Spinal fusion is used to treat diseases or disorders of the spine by fusing together two or more vertebrae. Two associated risks with spinal fusion are infection and blood loss. Administration of tranexamic acid is used to prevent blood loss, and transfusions are given following blood loss. Surgical site infections are prevented with vancomycin powder spread into the surgical wound, while established infections are treated by debridement and delivery of antibiotics for 4 to 6 weeks. The present research explored an alternate method to prevent and treat blood loss or infection in spinal fusion. Poly(lactic-co-glycolic acid) (PLGA) microspheres was used to encapsulate vancomycin for 42 days to treat infection. Vancomycin encapsulated in gelatin microspheres had a controlled release of 7 days to prevent infection. Tranexamic acid was dissolved into phosphate-buffered saline or carboxymethylcellulose to provide a release of 6 hours to prevent blood loss after surgery. The microspheres and tranexamic acid were delivered to a target region using a water based spray system. The spray system demonstrated the delivery and distribution of drugs to a target region. The microsphere spray system is capable of spraying drugs onto a target region to prevent or treat blood loss and infection over time.

OBJECTIVE: Chronic pain, including persistent postsurgical pain, reduces patients' quality of life, mood, and productivity. It presents a significant economic burden to society, yielding an estimated $600 billion annual cost due to health care and lost work productivity. Moderate to severe chronic pain affects 5% of children and adolescents. The current body of knowledge has demonstrated a consensus opinion that psychological factors and sensory factors are correlated with pain in the adult population. However, more research is necessary to determine what role depression and sensory function play in predicting severity of persistent postsurgical pain in children and adolescents. Thus, the present study seeks to explore how, if at all, post-operative pain and functional disability at 1 month postsurgery is correlated with pre-operative depression and sensory profile. METHODS: Eligible candidates were Adolescent Idiopathic Scoliosis (AIS) patients aged 10-17 who have been recommended to undergo spinal fusion surgery at Boston Children's Hospital (BCH). Fifteen participants were included in this study. Prior to surgery, all participants completed the Children's Depression Inventory: Short Form (CDI:S) via REDCap and underwent Quantitative Sensory Testing (QST) on their palmar thenar eminence (non-surgical site) and their lower back (surgical site). Participants' light touch detection thresholds and sharp prick pain threshold scores were determined using von Frey hairs. Participants' pressure-pain sensation threshold scores were determined using a pressure algometer. Warm and cool detection thresholds and hot and cold pain thresholds were measured using a thermode strapped to the skin. At 1 month postsurgery, participants completed the Functional Disability Inventory (FDI) and reported their pain scores, including their current pain, average and worst pain in the last week, average and worst pain in the last month, and average and worst pain in the last six months. Each presurgical variable was compared with each postsurgical variable using Pearson correlations at a significance level of p < 0.05. Additionally, postsurgical FDI scores were compared with postsurgical pain scores using Pearson correlations. RESULTS: Due to the small sample size (N = 15), the results should be considered preliminary. Preoperative CDI:S scores were not found to be correlated with postoperative pain and functional disability at 1 month postsurgery. Several preoperative QST variables were found to be correlated with postsurgical pain at 1 month. Namely, light touch detection threshold on the hand was negatively correlated with current pain (p < 0.05), average pain in the last week (p < 0.05), worst pain in the last week (p < 0.05), average pain in the last month (p < 0.05), and worst pain in the last month (p < 0.05). Warm detection threshold on the hand was negatively correlated with four different post-operative pain measures taken at one month post-surgery: worst pain in the last week (p < 0.05), worst pain in the last month (p < 0.05), average pain in the last six months (p < 0.05), and worst pain in the last six months (p < 0.05). Finally, heat pain threshold on the hand was negatively correlated with worst pain in the last 6 months at 1 month postsurgery (p < 0.05). Furthermore, postsurgical scores on the FDI were positively correlated with current pain at the 1-month post-surgical time point (p < 0.01), average pain in the last week at the 1-month post-surgical time point (p < 0.05), and worst pain in the last week at the 1-month post-surgical time point (p < 0.05). CONCLUSIONS: This study provides preliminary evidence of a correlation between heat sensitivity and poor postsurgical pain outcomes in the AIS population. Contrary to what was expected, hyposensitivity to light touch was correlated with worse pain outcomes. It is unclear why this is the case, and further research on the somatosensory profiles of pain patients is needed to examine this phenomenon. One of the most important findings in the present study is the correlation between post-operative pain and functional disability. The present study contributes to the small but growing body of knowledge surrounding the correlates of pediatric postsurgical pain. The use of QST provides an objective, quantifiable measure of patients' somatosensory profile. Furthermore, the present study contributes to the expansive research base that has shown the detrimental effects of chronic pain, highlighting the correlation between pain and functional disability in the AIS population following spinal fusion surgery.

M.Ing. (Mechanical Engineering) / A stand-alone anterior lumbar interbody fusion device is used to stabilise the spine and restore the disc space height without any other instrumentation. The stand-alone anterior lumbar interbody device is fixed to the adjacent vertebrae using titanium screws. In this research an experimental and numerical investigation on the structural strength of the SASCATM stand-alone anterior lumbar interbody fusion device are presented. The outcome of the investigation will be used as part of the device validation documentation necessary for market approval. The SASCATM device is manufactured from PEEK (a high strength polymer). Tensile and compressive testing was conducted to determine the appropriate mechanical properties of PEEK. The structural integrity of the SASCA device was evaluated by conducting full scale compression testing on a limited number of different design revisions. Comparisons as regards to their loaddisplacement behaviour were made. All specimens were visually inspected. The Finite Element Analysis (FEA) method was used in the numerical investigation of the SASCATM stand-alone anterior lumbar interbody device. Three studies were conducted. The first study aimed at comparing the full scale experimental compressive testing results with the FEA simulation. Although the desired results weren’t achieved, the model gave a fair representation of the initial region of the experimental setup in the sense that it had a similar slope. It was concluded that the nominal stress (4.1 MPa) fell within the proportional limit (35 MPa) as measured during the materials testing. The second study was aimed at determining the displacement at a worst-case load determined from the literature (2.7 kN). The study showed that the maximum Von Mises stress does not exceed the yield strength of the material. The third and final (parametric) study aimed at geometric optimisation of the cages. The motivation for the changes was based on the literature and customer suggestions for improvement. The geometric optimisation intended to show whether a desired increase in graft hole size would have an effect on the structural integrity of the device. The suggestion to move the screw holes of the threehole version closer to the center of the cage was also assessed. It was shown that enlarging the two graft holes does have an effect on the compressive strength. Higher stresses were presented in all but one case. Combining the holes also had an effect on the compressive strength. Movement of the screw holes more medially did have an impact on the compressive strength of the cages. The effect was significant. The closer the holes were to the center of the cage, the higher the Von Mises stress was. This change should therefore be considered before implementation. The results showed that different shapes and sizes of the graft holes do have an impact on the stress of this particular cage. None of the models exceeded the compressive yield strength of the material. The proposed graft hole opening design changes are therefore not warranted for the current SASCATM stand-alone anterior lumbar interbody device.

Background: Neuromuscular Scoliosis is a frequent complication of Cerebral Palsy that requires surgical management including spinal fusion. The objective of this observational study was to describe differences in the frequency of postoperative complications in children with Cerebral Palsy following spinal fusion surgery compared to children with Idiopathic Scoliosis. Methods: The 2016 Kids’ Inpatient Database was queried to identify pediatric patients (old) with concurrent diagnoses of Cerebral Palsy and Neuromuscular Scoliosis undergoing spinal fusion surgery. Cases were compared to children without Cerebral Palsy and with a diagnosis of Idiopathic Scoliosis undergoing the same procedure. Fitted Poisson regression analysis with robust variance was performed to estimate relative risks in the frequency of various clinical complications while adjusting for several potentially confounding variables of importance. Results: A total of 660 cases and 5,244 comparators were identified. Compared to children with Idiopathic Scoliosis, children with Cerebral Palsy were younger (13.6 vs. 14.3 years), more likely to be male (54% vs. 23%), and more likely to have had governmental insurance (52% vs. 32%). They also had longer hospital lengths of stay (8 days vs. 4 days). After adjusting for a number of potentially confounding sociodemographic and clinical variables, children with Cerebral Palsy were more likely to have postoperative pulmonary, gastrointestinal, and surgical complications, receive blood transfusions, and be admitted to the ICU. Conclusions: Children with Cerebral Palsy have an increased risk of complications following spinal fusion surgery leading to longer hospital stays. These results further inform surgical decision-making and anticipatory guidance for these children and their caregivers.

Children with medical complexity (CMC) require increased number and length of hospitalizations, and increased need for care coordination.1-3 Many complex children with neuromuscular diseases have scoliosis, or a deformity of the spine. Often, scoliosis in these patients affects multiple organ systems and requires spinal fusion surgery to repair the deformity and decrease the likelihood of further organ damage.4,5 While it is well-known that spinal fusion surgery is costly and a high-risk procedure, little research has evaluated the perioperative process of spinal fusion patients. Furthermore, few care pathways exist for medically complex patients undergoing spinal fusions.6 This study examines the pre-, peri-, and post-operative experiences of families of patients undergoing spinal fusion surgery at Boston Children’s Hospital. Providers, organization, leadership and teamwork, and overall outcomes are assessed by this qualitative study. Initial data suggest that a pathway improving coordination and communication, especially among interactions with the surgical coordinator, should be implemented to improve scheduling of surgery and appointments throughout the perioperative process

Propósito: Analizar si la adición de un espaciador interespinoso o la fusión intersomática ofrece ventajas en relación con la microdiscetomía aislada en el tratamiento de la hernia discal lumbar. Métodos: Pacientes con hernia de disco lumbar que iban a someterse a cirugía fueron elegidos para participar. En este estudio de cohorte los pacientes se dividieron en 3 grupos; Microdiscectomía sola (MD), microdiscectomía más espaciador interespinoso (IS) y fusión intersomática lumbar posterior (PLIF). La medida de resultado primaria fue la eficacia clínica mediante el índice de discapacidad de Oswestry (ODI). También evaluamos varios otros parámetros de resultado, entre los que se incluyeron: escala analógica visual para el dolor (EVA) de espalda y piernas, duración de la estancia, coste desde el ingreso hasta el alta hospitalaria, tasa de complicaciones de 90 días y tasa de reoperación tras 1 año. Resultados: Se incluyeron un total de 103 pacientes cuya edad media fue de 39,1 (± 8,5) años. En los 3 grupos se detectó una mejora significativa de la puntuación inicial del dolor de espalda y piernas con ODI y EVA. Las puntuaciones del ODI cambiaron de 62.66 a 13.77 en el grupo MD, 62.93 a 13.50 en el grupo IS, y 59.62 a 17.62 en el grupo PLIF (p <0.001). Después de 1 año, no se encontraron diferencias significativas en el ODI, ni en la EVA de espalda y piernas entre los 3 grupos. Hubo un aumento del 169% en el coste hospitalario en el grupo IS y del 287% en el grupo PLIF, en relación con la MD (p <0,001). La duración de la estancia fue un 86% mayor en el grupo IS y un 384% más en el grupo PLIF en comparación con MD (p <0,001). Las tasas de reoperación a 1 año fueron de 5,6%, 10% y 16,2% (p = 0,33) en los grupos MD, IS y PLIF respectivamente. Conclusión: La mejoría clínica parece deberse a la microdiscectomía, sin que el implante (interespinoso o fusión) agregue ningún beneficio. La adición de espaciador interespinoso o fusión no protegió contra la reoperación, y aumentó la duración de la estancia hospitalaria y los gastos quirúrgicos.

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Submitted by Carvalho Dias João Paulo (joao.dias@famerp.br) on 2018-04-05T13:53:11Z No. of bitstreams: 1 joao de melo neto_dissert.pdf: 3143812 bytes, checksum: f3defb0dcc5ec74209b625250898be75 (MD5) / Made available in DSpace on 2018-04-05T13:53:11Z (GMT). No. of bitstreams: 1 joao de melo neto_dissert.pdf: 3143812 bytes, checksum: f3defb0dcc5ec74209b625250898be75 (MD5) Previous issue date: 2016-12-16 / Introduction: Spinal cord injury (SCI) has a negative impact on quality of life and healthcare costs. In recent years, with the age pyramid inversion, there is a high prevalence of SCI in the elderly. In addition, the most common SCI-related lesion is Traumatic brain injury (TBI). Treatment planning depends on many factors, and is determining for the presence of morbidity and mortality. These factors must be explored so that we can have investments for the prevention and treatment of these patients. Objectives: To identify the characteristics and clinical features of patients with SCI, specifically: the elderly; individuals with TBI-related SCI and individuals undergoing surgery. Methods: Prospective study, including 321 previously selected patients with SCI. Clinical and socio-demographic variables were collected and analyzed. Patients were characterized and morbidity and mortality predictors in the elderly (≥60 years) (n=62) were analyzed, as well as individuals who had TBI-related SCI (n=52), and patients undergoing surgical treatment (n=211). Results: The comparison between the two genders showed that women have compression fracture associated to the thoracolumbar transition region; men presented listhesis more related to cervical lesions and increase in the number of complications; the need for surgical intervention is higher in men; among other factors. When we compared older and younger patients (<60 years; n = 259), we found that the morphological diagnosis, compression fracture and dislocation fracture are more associated with age ≥60 to <60, respectively; elderly after SCI had a greater association with late hemodynamic instability. With regards to patients who had TBI-related SCI, male gender (85%), age group between 21-30 years (25%), individuals who have a common-law marriage status (56%), low level of education (69%) and the Roman Catholic religion (77%) had a higher number of patients. The cervical segment had higher risk of injury (RR=3.48, CI: 1.856 to 6.526; p <0.0001). The neurological status ASIA-E (52%), syndromic presentation of neck pain (35%) and mild TBI (65%) were the most frequent. Complications were observed in 13 patients, and pneumonia was the most prevalent (62%). Hospital stay was significantly higher (20±28 days), and 17% of patients died. Men (RR=2.513, CI: 1.777 to 3.554; p=0.028) and individuals exposed to car accidents (RR=1.91, CI: 1.00 to 1.579; p=0.022) showed a greater risk to suffer these lesions concomitantly. Furthermore, these patients had a 2.48 (CI: 1.372 to 4.477; p<0.01) higher risk of death than patients with SCI alone. Finally, regarding the choice of treatment, fall and upper cervical and lumbosacral injuries were associated with conservative treatment. Patients with lesions in the lower cervical area, worse neurological status and unstable lesions were associated with surgery. Complications in the postoperative period occurred mainly in patients undergoing surgery. Afterwards, we assessed whether age influenced the characteristics of patients undergoing surgery. Subjects <60 years of age were associated with motorcycle accidents and the morphologic diagnosis of injury was listhesis. Subsequently, we analyzed the influence of gender on the characteristics of these patients. Women who had car accidents were associated with surgery. Women were associated with paraparesis and morphologic diagnosis of burst fracture, especially in the thoracolumbar and lumbosacral transition. Men who had TBI and thoracic trauma were related to surgery. These individuals had a worse neurological status and were associated with complications. Men and cervical region were the most affected and therefore, these patients were analyzed separately (n = 92). The presence of complications increases hospital stay. Patients with simultaneous morphological diagnosis, worse neurological status, quadriplegia and sensorimotor changes had more complications. Mortality was higher in cases with clinical pneumonia and thoracic trauma. Conclusion: There are clinical and demographic factors that are specific to the elderly, as well as to patients who have had TBI-related SCI and individuals undergoing surgical treatment. The understanding of these factors enables investments in prevention, rehabilitation and treatment aiming at reducing morbidity and mortality, losses in quality of life and hospital service expenditures. / Introdução: O traumatismo raquimedular (TRM) ocasiona prejuízos na qualidade de vida e gastos aos sistemas de saúde. Nos últimos anos, com a inversão da pirâmide etária, há alta prevalência de TRM em idosos. Além disso, a lesão associada ao TRM mais apresentada é o Traumatismo Cranioencefálico (TCE). O direcionamento do tratamento depende de inúmeros fatores, sendo determinante para a presença de morbimortalidade. Neste contexto, estes fatores precisam ser explorados para haver investimentos na prevenção e terapêutica destes pacientes. Objetivos: Identificar as características e aspectos clínicos de pacientes com traumatismo raquimedular, especificamente: idosos; indivíduos com TRM associado ao TCE; e sujeitos submetidos à cirurgia. Métodos: Estudo retrospectivo, sendo previamente selecionados 321 pacientes com TRM. As variáveis clínicas e sócio-demográficas foram coletadas e analisadas. Os pacientes foram caracterizados e analisados os fatores preditores de morbimortalidade em idosos (≥60 anos) (n=62), sujeitos que sofreram TCE associado ao TRM (n=52), e em pacientes submetidos a tratamento cirúrgico (n=211). Resultados: Durante a análise entre os diferentes sexos, observou-se que mulheres apresentam fratura compressão associada à região de transição toracolombar; homens apresentam listese mais relacionada com lesões na cervical e aumento no número de complicações; a necessidade de intervenção cirúrgica é maior em homens. Durante a comparação entre idosos e indivíduos jovens (<60 anos; n=259), observou-se que os diagnósticos morfológicos, fratura compressão e fratura luxação, são mais associados com idade ≥60 e <60, respectivamente; idosos após TRM tiveram maior associação com instabilidade hemodinâmica tardia. Com relação aos pacientes que sofreram TRM associado à TCE, o sexo masculino (85%), a faixa etária entre 21-30 anos (25%), o estado civil de união estável (56%), o baixo nível de escolaridade (69%). O acidente automobilístico (58%) foi a principal etiologia. O segmento cervical teve maior risco de lesão (RR=3,48, IC: 1,856-6,526; p<0,0001). O estado neurológico ASIA-E (52%), o quadro sindrômico de cervicalgia (35%) e o índice de TCE leve (65%) foram os mais frequentes. As complicações atingiram 13 pacientes, sendo pneumonia a de maior frequência (62%). O tempo de internação foi significativamente maior nos pacientes com TCE (20±28 dias), e 17% dos pacientes foram a óbito. Os homens (RR=2,513, IC: 1,777-3,554; p=0,028) e indivíduos expostos a acidentes com veículo automotor (RR=1,91, IC: 1,00-1,579; p=0,022) apresentaram maior risco de sofrer essas lesões concomitantemente. Além disso, esses pacientes apresentaram 2,48 (IC: 1,372-4,477; p<0,01) mais risco de morte que vítimas de TRM isolado. Por fim, com relação à escolha do tratamento, a queda e lesões nas regiões cervical superior e lombosacral foram associadas com tratamento conservador. Pacientes com lesões nas regiões cervical inferior, pior status neurológico e lesões instáveis foram associados com cirurgia. Complicações no pós-operatório ocorreram principalmente em pacientes que realizaram cirurgia, sendo pneumonia a mais frequente, visto que os pacientes que são submetidos a este tipo de intervenção é porque apresentam um pior quadro clínico na admissão. Posteriormente, durante a análise para verificar se a idade influenciava as características dos pacientes submetidos à cirurgia, observou-se que sujeitos com <60 anos foram associados com acidente motociclístico e com o diagnóstico morfológico de lesão: lístese. Subsequentemente, nós analisamos a influência do sexo sobre as características destes pacientes. Mulheres que sofreram acidente automobilístico foram associadas à cirurgia. Mulheres foram associadas com paraparesia e diagnóstico morfológico: fratura explosão, principalmente nas regiões de transição tóraco-lombar e lombo-sacral. Homens que apresentaram TCE e trauma torácico foram relacionados à cirurgia. Estes indivíduos tiveram um pior status neurológico e foram associados à complicação. Homens e a região cervical foram mais afetados, assim, estes pacientes foram analisados isoladamente (n=92). A presença de complicações aumenta a permanência hospitalar. Pacientes com diagnósticos morfológicos em multiníveis vertebrais e com pior status neurológico apresentaram mais complicações. A mortalidade foi maior nos casos clínicos com Pneumonia e traumatismo torácico. Conclusão: Existem fatores clínicos e demográficos específicos em idosos; assim como em pacientes que sofreram TRM associado ao TCE; e em indivíduos submetidos ao tratamento cirúrgico. O conhecimento destes fatores possibilitam investimentos em prevenção, reabilitação e tratamento, visando reduzir a morbimortalidade, prejuízos na qualidade de vida e gastos com os serviços hospitalares.

Abnormalities in lumbopelvic rhythm (LPR) play a role in occurrence/recurrence of low back pain (LBP). The LPR before spinal fusion surgery and its changes following the surgery are not understood. A repeated measure study was designed to investigate timing and magnitude aspects of LPR in a group of patients (n = 5) with LBP before and after a spinal fusion surgery. Participants completed a forward bending and backward return task at their preferred pace in the sagittal plane. The ranges of thoracic and pelvic rotations and lumbar flexion (as the magnitude aspects of LPR) as well as the mean absolute relative phase (MARP) and deviation phase (DP) between thoracic and pelvic rotations (as the timing aspects) were calculated. Thoracic, pelvic, and lumbar rotations/flexion were respectively 2.19° smaller, 17.69° larger, and 19.85° smaller after the surgery. Also, MARP and DP were smaller during both bending (MARP: 0.0159; DP 0.009) and return (MARP: 0.041; DP: 0.015) phases of the motion after surgery. The alterations in LPR after surgery can be the result of changes in lumbar spine structure due to vertebral fusion and/or new neuromuscular adaptations in response to the changes of lumbar spine structure. The effects of altered LPR on load sharing between passive and active components of lower back tissues and the resultant spinal loads should be further investigated in patients with spinal fusion surgery.