Tobias A. Mattei and Alisson R. Teles
Asdrubal Falavigna, Orlando Righesso and Alisson Roberto Teles
The purpose of this study was to present straightforward preoperative methods to define the need for manubriotomy in the anterior surgical approach to the cervicothoracic junction.
Preoperative MR imaging and CT scanning studies were performed in all patients. The CT images with sagittal reconstructions including the manubrium were done to apply the so-called surgeons' view line. This line is parallel to the inferior plateau of the superior healthy vertebrae or the vertebrae above the herniated intervertebral disc, and the decision concerning the need for manubriotomy depends on the correlation between this line and the manubrium.
Preoperative planning of the need for manubriotomy was correct in all cases. Manubriotomy was never performed in C-7 corpectomy or C7–T1 discectomy cases; nevertheless, manubriotomy was needed in half of the cases when the T-1 corpectomy was the lowest level to be resected (8 cases), and in 4 cases the lowest level to be approached was T-2. The mean surgical time, bleeding volume, postoperative pain intensity, and length of hospital stay were less in the cervicotomy than in the manubriotomy group.
By using the surgeons' view line and its correlation with the manubrium, the need for manubriotomy can be predicted without compromising decompression and reconstruction. The statistical differences observed in the surgical variables between the manubriotomy and cervicotomy cases justified the use of preoperative evaluation of the need for manubriotomy as an aid to surgical planning and to give the patient and family realistic expectations about the surgery.
Asdrubal Falavigna, Orlando Righesso, Vincent C. Traynelis, Alisson Roberto Teles and Pedro Guarise da Silva
Deep wound infections are one of the most common and serious complications of spinal surgery. The impact of such infections on long-term outcomes is not well understood. The purpose of this study was to evaluate the functional status and satisfaction in patients who suffered a deep wound infection after undergoing lumbar arthrodesis for symptomatic degenerative disc disease.
The authors conducted a prospective study in 13 patients with a clinical and radiological diagnosis of symptomatic degenerative lumbar stenosis and instability; after undergoing decompression and instrumentation-augmented arthrodesis, the patients suffered a deep wound infection (infection group). A 3:1 (39-patient) matched cohort was selected for comparison (control group). All surgeries were performed during the same period and by a single surgeon. The postoperative infections were all treated in a similar manner and the instrumentation was not removed. Both groups were followed up and assessed with validated outcome instruments: Numerical Rating Scale of pain, Oswestry Disability Index, 36-Item Short Form Health Survey, Beck Depression Inventory, and Hospital Anxiety and Depression Scale. Patient satisfaction was also determined.
The median follow-up duration was 22 months (range 6–108 months). The mean patient age was 62 ± 10 years, and 59.6% of the patients were female. There was no significant difference between the groups in pain, functional disability, quality of life, or depression and anxiety. However, 53.8% of the patients with infection were not satisfied with the procedure at the final evaluation, compared with 15.4% of the patients without a deep wound infection (p = 0.003).
Patients with successfully treated postoperative deep wound infections do not have a difference in functional outcome compared with patients who underwent an identical operation but did not suffer a complicating infection. Patients who suffered an infection were more likely to be unsatisfied with the procedure than patients who did not.
Rodrigo Navarro-Ramirez, Oded Rabau, Alisson Teles, Susan Ge, Abdulaziz Bin Shebreen, Neil Saran and Jean Ouellet
Early-onset scoliosis (EOS) correction techniques have evolved slowly over the past 40 years and still remain a challenge for the spine surgeon. Avoiding spinal fusion in these patients is key to decreasing morbidity and mortality in this population.
Current treatments for EOS include both conservative and surgical options. The authors present the modified Luqué technique that has been performed at their institution for the past decade. This modified technique relies on Luqué’s principle, but with newer “gliding” implants through a less disruptive approach. The goal of this technique is to delay fusion as long as possible, with the intent to prevent deformity progression while preserving maximal growth.
Normally, these patients will have definitive fusion surgery once they have reached skeletal maturity or as close as possible. Out of 23 patients until present (close to 4-year follow-up), the authors have not performed any revision due to implant failure. Three patients have undergone final fusion as the curve progressed (one patient, 4 years out, had final fusion at age 12 years; two other patients had final fusion at 3 years). These implants, which have the CE mark in Europe, are available in Canada via a special access process with Health Canada. The implants have not yet been submitted to the FDA, as they are waiting on clinical data out of Europe and Canada.
In the following video the authors describe the modified Luqué technique step-by-step.
The video can be found here: https://youtu.be/k0AuFa9lYXY.
Asdrubal Falavigna, Nicolas Scheverin, Orlando Righesso, Alisson R. Teles, Maria Carolina Gullo, Joseph S. Cheng and K. Daniel Riew
Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil.
The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation).
The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197–0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained.
The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.
Asdrubal Falavigna, Alisson Roberto Teles, Maíra Cristina Velho, Gregory Saraiva Medeiros, Carolina Travi Canabarro, Gustavo Lisbôa de Braga, Daniel Ongaratto Barazzetti, Viviane Maria Vedana and Fabrício Diniz Kleber
Trauma is the leading cause of mortality and morbidity in children, young people, and working-age adults. Because of the high incidence of intentional and unintentional injuries in young people, it is necessary to implement injury-prevention programs and measure the efficacy of these initiatives. The authors evaluated the effectiveness of an injury-prevention program in high school students in a city in southern Brazil.
In a randomized controlled study, 1049 high school students were divided into a control group and intervention group. The study was conducted in the following 3 stages: a questionnaire was applied 1 week before the educational intervention (P0), shortly after the intervention (P1), and 5 months later (P3). In the control group, a questionnaire based on the Pense Bem Project was applied at the 3 time stages, without any intervention between the stages.
The postintervention analysis evidenced a slight change in knowledge about unintentional spinal cord and brain injuries. Regarding attitudes, the only significant improvement after the intervention lecture was in the use of helmets, which remained high 5 months later. A substantial number of students only partially agreed with using safety behaviors. The only significant postintervention change was the major agreement to check swimming pool depth before entering the water (P0 89% and P1 97.8%, p < 0.001; P2 92.8%, p = 0.005).
An educational intervention based on a single lecture improved students' knowledge of traumatic brain and spinal cord injuries, but this type of intervention did not modify most attitudes toward injury prevention. Clinical trial registration no.: U1111-1121-0192.
Michael H. Weber, Lojan Sivakumaran, Maryse Fortin, Alisson R. Teles, Jeff D. Golan, Carlo Santaguida, Peter Jarzem and Thierry Pauyo
The cost of spine management is rising. As diagnostic imaging accounts for approximately 10% of total patient care spending, there is interest in determining if economies could be made with regard to the routine consultation of radiology for image interpretation. In the context of spine trauma, both the spine surgeon and the radiologist interpret perioperative imaging. Authors of the present study investigated the impact of radiologist interpretation of perioperative imaging from patients with traumatic single-level thoracolumbar fractures given that spine surgeons are expected to be comfortable interpreting pathologies of the musculoskeletal system.
The authors conducted a retrospective review of all patients presenting with a single-level thoracolumbar fracture treated at the McGill University Health Centre in the period from January 2003 to December 2010. The time between image capture and radiologist interpretation as well as the number of extraskeletal and/or incidental findings was extracted from the radiology reports on all perioperative images including radiographic, fluoroscopic, and CT images. The cost of interpretation was obtained from the provincial health insurance entity of Quebec.
Eighty-two patients met the study inclusion criteria. Radiologists took a median of 1 day (IQR 0–5.5 days) to interpret preoperative radiographs. Intraoperative fluoroscopic images and postoperative radiographs were read by the radiologist a median of 19 days (IQR 4–56.75 days) and 34 days (IQR 1–137.5 days) after capture, respectively (p < 0.05). Preoperative radiologist dictations reported extraskeletal and/or incidental findings for 8.1% of radiographs; there were no intraoperative or postoperative extraskeletal findings beyond those previously reported on the preoperative radiographs. Radiologists took a median of 1 day (IQR 0–1 day) to read both preoperative and postoperative CT scans; extraskeletal and/or incidental findings were present in 46.2% of preoperative reports and 4.5% of postoperative reports. There were no intraoperative or postoperative radiological findings that provoked reoperation. A total of 66 intraoperative fluoroscopy images and 225 postoperative radiographs were read for a cost of $1399.20 and $1867.50 (Canadian dollars), respectively, for radiologist interpretation. This cost amounted to 40.3% of all perioperative image interpretation spending.
In the management of single-level thoracolumbar fractures, radiologists add information to the diagnostic picture when interpreting preoperative radiographs and perioperative CT scans; however, the interpretation of intraoperative fluoroscopic images and postoperative radiographs comes with significant delay, does not add additional information, and represents an area of potential cost and professional-resource reduction.
Alisson R. Teles, Michael Paci, Gabriel Gutman, Fahad H. Abduljabbar, Jean A. Ouellet, Michael H. Weber and Jeff D. Golan
The aim of this study was to evaluate the anatomical and surgical risk factors for screw-related facet joint violation at the superior level in lumbar fusion.
The authors conducted a retrospective review of a consecutive series of posterior lumbar instrumented fusions performed by a single surgeon. Inclusion criteria were primary lumbar fusion of 1 or 2 levels for degenerative disorders. The following variables were analyzed as possible risk factors: surgical technique (percutaneous vs open screw placement), depth of surgical field, degree of anterior slippage of the superior level, pedicle and facet angle, and facet degeneration of the superior level. Postoperative CT scans were evaluated by 2 independent reviewers. Axial, sagittal, and coronal views were reviewed. Pedicle screws were graded as intra-articular if they clearly interposed between the superior and inferior facet joints of the superior level. Multivariate logistic regression analyses were conducted to assess the factors associated with this complication.
One hundred thirty-one patients were included. Interobserver reliability for facet joint violation assessment was high (κ = 0.789). The incidence of superior facet joint violation was 12.59% per top-level screw (33 of 262 proximal screws). The rate of facet violation was 28.0% in the percutaneous technique group (14 of 50 patients) and 12.3% in the open surgery group (10 of 81 patients) (OR 2.26, 95% CI 1.09–4.21; p = 0.024). In multivariate logistic regression analysis, independent predictors of facet violation were percutaneous screw placement (adjusted OR 3.31, 95% CI 1.42–7.73; p = 0.006), right-side pedicle screw (adjusted OR 3.14, 95% CI 1.29–7.63; p = 0.011), and facet angle > 45° (adjusted OR 10.95, 95% CI 4.64–25.84; p < 0.0001).
The incidence of facet joint violation was higher in percutaneous minimally invasive than in open technique for posterior lumbar spine surgery. Also, coronal orientation of the facet joint is a significant risk factor independent of the surgical technique.
Asdrubal Falavigna, Gregory Saraiva Medeiros, Carolina Travi Canabarro, Daniel Ongaratto Barazzetti, Grasiela Marcon, Gabriela Massaro Carneiro Monteiro, Júlia Bertholdo Bossardi, Pedro Guarise da Silva, Alisson Roberto Teles, Maíra Cristina Velho and Priscila Ferrari
A previous study published by the authors showed that a single intervention could not change the baseline attitudes toward neurotrauma prevention. The present study was designed to evaluate the effectiveness of multiple interventions in modifying knowledge and attitudes for the prevention of neurotrauma in Brazilian preteens and adolescents.
In a randomized controlled trial, fifth-year primary school (PS) and second-year high school (HS) students were divided into a control and 2 intervention (single/multiple) groups. The study was conducted in the following 8 stages: T1, questionnaire to measure baseline characteristics; T2, lecture on trauma prevention; T3, reapplying the questionnaire used in T1; T4, Traffic Department intervention; T5, a play about trauma and its consequences; T6, Fire Department intervention; T7, Emergency Medical Service intervention; and T8, reapplying the questionnaire used in T1 and T3. Positive answers were considered those affirming the use of safety devices “always or sometimes” and negative as “never” using safety devices.
The sample consisted of 535 students. Regarding attitudes, students in all groups at any stage of measurement showed protective behavior more than 95% of the time about seat belt use. There were only differences between attitudes in PS and HS students on T8 assessment concerning the use of safety equipment on bikes in the multiple-intervention group and concerning the use of safety equipment on skateboards and rollerblades in single- and multiple-intervention groups. These differences were caused mainly by the reduction in positive answers by the HS group, rather than by the increase in positive or protective answers by the PS group. However, there was no difference when the control and intervention groups were compared, independent of the attitudes or the student groups studied. The most important reason for not using protective devices was the belief that they would not get hurt.
Multiple and different types of educational interventions, such as lectures, scenes from plays about trauma and its consequences, traffic and fire department intervention, and medical emergency intervention directed to preteens and adolescents from public and private schools did not modify most students' attitudes toward injury prevention. Clinical trial registration no: U1111–1121–0192 (National System of Ethics and Research in Brazil).