’s functional situation. Materials and methods: Prospective study in which 41 patients, with [5 years of follow-up, and 2–3 levels instrumented lumbar arthrodesis were included. Radiological changes on the adjacent segment and on the two upper levels were identified (disc height, angulation, degenerative changes), as well as the spinopelvic parameters during the first postoperative control, at 3 months, and in the last check-up. For the functional assessment, lumbar VAS, mm.ii VAS, Oswestry Disability Index (ODI), COMI, and SF-6 are applied. Complications and cases that required surgical revision were recorded. Results: 40% of the patients showed degenerative changes in the adjacent segment at 5 years. Degenerative changes in another level above the adjacent segment were detected in 14% of study subjects.
123
SD
3.85
1.22757435 2.76575035 2.43464576
With Mean 8.328125 changes
RADIOLOGICAL ALTERATIONS OF ADJACENT SEGMENTS IN SHORT INSTRUMENTED FUSIONS IN AGED PATIENTS. CORRELATION WITH THE CLINICAL COURSE
26.78
17.5517313 21.1594092 20.3613179
VAS With no Mean 8.48571429 3.725 COL changes
48
24.9
13.3581337 18.5627146 18.8888856
With Mean 57.7435897 29.452381 changes SD
[5 years
3.23255814 3.32653061
1.63352465 2.65982936 2.92537572
49 SURVIVAL ANALYSIS OF ALL UNFUSED SEGMENTS AFTER LUMBAR FUSION SURGERY Authors: 1Ramı´rez Villaescusa, Jose´ Vicente; 2Lo´pez-Torres Hidalgo, Jesu´s; 3Martı´n Benlloch, J. Antonio; 1Ruiz Picazo, David; 4 Gomar Sancho, Francisco Workplaces: 1Complejo Hospitalario Universitario de Albacete, Albacete, Spain; 2Centro de Salud Zona VIII de Albacete, Albacete, Spain; 3Hospital Universitario Dr. Peset, Valencia, Spain; 4Hospital Clı´nico Universitario de Valencia, Valencia, Spain Introduction: Adjacent segment degeneration (ASD) is a frequent complication after lumbar fusion surgery. Few studies have analyzed the changes in all non-fused discs and the risk factors assessed at different time intervals during follow-up. Objective: To analyze ASD-related risk factors associated with the survival of free discs following a lumbar fusion surgery. Methods: Retrospective study of patients who underwent lumbar fusion surgery (minimum 2-year follow-up). We performed a descriptive analysis of radiological variables (rotation, slippage, loss of disc height, and disc degeneration) through frequencies, measures of central tendency and dispersion (95% CI) and comparison of the pain (VAS) and disability (ODI) using variance of repeated measures analysis (ANOVA) and ascertaining the homogeneity of the variables and degree of significance (p \ 0.5). We also performed the analysis of the probability of remaining without degeneration (using the actuarial method, Kaplan–Meier, and comparison of survival curves using the ‘‘Log-Rank’’ test), and multivariate analysis using Cox
Eur Spine J (2017) 26:2682–2717 regression model, being time without disc degeneration the dependent variable. Results: Among the 263 patients included in the study, the cumulative proportion of survival decreased in the different follow-up intervals (95% in the third year, 87% in the fourth, 75% in the fifth, 62% in the sixth, and 36% after the seventh year). Cox proportionalhazards regression analysis showed that the risk of ASD increased three-times (HR = 2.983; 95% CI 1.548–5.748; p = 0.001) in patients who had undergone surgery with top-loading screws and increased twice in patients with three or more fused levels (HR = 2.076; 95% CI 1.047–4.116; p = 0.037). In 151 patients with clinical and/or radiological ASD, the following variables were associated with symptoms for which a second procedure was required (53 patients): number of fused levels (HR = 2.904; 95% CI 1.423–5.925; p = 0.003) and top-loading pedicle screws (HR = 2.590; 95% CI 1.337–5.017; p = 0.005). Conclusions: The risk of ASD increases three-times in patients who have undergone surgery with top-loading screws and increases twice in those with two or more fused levels. The risk of requiring a second procedure increases three-times in patients with three or more fused levels and two and a half with the use of top-loading screws.
2713 after the BED, a significant mean difference was detected through the VAS (diff = 2.67; 95% CI = 1.67–3.67; p \ 0.001), as well as by al the subdomains of the ZCQ; the most outstanding difference was for the pain domain (dif = 0.79; 95% CI = 0.41–1.17; p \ 0.001). No statistically significant scores were obtained with the ODI after epidural corticoid injection (diff = 5.59; 95% CI = -0.68 to 11.86; p = 0.172). Discussion: The relationships regarding the behavior of the three tests in our population were as expected. However, the ZCQ and the VAS seem to be more sensitive in comparison to the ODI for detecting clinical changes in patients with lumbar spinal stenosis who had received epidural corticoid injections.
51 HOSPITAL COSTS OF MEDICALLY UNEXPLAINED SYMPTOMS OF LOW BACK PAIN: A 15 YEAR ANALYSIS Authors: Serrano Garcı´a, Antonio; Sua´rez Huerta, Marı´a Luz
50 THE OSWESTRY DISABILITY INDEX, THE ZURICH CLAUDICATION QUESTIONNAIRE, AND THE VISUAL ANALOGUE SCALE FOR PAIN: COMPARATIVE STUDY. WHICH IS MORE SENSITIVE TO SYMPTOMATIC CHANGES CAUSED BY AN EPIDURAL BLOCK? ´ ngel; Authors: Mene´ndez Garcı´a, Miguel; Hidalgo Ovejero, A Manrique Cuevas, Diego; Izco Cabezo´n, Toma´s; Zabalza Hermoso de Mendoza, Norberto; Azcona Salvatierra, Leyre; Pe´rez Cintas, Alba; Mondrago´n Rubio, Jaime Workplace: Complejo Hospitalario de Navarra, Navarra, Spain Objectives and introduction: The measurement of the quality of life and health as perceived by the patient is essential for his/her evaluation. In the case of lumbar spinal stenosis, several questionnaires are available such as the Oswestry Disability Index (ODI), the Zurich Claudication Questionnaire (ZCQ), and the pain Visual Analogue Scale (VAS). The goal of this study is to determine the sensitivity of the tests towards somatic change by an epidural block. Materials and methods: Prospective study with 76 patients who suffered lumbar spinal stenosis, from which 33 received epidural corticoid injections (BED) and 43 were part of the control group. On Day 0, all the patients completed the three questionnaires (correlation study between the tests). The patients from the BED group completed the tests again after 15 days (sensitivity to change analysis). For baseline comparison of these questionnaires between the BED group and the control group, the Mann–Whitney U test was applied. For the correlation analysis, Spearman’s correlation coefficient q (‘‘rho’’) was used. The sensitivity to change of each test was assessed with the Wilcoxon test. Results: A positive and statistically significant correlation between the ZCQ and the ODI was found, being stronger on the physical function subdomain (rho = 0.662). Similar results were obtained for the VAS (rho = 0.464). Regarding the sensitivity study de sensitivity
Workplace: Complejo Asistencial Universitario de Leo´n, Leo´n, Spain Introduction: In their article, Bermingham SL et al. (2010) estimated that the direct overcharge associated to patients with medically unexplained symptoms (MUS) reaches 10% of NHS expenses. Low back pain is one of the most frequent symptoms that appears as unexplained. Objectives: quantify hospital costs of MUS low back pains and compare the results with the general population. Materials and methods: Systematic review of the procedures performed on a sample of patients with MUS low back pain. Their classification post-psychometry and psychiatric interview. Quantification of the costs per patient over the last 15 years. Statistical analysis. Results: Between July 2015 and July 2016, 78 patients with low back pain were categorized as MUS. In our sample, a mean of 67.69 ± 46.82 consultations were made, 10.26 ± 12.72 days of hospital stay, 14.05 ± 12.47 simple X-rays, 1.24 ± 1.88 CT scans, 2.38 ± 2.65 ecographies, and 2.54 ± 2.23 NMRs. After the psychiatric evaluation, four groups of patients were identified: somatoform disorders (n = 20), simulators (n = 14), factitious disorders (n = 17), and another group in which the psychopathology was not determined to be the cause of the clinical presentation (n = 27). No significant inter-group differences were determined regarding the total costs of the procedures, nor in surgical costs, or the number of medical consultations. There were however differences regarding the costs of the tests (p = 0.042) and those of hospital stay (p = 0.002). The mean cost per person in 2014 in Castilla y Leo´n was 1,268 euros, from which 61.4% is for hospital and specialized services. Thus, the estimated cost generated by our study population is 910,906 euros in 15 years. The cost of the procedures performed on our sample over the last 15 years has been 1,701,257 euros. Thus, there is a generated overcharge of 86.77% by patients with MUS low back pains. Conclusions: Patients suffering MUS low back pain represent a very important overcharge for the health system. There are no significant differences on total cost based on the characterization of MUS low back pain; however, there are differences in the composition of these costs.
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2714
E-POSTER COMMUNICATION
Eur Spine J (2017) 26:2682–2717 impairment and pain. However, for the NMB study group alone, a clinically relevant improvement is maintained for impairment at six months. Amongst the assessed psychological factors, only catastrophic ideations have a prognostic value in the degree of impairment. Registry: ClinicalTrials.gov: NCT02604290.
1 (ELIGIBLE FOR BEST POSTER COMMUNICATION AWARD) NEUROMUSCULAR BANDAGE IN THE TREATMENT OF CHRONIC MECHANICAL LOW BACK PAIN: RANDOMIZED CLINICAL TRIAL Authors: 1Pen˜alver Barrios, Lourdes; 1Dome´nech Ferna´ndez, Julio; 2´ Alvarez Llanas, Alejandro; 1Llombart Blanco, Rafael; 3Liso´n Parraga, Juan Francisco Workplaces: 1Hospital Arnau de Vilanova, Valencia, Spain; 2Serv. de COT, Hospital Arnau de Vilanova, Universidad Cardenal Herrera Ceu, Valencia, Spain; 3Facultad de Ciencias de la Salud, Universidad Cardenal Herrera Ceu, Valencia, Spain Background: Neuromuscular bandage (NMB) is a widely used technique in the treatment of chronic mechanical low back pain (CMLBP); however, benefits tested against a placebo have not been shown. Few clinical trials have been carried out using standardized guidelines not taking into account the physical examination of the patient as an indication selector factor. Aim of the study: (1) Assess the effectiveness of NMB in the treatment of CMLBP when skin/fasciae mobilizing during exploration is shown to be a possible modifying factor of treatment effect. (2) Analyze the effect of fear-avoidance beliefs, anxiety/depression, and catastrophic ideation on NMB efficacy. Methods: Double-blind randomized clinical trial with concealment of the allocation sequence and intention-to-treat analysis. Sixty-two (62) participants were randomly assigned to one of two possible treatment groups: the NMB study group or the placebo bandage study group. Each study subject underwent four weekly treatments. The following variables were assessed pre-/post-treatment and at 6 months: RolandMorris Disability Questionnaire (RMDQ), Numeric Pain Rating Scale (NPRS), EuroQol 5D-5L, Fear-Avoidance Beliefs Questionnaire, Pain Catastrophizing Scale, and Hospital Anxiety-Depression Scale. Results: ANOVA showed significant differences regarding the main effects in impairment and pain only for the factor time. Statistically significant improvements of impairment and pain were determined post-treatment for both study groups. At six months, these changes were still significant and clinically relevant only for the NMB study group. However, inter-group analysis revealed that neither variable showed significant mean differences at any evaluation time points. For the whole sample the prospective stepwise regression analysis for impairment at 6 months, only included catastrophic ideation as the variable that explains 22% of its variance. Conclusions: NMB in the treatment of CMLBP is not significantly more effective in comparison with the placebo bandage regarding
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2 (ELIGIBLE FOR BEST POSTER COMMUNICATION AWARD) DEFINING ‘‘SAFE ZONE’’ IN ANTERIOR SCOLIOSIS SURGERY. PROSPECTIVE STUDY Authors: 1Egea Ga´mez, Rosa Marı´a; 2Gonza´lez Dı´az, Rafael; 3 Wilson-MacDonald, James; 3Murray, David Workplaces: 1Hospital Universitario De Mo´stoles, Madrid, Spain; Hospital Infantil Universitario Nin˜o Jesu´s, Madrid, Spain; 3Oxford University Hospitals: Nuffield Orthopedic Centre and John Radcliffe Hospital, Oxford, UK
2
Introduction: Lesions of vascular structures during spine surgery are relatively infrequent; however, when they occur the consequences can be devastating. This study aims assessing the relationship of major vessels with the vertebral body, focusing on defining the safety zone for the placement of anterior instrumentation during scoliosis surgery. Materials and methods: prospective study of 34 pediatric patients (4 male and 30 female) who underwent idiopathic scoliosis surgery between 2010 and 2016. The location of the major vessels was identified in relation to the body from T4 to L4 and a coordinate system to pinpoint the area at which the interbody devices could be placed with relative safety was developed. Two SZL variables were defined: the Left Safe Zone (LSZ) Left, which includes the area between the lateral left border of the aorta up to 1808 and the Right Safe Zone (RSZ): from 08 to the right lateral border of the aorta. Results: Mean age of participants was 14.30 years (88.2% female). The most common curve as per Lenke was 1BN (20.6%), followed by 1AN, 3C-, and 6CN. The apex was at T8 and T9 (23.5 and 29.4%). 58% of the curves were on the right side. Mean LSZ was 155.78–1808 in T4 at 104.38–1808 in L4. Mean RSZ was 0°–110.78 in T4 at 08– 76.188 in L4. Significant differences were found when preoperative and postoperative measurements where compared for T12, L1, and L2 in the RSZ and T11, T12, L1, and L2 in the LSZ. A significant correlation was seen between the side of the convexity of the curves and both SZ. Conclusions: The right hemibody of the T4 to T11 thoracic vertebrae is safe for placing the interbody devices. Between T12 and L4 the safe areas are reduced and lateral, whilst the most troublesome region is the anterior part of the vertebral body. The posterolateral portion in right thoracic scoliosis is the area associated to vascular danger, while in left scoliosis the danger area is anteromedial. Knowing these areas allows a safer placement of anterior devices in scoliosis surgery.
Eur Spine J (2017) 26:2682–2717
2715
Total
Safe zone
T4 right T4 left
Right convexity
Left convexity
N
Mean (±DS)
N
Mean (±DS)
N
Mean (±DS)
19 19
0–110.7 (±15.7) 155.7 (±15.4)–180
14 14
0–111.6 (±16.9) 160.3(± 13.3)–180
5 5
0–108.1 (±13.3) 142.8(±14.5)–180 0–118.8 (±11.4)
T5 right
21
0–127.1 (±14.7)
15
0–130.4 (±14.9)
6
T5 left
21
168 (±14.7)–180
15
172.5(±11.9)–180
6
156.7(±16.2)–180
T6 right
21
0–133.9 (±16.3)
17
0–137.8 (±14.1)
4
0–117.4 (±16.3)
T6 left
21
172.2 (±12.6)–180
17
175.3(±5.8)–180
4
159(±24.2)–180
T7 right
23
0–133.7 (±20.4)
17
0–141.5 (±11.2)
6
0–111.4 (±25)
T7 left
23
169.1 (±20.1)–180
17
176.3(±4.8)–180
6
148.7(±32.1)–180
T8 right
26
0–133.3 (±21.2)
19
0–141.4 (±10.7)
7
0–111.3 (±27.7)
T8 left
26
166.9 (±21.1)–180
19
174.4(±5.7)–180
7
146.6(±33.1)–180
T9 right
27
0–126.6 (±20.4)
20
0–134.3 (±8.6)
7
0–104.4 (±28.4)
T9 left
27
161.3 (±21.1)–180
20
169.2(±7.9)–180
7
138.9(±30.7)–180
T10 right
28
0–117 (±21.1)
19
0–126.5 (±10.4)
8
0–97.7 (±26.1)
T10 left
28
148.2 (±22.8)–180
19
157.5(±12)–180
8
129.9(±29.6)–180
T11 right
29
0–105 (±21.2)
19
0–116.2 (±10.7)
9
0–82.6 (±21)
T11 left
29
133.4 (±23.1)–180
19
145.3(± 14.1)–180
9
110(±21)–180
T12 right T12 left
29 29
0–90.9 (±20.7) 121 (±20.6)–180
19 19
0–101.2 (±12.7) 131.3(±13.6)–180
10 10
0–71.4 (±19.1) 101.6(±17.6)–180
L1 right
29
0–78.6 (±18.4)
20
0–85.2 (±15.5)
9
0–63.9 (±16.1)
L1 left
29
104.3 (±19.8)–180
20
111.9(±16.9)–180
9
87.4(±15.1)–180
L2 right
29
0–74.5 (±13.6)
20
0–79 (±9.7)
9
0–64.6 (±16.3)
L2 left
29
96.4 (±13.2)–180
20
100.4 (±11.2)–180
9
87.5 (±13.4)–180
L3 right
29
0–75.6 (±7.7)
20
0–76.9 (±6.2)
9
0–72.5 (±10)
L3 left
29
97.4 (±7.8)–180
20
98.8(±6.7)–180
9
94.3(±9.6)–180
L4 right
29
0–76.1 (±7.4)
20
0–76.6 (±5.5)
8
0–75.8 (±11.5)
L4 left
29
104.3 (±8.7)–180
20
102.5(±6.4)–180
8
108(±12.7)–180
3 (ELIGIBLE FOR BEST POSTER COMMUNICATION AWARD) THORACIC AORTIC PSEUDOANEURYSM DUE TO RETROGRADE LOOSENING OF THE ANTERIOR VERTEBRA ARTHRODESIS SCREW. CASE REPORT Authors: 1Ferren˜o Marquez, David Manuel, 1De Benito Ferna´ndez, Luis, 1Garcı´a Franco, Carlos Enrique, 1Peces Garcı´a, Enrique, 1 Alfayate Garcı´a, Jesu´s Manuel,1 Losada Vin˜as, Jose´ Isaac, 2Gonza´lez Dı´az, Rafael Workplace: 1Hospital Universitario Fundacio´n de Alcorco´n, Madrid, Spain; 2Hospital Infantil Universitario Nin˜o Jesu´s, Madrid, Spain Objetives and introduction: The authors describe an unusual complication after the anterior stabilization of a D9–D10 pseudoarthrosis using a plate and screws. Pseudoaneurysms are serious complications that are not easy to treat, most of them occurring at lumbar level. In the literature, only exceptional cases of pseudoaneurysm of the thoracic aorta post-late loosening of the screws are described.
Materials and methods. 57-year old male with scoliosis following poliomyelitis who underwent non-instrumented T4–L3 fusion at an early age. Later, at adult age, the patient suffered a banal D9–D10 fracture due to trauma, evolving to pseudoarthrosis and compression of the medulla, paraparesis, and sphincter disturbance. A sequential dual approach was performed (decompression and posterior fixation and anterior fusion through left thoracotomy, using a mesh, autologous graft, and a screwed plate). The patient progressed well with full neurological recovery. Eighteen months later, the patient presented with occasional hemoptysis; and a chest CT scan revealed an aortic pseudoaneurysm caused by the loosening of one of the screws. The vascular surgeon decided to implant an endoprosthesis that temporarily controlled the pseudoaneurysm, as confirmed by image-based analysis. However, the loosening of the screw posed a serious risk of perforation of the aorta and the endoprosthesis, for which reason it was decided to remove it. A thoracotomy was performed; after a careful dissection of the aorta, active bleeding was confirmed when trying to dissect the area adhered to the screw, caused by an intraaortic protrusion. Aortic clamping was perfomed, as well as sectioning at the level of the lesion, removal of the screw, and finally a termino-terminal suture. Results: The immediate progress of the patient was satisfactory. A week later the patient had to undergo surgery again because of active intercostal arterial bleeding; this problem was solved without difficulties. The patient was discharged with no late complications.
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2716
Eur Spine J (2017) 26:2682–2717
Conclusions: The removal of the anterior instrumentation after an anterior thoracic surgery is a highly demanding technical procedure. It is important to bear in mind the possible serious intraoperative complications when planning this type of surgery, for which a multidisciplinary approach is required. For solving this type of problems, endovascular and open procedures should be taken into consideration.
appropriate control of the deformity and over 50% reduction of the Cobb angle of the primary curvature, as well as a thoracic (T1–T12) and trunk growth of 54.2 and 110 mm, respectively.
5 (ELIGIBLE FOR BEST POSTER COMMUNICATION AWARD) 4 (ELIGIBLE FOR BEST POSTER COMMUNICATION AWARD) TREATMENT OF SCOLIOSIS ASSOCIATED WITH EXTENSIVE RIB RESECTION IN ASKIN TUMORS DURING PEDIATRIC AGE Authors: 1Marque´s Parrilla, Carlos; 2Pizones Arce, Javier; 2 Talavera Buedo, Gloria; 2Pe´rez Martı´n-Buitrago, Mar; 2Sa´nchez Marquez, Jose´ Miguel; 2Ferna´ndez-Baillo Gallego Sacristana, Nicomedes; 2Sa´nchez Pe´rez-Grueso, Francisco J 1
Workplaces: Complejo Asistencial Universitario De Salamanca, Salamanca, Spain; 2Hospital Universitario La Paz, Madrid, Spain Introduction: Askin tumors (primitive neuroectodermal tumors) are a type of rare chest wall solid tumors that can develop in children; these tumors have poor prognosis. Their treatment involves chemotherapy and extensive surgical resection, including disarticulation of several ribs and sometimes partial vertebral body resection. All of this causes thoracogenic scoliosis with unique features; very scarce data is found in the literature regarding its treatment, progress, and prognosis. Materials and methods: In this study we present a retrospective descriptive series of four cases of scoliosis in pediatric patients secondary to extensive chest resections due to Akin tumors. We analyzed the treatments received by the patients and the outcome on spine growth, as well as medium-term curve progress. Results: Three girls and one boy with a mean age of 8.7 ± 2.2 and 7 ± 3.6 years of follow-up were included in the study. In all cases the convexity of the thoracic curvature was towards the area of chest resection, 1.9 ± 1.3 years after the thoracic surgery. In two of the cases the Vertical Expandable Prosthetic Titanium Rib (VEPTR) system was used, although one was changed for growing rods, and in the two other study subjects growing rods were used. Mean of 12.5 levels were instrumented and 4.75 ± 2.5 re-stretched. Ppreoperative Cobb angle was 68.78 ± 22.88 and by the end of the follow-up period it was corrected to 32.58 ± 9.68. Preoperative coronal imbalance of 29.5 ± 18.6 mm was corrected to 3 ± 6 mm by the end of follow-up. The initial SVA of 8 ± 34 was 8 ± 10 mm by the end. No changes were observed regarding preoperative kyphosis 308 ± 388 (338 ± 24.78 at the end). The initial length of T1–S1 was 296.5 mm changing to 406.5 mm and T1–T12 length went from 182.5 to 236.7 mm. There were two complications secondary to the proximal anchoring. Conclusions: For the treatment of scoliosis secondary to extensive chest resection in growing children with Askin tumors, growing rods proved to be a good surgical alternative; 7 years of follow-up showed
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3D PRINTED MODELS AS PLANNING AIDS FOR COMPLEX SURGERIES IN SERIOUS SPINAL DEFORMITIES Authors: Carbonell Escobar, Rafael; Pizones Arce, Javier; Pe´rez Martı´n-Buitrago, Mar; Sa´nchez Marquez, Jose´ Miguel; Ferna´ndezBaillo Gallego de la Sacristana, Nicomedes; Sa´nchez Perez-Grueso, Francisco J Workplace: Hospital Universitario La Paz, Madrid, Spain Introduction: 3D printed models from CT scan data are known to be of help for the resection of spinal tumors. However, there are no publications on the use of these models for planning complex surgeries in deformity cases. Here, we analyze a series of cases of patients who underwent surgery in our hospital with the aid of 3D deformity models. Materials and methods: Retrospective analysis of a consecutive series of cases with serious deformity who underwent reconstructive surgery. The procedures were planned using 3D printed models based on thin-section CT images. Demographic and radiographic information, surgical data, and outcome were considered for the analysis. Results: Seven patients (5 male, 2 female) with a mean age of 14 years. Patients suffered osteogenesis imperfecta (2), Type 1 neurofibromatosis (2), congenital scoliosis (hemivertebrae) (1), Noonan Syndrome (Noonan) (1), and tumor postlaminectomy kyphosis (1). The 3D models revealed three hyperrotatory deformities, three kyphorotatory, and one mixed deformity of segmentation and formation. The mean primary Cobb angle was 968, and 438 compensatory curve, 20.5 mm of coronal imbalance, and 64.8 mm of anterior imbalance (SVA). Mean preoperative kyphosis was 85.88. 20% improvement of coronal deformity and 45% of hyperkyphosis were achieved with the use of preoperative halo crown traction. Surgery reduced the major Cobb angle to 35.68 (63%), the compensatory curve to 208 (53%), the coronal imbalance to 15.3 mm, the sagittal misalignment to 52 mm, and the kyphosis to 55.48 (54.8%). Most of the study patients (5/7) required multiple Ponte osteotomies and there was one vertebrectomy. The mean bleeding was 1000 ml, length of the surgery 331.25 min, and a mean 14.8 levels were fused. The models allow to precisely calculate the osteotomy areas, the morphology of the pedicles, and areas of potential neurological risk (rotatory luxation, congenital malformations). Conclusions: 3D printed models allow to precisely draw the anatomy of the deformity, and thus plan a more effective surgery adjusted to the personal needs and risks of the patient. These models are useful for kyphorotatory, hyperrotatory, and congenital deformities, and are a good aid for reconstructive surgery.
Eur Spine J (2017) 26:2682–2717
6 (ELIGIBLE FOR BEST POSTER COMMUNICATION AWARD) INFLUENCE OF PREOPERATIVE PAIN SENSITIVITY ON THE FUNCTIONAL RECOVERY OF SUBJECTS WITH DEGENERATIVE DISC DISEASE: ESTABLISHEMENT OF PREDICTIVE MODELS Authors: Marque´s Parrilla, Carlos; Pescador Herna´ndez, David; Pe´rez Bermejo, Diego; Blanco Blanco, Juan Francisco Workplace: Complejo Asistencial Universitario De Salamanca, Salamanca, Spain Objectives: Determine the predictive ability on therapeutic success (surgery for degenerative disc disease) of pressure pain thresholds (PPT), as well as their relationship with psychosocial, cognitive, and quality of life factors. Materials and methods: Thirty (30) patients with degenerative disc disease with indication for posterior instrumented fusion were
2717 recruited. Study participants were evaluated the day before the surgical intervention (pre) and two times after the surgery (post1: one month after; post2: 6 months after). At each evaluation, five PPTs were determined bilaterally, assessment of pain (visual numeric scale), disability (OSWESTRY), quality of life (SF-36 and EQ-5D), and and sleep quality (Pittsburgh, USA). Results: Variable differences were observed between pre and post evaluations (p \ 0.05), with a reduction of pain and disability and quality of life improvement. Maximum pain on the previous week, as per the EVA and low scoring in SF36 and EQ5D questionnaires were associated with the worst results assessed with the same questionnaires. In this study, it was not possible to establish a linear relationship between the results and pressure pain thresholds values. Conclusions: No significant increases of lower limb and trunk PPTs were seen, indicating local/regional pre-surgery sensitivity, and the existence of central sensitivity becomes questionable. High preoperative EVAs and low levels of physical quality of life are factors associated with reduced surgical success. Surgical treatment improves pain and disability in patients with degenerative disc disease. Variables such as preoperative pain predict post-surgical outcome.
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