Orientadores: Helder Tedeschi, Andrei Fernandes Joaquim / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-27T03:41:44Z (GMT). No. of bitstreams: 1 Cruz_HalissonYoshinari_M.pdf: 548904 bytes, checksum: f83210d67f0f8e7df7a28e330c894fb3 (MD5) Previous issue date: 2015 / Resumo: Introdução: O SLICS (Subaxial Cervical Spine Injury Classification System) foi proposto para auxílio na tomada de decisão do traumatismo da coluna cervical sub-axial, contudo poucos trabalhos avaliaram sua segurança e eficácia. Método: comparar coorte histórica de pacientes tratados com base na preferência do cirurgião com pacientes tratados baseando-se no escore obtido com a aplicação do sistema. Foram incluidos pacientes com lesão traumática aguda de C3-7 com exames radiológicos e dados clínicos completos. O status neurológico foi avaliado através do ASIA Impairment Scale (AIS). Resultados: entre 2009-10, 12 pacientes foram incluídos (seguimento médio de 24,5 meses). Na admissão hospitalar 5 pacientes (41,6%) apresentavam AIS E, 1 (8,3%) AIS D, 1 (8,3%) AIS C, 1 (8,3%) AIS B e 4 (33.3%) AIS A. Dois de sete pacientes com déficit incompleto melhoraram durante o seguimento clínico. O SLICS escore variou de 2 a 9 pontos (média de 5.5 e mediana de 5.75), onde dois pacientes tinham escore menor do que 4. Entre 2011-13, 28 pacientes foram incluídos (média de 6,1 meses), com média de idade de 41,5 anos. Na admissão hospitalar 12 pacientes (42,9%) apresentavam AIS E, 4 (14,3%) AIS D, 5 (17,9%) AIS C, 2 (7,15%) AIS B e 5 (17,9%) AIS A. Seis pacientes entre os 11 com déficit incompleto apresentaram melhora. O escore de SLICS variou de 4 a 9 pontos, com média e mediana de 6. Conclusões: observamos que após a aplicação do sistema, houve uma diminuição de indicação cirúrgica nos pacientes com lesões mais estáveis ou menos graves, sem que se detectasse piora neurológica em ambos os grupos. Isso sugere que o SLICS pode ser útil para auxiliar a diferenciação das lesões mais instáveis que acometem a coluna cervical sub-axial que requeiram tratamento cirúrgico / Abstract: Introduction: The SLICS (Subaxial Cervical Spine Injury Classification System) was proposed to help in the decision-making process of surgical treatment of sub-axial cervical spine trauma, eventhough the literature assessing its safety and efficacy is scarce. Methods: we compared a cohort series of patients treated based on surgeon¿s preference with patients treated based on the SLICS. We have only included patients with acute spinal trauma from C3-7 that had complete clinical and radiological data. Results: between 2009-10, 12 patients were included (mean 24.5 months of follow-up). The preoperative AIS was: 5 patients (41.6%) were AIS E, 1 (8.3%) AIS D, 1 (8.3%) AIS C, 1 (8.3%) AIS B and 4 (33.3%) AIS A. Two out of seven patients had neurological improvement during follow-up. The SLICS score ranged from 2 to 9 points (mean of 5.5 and median of 5.75 points) with two patients with less than 4 points. From 2011-13, 28 patients were included with a SLICS (mean of 6.1 months of follow-up). The preoperative AIS was: 12 patients (42.9%) with AIS E, 4 (14.3%) AIS D, 5 (17.9%) AIS C, 2 (7.15%) AIS B and 5 (17.9%) AIS A. Six patients out of 11 had some neurological improvement. The SLICS score ranged from 4 to 9 points (mean and median of 6). There was no neurological deterioration in any group. Conclusions: after using the SLICS there was a decrease in the number of patients with less severe injuries that were treated surgically, with no reflection on neurological outcome. This suggests that the SLICS can be helpful in differentiating mild from severe injuries, potentially improving the results of treatment / Mestrado / Neurologia / Mestre em Ciências Médicas

Procurou-se avaliar a sensibilidade e a reprodutibilidade da escala funcional de Basso, Beattie e Bresnahan (escala BBB) para a avaliação da capacidade locomotora dos ratos após lesão medular. A escala BBB é uma medida preditiva baseada em critérios observacionais específicos da movimentação do animal durante a marcha e que atribui uma pontuação seqüencial e acumulativa correspondente aos critérios pré-estabelecidos satisfeitos. Submeteram-se 30 ratos Wistar à laminectomia e à contusão medular leve, moderada e grave produzida pelo equipamento computadorizado de impacto por queda de peso desenvolvido pela Universidade de Nova Iorque (NYU Weight-Drop Impactor). No 28º dia após a contusão medular, cada rato foi colocado numa caixa transparente (80x80x30cm), com o fundo e a parede posterior forrados com material antiderrapante escuro e estimulado a se movimentar. A movimentação de cada rato foi registrada, simultaneamente, por 3 câmeras digitais e, após a edição, cópias idênticas dos filmes foram encaminhadas à seis pesquisadores independentes, sem a informação sobre a gravidade da lesão correspondente de cada rato, para a determinação da capacidade locomotora segundo a escala funcional de Basso, Beattie e Bresnaham. Verificou-se a sensibilidade do método para detectar diferenças entre os resultados das patas do lado esquerdo e direito, entre os ratos submetidos a lesões leves, moderadas e graves e entre os avaliadores através de comparações dos resultados funcionais e a reprodutibilidade através de testes de correlação. A escala BBB apresenta: a) nas lesões leves sensibilidade satisfatória e elevada reprodutibilidade; b) nas lesões moderadas a sensibilidade é insatisfatória e a reprodutibilidade satisfatória, porém moderada; c) sensibilidade insatisfatória e redução da reprodutibilidade. / An assessment of the sensitivity and reproducibility of the Basso, Beattie and Bresnahan functional scale (BBB scale) was carried out, to evaluate the locomotion capacity following spinal cord injury. The BBB scale is a predictive procedure based on specific observational criteria of the locomotion of the animal under way, which attributes a sequential and cumulative score corresponding to satisfied pre-established criteria. 30 Wistar rats underwent laminectomy and light, moderate and severe spinal cord injury generated by the computerized equipment of impact through weight-drop developed by the University of New York (NYU Weight-Drop Impactor). At day 28 following the spinal cord injury, each rat was placed into a transparent box (80x80x30cm), with the bottom and the posterior wall lined with dark anti-slip material, and stimulated to move. The locomotion of each rat was recorded, simultaneously, by 3 digital cameras and, after editing, identical copies of the films were sent to six independent researchers, with no information regarding the severity of the injure in each rat, for determining the locomotory capabilities according to the Basso, Beattie and Bresnahan scale. The sensitivity of the method was verified for detecting differences between the results obtained from the left and right-side paws, among the rats subjected to light, moderate and severe injuries and among the evaluators through comparisons of the functional results and the reproducibility through correlation tests.

Procurou-se avaliar a sensibilidade e a reprodutibilidade da escala funcional de Basso, Beattie e Bresnahan (escala BBB) para a avaliação da capacidade locomotora dos ratos após lesão medular. A escala BBB é uma medida preditiva baseada em critérios observacionais específicos da movimentação do animal durante a marcha e que atribui uma pontuação seqüencial e acumulativa correspondente aos critérios pré-estabelecidos satisfeitos. Submeteram-se 30 ratos Wistar à laminectomia e à contusão medular leve, moderada e grave produzida pelo equipamento computadorizado de impacto por queda de peso desenvolvido pela Universidade de Nova Iorque (NYU Weight-Drop Impactor). No 28º dia após a contusão medular, cada rato foi colocado numa caixa transparente (80x80x30cm), com o fundo e a parede posterior forrados com material antiderrapante escuro e estimulado a se movimentar. A movimentação de cada rato foi registrada, simultaneamente, por 3 câmeras digitais e, após a edição, cópias idênticas dos filmes foram encaminhadas à seis pesquisadores independentes, sem a informação sobre a gravidade da lesão correspondente de cada rato, para a determinação da capacidade locomotora segundo a escala funcional de Basso, Beattie e Bresnaham. Verificou-se a sensibilidade do método para detectar diferenças entre os resultados das patas do lado esquerdo e direito, entre os ratos submetidos a lesões leves, moderadas e graves e entre os avaliadores através de comparações dos resultados funcionais e a reprodutibilidade através de testes de correlação. A escala BBB apresenta: a) nas lesões leves sensibilidade satisfatória e elevada reprodutibilidade; b) nas lesões moderadas a sensibilidade é insatisfatória e a reprodutibilidade satisfatória, porém moderada; c) sensibilidade insatisfatória e redução da reprodutibilidade. / An assessment of the sensitivity and reproducibility of the Basso, Beattie and Bresnahan functional scale (BBB scale) was carried out, to evaluate the locomotion capacity following spinal cord injury. The BBB scale is a predictive procedure based on specific observational criteria of the locomotion of the animal under way, which attributes a sequential and cumulative score corresponding to satisfied pre-established criteria. 30 Wistar rats underwent laminectomy and light, moderate and severe spinal cord injury generated by the computerized equipment of impact through weight-drop developed by the University of New York (NYU Weight-Drop Impactor). At day 28 following the spinal cord injury, each rat was placed into a transparent box (80x80x30cm), with the bottom and the posterior wall lined with dark anti-slip material, and stimulated to move. The locomotion of each rat was recorded, simultaneously, by 3 digital cameras and, after editing, identical copies of the films were sent to six independent researchers, with no information regarding the severity of the injure in each rat, for determining the locomotory capabilities according to the Basso, Beattie and Bresnahan scale. The sensitivity of the method was verified for detecting differences between the results obtained from the left and right-side paws, among the rats subjected to light, moderate and severe injuries and among the evaluators through comparisons of the functional results and the reproducibility through correlation tests.

Σκοπός: Η προσέγγιση και η αντιμετώπιση των κακώσεων της Αυχενικής Μοίρας της Σπονδυλικής Στήλης (ΑΜΣΣ) εξακολουθεί και σήμερα να παρουσιάζει διαφορές μεταξύ των διαφόρων κέντρων. Κατά καιρούς μάλιστα έχουν προταθεί πλείστοι τρόποι αντιμετώπισης: από συντηρητική με κρανιακή έλξη μέχρι πολύ επιθετική χειρουργική αντιμετώπιση με συνδυασμένες πρόσθιες και οπίσθιες προσπελάσεις. Στόχος της διατριβής ήταν η παρουσίαση της χειρουργικής εμπειρίας της Ορθοπαιδικής Κλινικής του Πανεπιστημίου Πατρών στην αντιμετώπιση των ασθενών αυτών και η ανάλυση των επιπλοκών των διαφόρων μεθόδων σταθεροποίησης. Έγινε προσπάθεια να απαντηθούν τα ακόλουθα ερωτήματα: 1) Ποια πρέπει να είναι σήμερα η διαγνωστική προσέγγιση των ασθενών με κάκωση στην ΑΜΣΣ; 2) Ποιοι ασθενείς χρειάζονται σταθεροποίηση; 3) Τι είδους σταθεροποίηση και ποιες είναι οι επιπλοκές αυτής; Ακολούθως, ποιος πρέπει να είναι ο σύγχρονος αλγόριθμος προσέγγισης των ασθενών με κακώσεις στην ΑΜΣΣ; 4) Ποιες είναι οι μακροχρόνιες επιπτώσεις της σταθεροποίησης; Μεθοδολογία: Εκατόν-δώδεκα ασθενείς με ασταθείς κακώσεις στην ΑΜΣΣ υποβλήθηκαν στην Κλινική μας σε πρόσθια, οπίσθια σταθεροποίηση ή και στις δύο. Ένας ασθενής θεωρούνταν ότι είχε ασταθή κάκωση της ΑΜΣΣ εάν είχε 5 ή παραπάνω βαθμούς με βάση τα κριτήρια αστάθειας των White & Panjabi. Τουλάχιστον ένας χρόνος παρακολούθησης (follow-up) ήταν αναγκαίος για να ενταχθεί ένας ασθενής στη μελέτη, με αποτέλεσμα να επιλεγούν τελικά 97 ασθενείς. Εβδομηντατέσσερις ασθενείς υποβλήθηκαν σε αριστερή προσθιοπλάγια προσπέλαση [Ομάδα Α]. Σε 65 ασθενείς έγινε πρόσθια αποσυμπίεση και τοποθέτηση φλοιοσπογγώδους λαγονίου αυτομοσχεύματος και σταθεροποίηση με πλάκα και βίδες, είτε με πλάκα της AO/ASIF ή με πλάκα CSLP. Στους υπόλοιπους 9 ασθενείς, η αποκατάσταση της σπονδυλικής στήλης περιελάμβανε τη χρήση κλωβού πλέγματος τιτανίου στο οποίο τοποθετούνταν σπογγώδη αυτομοσχεύματα από την περιοχή της σωματεκτομής. Εικοσιτρείς ασθενείς υποβλήθηκαν σε οπίσθια σταθεροποίηση είτε με πλάκες πλαγίων ογκωμάτων (πλάκες Roy-Camille) (19 ασθενείς), ή με πολυαξονικές βίδες (4 ασθενείς) [Ομάδα Β]. Αποτελέσματα – Συμπεράσματα: 1) Εφόσον η κλινική εικόνα ενός ασθενούς με κάκωση στην ΑΜΣΣ επιβάλλει τη διενέργεια αξονικής τομογραφίας, η διερεύνηση μπορεί να γίνει με ασφάλεια με τη χρήση ενός σύγχρονου πολυτομικού αξονικού τομογράφου (MDCT) και μόνο, παραλείποντας τις απλές ακτινογραφίες. 2) Τα κριτήρια αστάθειας των White και Panjabi υπαγορεύουν μια ασταθή κάκωση στην ΑΜΣΣ, η οποία θα πρέπει να αντιμετωπίζεται κατά προτίμηση με χειρουργικό τρόπο. 3) Η στατιστική ανάλυση των αποτελεσμάτων δεν ανέδειξε στατιστικά σημαντικές διαφορές μεταξύ των 2 ομάδων σταθεροποίησης όσον αφορά τις κλινικά σημαντικές επιπλοκές (p=0.26). Ομοίως, οι κλινικά μη σημαντικές επιπλοκές, καθώς και το ποσοστό επανεγχειρήσεων δε διέφεραν στατιστικά μεταξύ των δύο ομάδων (p=0.245 και p=0.475 αντίστοιχα). Ωστόσο, η πρόσθια σταθεροποίηση παρουσιάζει σημαντικά πλεονεκτήματα, μπορεί να αντιμετωπίσει το σύνολο σχεδόν των κακώσεων της ΑΜΣΣ συμπεριλαμβανομένου των εξαρθρημάτων, και μόνο κατ’ εξαίρεση απαιτείται συμπληρωματική σταθεροποίηση. Επιπλέον, η εξέλιξη της μεθόδου βοήθησε στην εξάλειψη επιπλοκών που παρατηρούνταν με τα παλαιότερης τεχνολογίας υλικά. Ως εκ τούτου, οι τρέχουσες ενδείξεις για οπίσθια σταθεροποίηση είναι τα μη ανατασσόμενα εξαρθρήματα, οι κακώσεις πολλαπλών επιπέδων και οι ασθενείς με τραχειοστομία. 4) Η οστεοποίηση των παρακειμένων διαστημάτων στις κακώσεις της ΑΜΣΣ φαίνεται ότι έχει διαφορετική αιτιολογία από αυτή της αυχενικής σπονδύλωσης, μπορεί να εμφανιστεί πολύ πρώιμα στην μετεγχειρητική περίοδο και, ακόμα και όταν είναι εμφανής ακτινολογικά, σπανίως προκαλεί συμπτώματα. / Aim: The diagnostic approach and management of patients with cervical spine injuries differs among various centers. Conservative management with skeletal traction to aggressive surgical treatment with combined anterior and prosterior stabilization are within the possible alternatives. We aimed at presenting the experience from the surgical treatment of these patients gathered in the Department of Orthopaedic Surgery in the University Hospital of Patras. We further analyzed the complications associated with each approach and we tried to answer the following questions: 1) Which is the current diagnostic approach of patients with cervical spine injuries? 2) Which patients should be stabilized? 3) What type the stabilization should be and which are its complications? Moreover, which is the appropriate algorithm in the treatment of these patients? 4) Which are the long-term consequences of the stabilization? Materials & Methods: One hundred and twelve patients with unstable cervical spine injuries underwent anterior, posterior stabilization or both. A patient was considered to have an unstable injury if he had ≥ 5 points in the White and Panjabi checklist. At least one year of follow-up was necessary for a patient to be included in the study, which yielded a total of 97 patients. Seventy-four patients underwent a left-sided anterolateral approach [Group A]. Sixty-five of them had anterior decompression and iliac bone grafting. The remaining 9 patients underwent corpectomy and cervical spine reconstruction with titanium mesh cage, filled with morselized autograft from the corpectomy site. All these patients were instrumented using an anterior cervical plate. Twenty-three patients underwent posterior stabilization, either with lateral mass plates of Roy-Camille (19 patients), or polyaxial screws and rods (4 patients) [Group B], along with concomitant iliac bone autografting. Results – Conclusions: 1) If there is a need for computed tomography (CT) in a patient with cervical spine injury, the diagnostic work-up can be done with safety using only a modern multi-detector CT, obviating the need for plain radiographs. 2) The White and Panjabi criteria imply an unstable injury which should be preferentially stabilized by surgical means. 3) Statistical analysis of the clinically significant complications did not reveal significant difference between the posterior procedures and the anterior ones (p=0.26). Likewise, insignificant complications, as well as reoperation rates did not differ significantly among the two groups (p=0.245 and p=0.475 respectively). However, anterior stabilization for cervical spine injuries presents several advantages, can deal with almost all types of injuries and it only exceptionally requires supplemental stabilization. It should be also stressed that the advances in technology and metallurgy have eliminated the complications observed with older implants. Current indications for posterior stabilization are the irreducible dislocations, multilevel injuries and patients with tracheostomy. 4) Adjacent-level ossification in cervical spine injuries appears to be of different etiology than in cervical spondylosis, it may appear very early in the postoperative period and, even when it is evident radiographically, it very rarely (if ever) produces any symptoms.