RESUMO
Back pain has long been considered an uncommon complaint in the pediatric population. When present, teaching had been that pediatric back pain almost always has a diagnosable cause, many of which are progressive and potentially debilitating. Recent evidence has suggested that pediatric back pain is not only more common than once thought but also, within certain populations, benign and idiopathic. This, in turn, places an increasing amount of pressure on pediatricians to accurately assess and manage their patients presenting with complaints of back pain. The aim of this article is to serve as a review of the current literature on pediatric back pain. The article reviews the epidemiology, basic anatomy, and important elements of a history and examination, which should be considered when a child presents complaining of back pain. Last, a common differential diagnosis with evaluation and management is also given to help guide pediatricians through their medical decision making.
Assuntos
Dor nas Costas/etiologia , Doenças da Coluna Vertebral/diagnóstico , Adolescente , Dorso/anatomia & histologia , Dor nas Costas/epidemiologia , Dor nas Costas/terapia , Criança , Diagnóstico Diferencial , Humanos , Anamnese , Exame Físico , Doenças da Coluna Vertebral/complicações , Doenças da Coluna Vertebral/terapia , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/diagnóstico , Coluna Vertebral/anatomia & histologia , Coluna Vertebral/diagnóstico por imagemRESUMO
BACKGROUND: Cervical spine degenerative disease is one of the main causes of myelopathy. Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure used to treat cervical myelopathy. Therefore, it is important to study pseudarthrosis rates after ACDF and correlate them with the graft used. METHODS: We performed a systematic review to evaluate the relationship between pseudarthrosis after ACDF and the interbody graft used. RESULTS: A total of 3732 patients were evaluated in 46 studies. The mean age of the included patients was 51.5 ± 4.18 years (range, 42-59.6 years). ACDF is most often perforemd as single-level surgery and the level most impaired is C5-C6. The use of titanium cages, zero profile, recombinant human bone morphogenetic protein 2, and carbon cages was seen as a protective factor for pseudarthrosis compared with the autograft group (control group); with an odds ratio of 0.29, 0.51, 0.03, and 0.3, respectively; the results were statistically relevant. The use of polyetheretherketone, poly(methyl methacrylate), and trabecular metal was a risk factor for development of pseudarthrosis compared with the control group, with an odds ratio of 1.7, 8.7, and 6.8, respectively; the results were statistically relevant. Radiologic follow-up was an important factor for the pseudarthrosis rate; paradoxically, a short follow-up (<1 year) had lower rates of pseudarthrosis and follow-up >2 years increased the chance of finding pseudarthrosis. CONCLUSIONS: Different types of grafts lead to a significant difference in pseudarthrosis rates. Follow-up time is also an important factor that affects the rate of pseudarthrosis after ACDF.
Assuntos
Transplante Ósseo/métodos , Vértebras Cervicais/cirurgia , Discotomia/métodos , Complicações Pós-Operatórias/epidemiologia , Implantação de Prótese/métodos , Pseudoartrose/epidemiologia , Doenças da Coluna Vertebral/cirurgia , Fusão Vertebral/métodos , Benzofenonas , Proteína Morfogenética Óssea 2/uso terapêutico , Carbono , Humanos , Cetonas , Razão de Chances , Polietilenoglicóis , Polímeros , Polimetil Metacrilato , Desenho de Prótese , Proteínas Recombinantes/uso terapêutico , Fatores de Risco , Doenças da Medula Espinal/etiologia , Doenças da Medula Espinal/cirurgia , Doenças da Coluna Vertebral/complicações , Titânio , Fator de Crescimento Transformador beta/uso terapêutico , Transplante AutólogoRESUMO
ABSTRACT Objective: The aim of this study was to evaluate the implications of long waiting times on surgery lists for the treatment of patients with scoliosis. Methods: Radiographs of 87 patients with scoliosis who had been on the waiting list for surgery for more than six months were selected. Two surgeons answered questionnaires analyzing the radiographs when entering the waiting list and the current images of each patient. Results: Data from 87 patients were analyzed. The mean waiting time for surgery was 21.7 months (ranging from seven to 32 months). The average progression of the Cobb angle in the curvature was 21.1 degrees. Delayed surgery implied changes in surgical planning, such as greater need of instrumentation, osteotomies, and double approach. Conclusions: Long waiting lists have a significant negative impact on surgical morbidity of patients with scoliosis, since they increase the complexity of the surgery. Level of evidence: IV. Type of study: Descriptive study.
RESUMO Objetivo: A meta desse estudo foi avaliar as implicações das longas listas de espera de cirurgia no tratamento dos pacientes portadores de escoliose. Métodos: Foram selecionados radiografias de 87 pacientes portadores de escoliose que estavam na lista de espera por cirurgia há mais de seis meses. Dois cirurgiões responderam questionários, analisando as radiografias de entrada na lista de espera e as imagens atuais de cada paciente. Resultados: Dados de 87 pacientes foram analisados. A média de espera pela cirurgia foi de 21,7 meses (variando de sete a 32 meses). A média de progressão do ângulo de Cobb na curvatura foi de 21,1 graus. A demora pela cirurgia implicou em alterações no planejamento cirúrgico, como maior necessidade de instrumentação, osteotomias e dupla via de acesso. Conclusão: As longas listas de espera tem um significativo impacto negativo na morbidade cirúrgica dos pacientes com escoliose, por aumentar a complexidade da cirurgia. Nível de evidência: IV. Tipo de estudo: Estudo descritivo
RESUMEN Objetivo: El objetivo de este estudio fue evaluar las implicaciones de los largos tiempos de espera en las listas de cirugía para el tratamiento de pacientes con escoliosis.. Métodos: Se seleccionaron radiografías de 87 pacientes con escoliosis que habían estado en la lista de espera para cirugía durante más de seis meses. Dos cirujanos respondieron cuestionarios analizando las radiografías al entrar en la lista de espera y las imágenes actuales de cada paciente. Resultados: Se analizaron los datos de 87 pacientes. El tiempo promedio de espera para la cirugía fue de 21,7 meses (variando de siete a 32 meses). La progresión promedio del ángulo de Cobb en la curvatura fue de 21,1 grados. La demora de la cirugía implicó cambios en la planificación quirúrgica, como mayor necesidad de instrumentación, osteotomías y doble vía de acceso. Conclusiones: Las largas listas de espera tienen un impacto negativo significativo en la morbilidad quirúrgica de los pacientes con escoliosis, ya que aumentan la complejidad de la cirugía. Nivel de evidencia: IV. Tipo de estudio: Estudio descriptivo.
Assuntos
Humanos , Doenças da Coluna Vertebral/complicações , Escoliose , Doenças da Coluna Vertebral/diagnóstico por imagem , Listas de EsperaRESUMO
BACKGROUND: Arachnoid cysts of spine are a very rare occurrence. The aetiology still remains unclear, but the most accepted explanation is the existence of areas of weakness in the spinal dura. Symptoms depend on the location in the spine. Magnetic resonance imaging is used for its diagnosis. Management depends of clinical presentation, and the surgery is reserved for patients with neurological impairment. CLINICAL CASE: A case is described of 67 year-old male with myelopathy and radiculopathy symptoms, both diagnosed simultaneously. The magnetic resonance imaging was used to diagnose a thoracolumbar extradural arachnoid cyst from T12-L2 and lumbar spinal canal stenosis. The patient was treated with a puncture procedure to empty the cyst and decompress the neural elements. There was a clinical improvement of myelopathy syndrome after puncture procedure. One month later, the patient underwent a minimally invasive surgical approach to decompress the neural elements in lumbar spine, achieving improvement of the radiculopathy syndrome and neurogenic claudication in both legs. CONCLUSION: There is currently no standard minimally invasive approach to surgically treat these cysts, but if the patient has mild symptoms, clinical observation is recommended.
Assuntos
Cistos Aracnóideos/cirurgia , Doenças da Coluna Vertebral/cirurgia , Idoso , Cistos Aracnóideos/complicações , Cistos Aracnóideos/diagnóstico por imagem , Descompressão Cirúrgica , Fluoroscopia , Humanos , Claudicação Intermitente/etiologia , Vértebras Lombares , Imageamento por Ressonância Magnética , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Polirradiculopatia/etiologia , Radiografia Intervencionista , Compressão da Medula Espinal/etiologia , Doenças da Coluna Vertebral/complicações , Doenças da Coluna Vertebral/diagnóstico por imagem , Punção Espinal , Estenose Espinal/etiologia , Vértebras TorácicasRESUMO
El absceso del psoas es una enfermedad infrecuente en niños. Puede tener una presentación clínica inespecífica, ser de inicio insidioso y relacionarse o no con fiebre. El tipo más frecuente en pediatría es primario; sin embargo, en ocasiones, puede ser de origen secundario y asociarse a infecciones graves, como la osteomielitis, por lo que se requiere un alto índice de sospecha para detectarlo y tratarlo oportunamente. Presentamos un caso atípico de absceso del psoas con infiltración del cuerpo vertebral de L2 en un paciente masculino de 14 años previamente sano, sin antecedente de traumatismo ni fiebre al momento del ingreso. Se realizaron una radiografía y una ecografía, pero el diagnóstico se confirmó a través de una resonancia nuclear magnética de columna lumbosacra. Conhemocultivos positivos para Staphylococcus aureus meticilino resistente, completó 2 semanas de tratamiento antibiótico endovenoso y 4 semanas por vía oral con negativización de cultivos y resolvió por completo la sintomatología inicial.
Psoas abscess is a common disease in children. It can have a nonspecific clinical presentation, insidious onset and sometimes fever. The most common type in children is the primary one; however, it can sometimes be of secondary origin and associated with severe infections such as osteomyelitis so a high index of suspicion is required to detect and treat it promptly. We present an unusual case of psoas abscess with infiltration of the vertebral body of L2 in a 14 year old male patient previously healthy with no history of trauma or fever on admission. X-ray and ultrasound were performed but the diagnosis was confirmed by magnetic resonance imaging of the lumbosacral spine. With positive blood cultures for methicillin-resistant Staphylococcus aureus he completed 2 weeks of intravenous antibiotic therapy and 4 weeks of oral antibiotic therapy with blood cultures negativization and resolution of symptoms.
Assuntos
Humanos , Masculino , Adolescente , Osteomielite/complicações , Osteomielite/microbiologia , Doenças da Coluna Vertebral/complicações , Doenças da Coluna Vertebral/microbiologia , Infecções Estafilocócicas/complicações , Abscesso do Psoas/complicações , Staphylococcus aureus Resistente à Meticilina , Vértebras LombaresRESUMO
Psoas abscess is a common disease in children. It can have a nonspecific clinical presentation, insidious onset and sometimes fever. The most common type in children is the primary one; however, it can sometimes be of secondary origin and associated with severe infections such as osteomyelitis so a high index of suspicion is required to detect and treat it promptly. We present an unusual case of psoas abscess with infiltration of the vertebral body of L2 in a 14 year old male patient previously healthy with no history of trauma or fever on admission. X-ray and ultrasound were performed but the diagnosis was confirmed by magnetic resonance imaging of the lumbosacral spine. With positive blood cultures for methicillin-resistant Staphylococcus aureus he completed 2 weeks of intravenous antibiotic therapy and 4 weeks of oral antibiotic therapy with blood cultures negativization and resolution of symptoms.
El absceso del psoas es una enfermedad infrecuente en niños. Puede tener una presentación clínica inespecífica, ser de inicio insidioso y relacionarse o no con fiebre. El tipo más frecuente en pediatría es primario; sin embargo, en ocasiones, puede ser de origen secundario y asociarse a infecciones graves, como la osteomielitis, por lo que se requiere un alto índice de sospecha para detectarlo y tratarlo oportunamente. Presentamos un caso atípico de absceso del psoas con infiltración del cuerpo vertebral de L2 en un paciente masculino de 14 años previamente sano, sin antecedente de traumatismo ni fiebre al momento del ingreso. Se realizaron una radiografía y una ecografía, pero el diagnóstico se confirmó a través de una resonancia nuclear magnética de columna lumbosacra. Conhemocultivos positivos para Staphylococcus aureus meticilino resistente, completó 2 semanas de tratamiento antibiótico endovenoso y 4 semanas por vía oral con negativización de cultivos y resolvió por completo la sintomatología inicial.
Assuntos
Vértebras Lombares , Staphylococcus aureus Resistente à Meticilina , Osteomielite/complicações , Osteomielite/microbiologia , Abscesso do Psoas/complicações , Doenças da Coluna Vertebral/complicações , Doenças da Coluna Vertebral/microbiologia , Infecções Estafilocócicas/complicações , Adolescente , Humanos , MasculinoRESUMO
The authors present their experience in a programme for second opinion evaluation of spine surgery candidates within a cohort of patients from a healthcare provider in Brazil. Ninety-four patients were evaluated, and the second opinion was divided in complete agreement, partial disagreement, and complete disagreement. Patients with complete disagreement were referred for a third medical opinion. A complete agreement was found in 22 cases, partial disagreement in 28 cases, and complete disagreement in 44 cases. The majority of the discrepancies between first and second opinion were found in lumbar degenerative disorders, with a reduction of 50% in the amount of surgical procedures and a 50% reduction in the rate of instrumentation within this subset of patients. Within 1 year of the index evaluation, only two patients who followed the proposed treatment guidelines were reoperated, giving an estimate of the adequacy of this second opinion programme.
Assuntos
Encaminhamento e Consulta/estatística & dados numéricos , Doenças da Coluna Vertebral/cirurgia , Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Feminino , Humanos , Dor Lombar/etiologia , Dor Lombar/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reoperação , Doenças da Coluna Vertebral/complicações , Adulto JovemRESUMO
BACKGROUND: Several studies have suggested that back pain in the majority of pediatric patients does not have an identifiable cause. Many children undergo extensive diagnostic workup that ultimately results in a nonconfirmative diagnosis. The purpose of this study was to (1) describe the prevalence of back pain seen in a pediatric orthopaedic clinic; (2) evaluate the efficacy of a systematic approach dependent on magnetic resonance imaging (MRI) in the diagnosis of pediatric back pain; and (3) analyze sensitivity, specificity, positive predictive value, and negative predictive value of various clinical signs and symptoms. METHODS: For a 24-month period, all patients that presented with a chief complaint of back pain were prospectively enrolled in this study and evaluated in a systematic approach which utilized MRI for patients with constant pain, night pain, radicular pain, or abnormal neurological examination after an initial history, physical examination, and negative radiographic examination. RESULTS: The prevalence of chief complaint of back pain was 8.6% (261/3042 patients). Of the 261 patients, 34% had an identifiable pathology following the systematic approach. In 8.8% of patients, the diagnosis was established with the history, physical examination, and plain radiographs. MRI yielded a definitive diagnosis in another 25% of patients. It is noteworthy that of the 89 patients with a confirmed pathology, 26% were identified with plain radiographs and 74% with MRI. CONCLUSIONS: A systematic approach to diagnose pediatric back pain demonstrated that 34% of pediatric patients that present to an outpatient orthopaedic clinic complaining of back pain will have identifiable pathology. The diagnostic yield increased from 8.8% with the history, physical examination, and plain radiographs to 22% with the TCN Bone Scan to 36% with the use of the MRI. The clinician should be aware that the presences of lumbar pain or constant pain are red flags for the presence of underlying pathology. LEVEL OF EVIDENCE: Level III.
Assuntos
Dor Lombar , Vértebras Lombares/patologia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Doenças da Coluna Vertebral , Adolescente , Algoritmos , Dor nas Costas , Criança , Pré-Escolar , Gerenciamento Clínico , Feminino , Humanos , Dor Lombar/diagnóstico , Dor Lombar/etiologia , Masculino , Ortopedia/métodos , Pediatria/métodos , Valor Preditivo dos Testes , Prevalência , Sensibilidade e Especificidade , Doenças da Coluna Vertebral/complicações , Doenças da Coluna Vertebral/diagnóstico , Avaliação de Sintomas/métodosRESUMO
Lumbar synovial cysts are an uncommon cause of back pain and radiculopathy, usually manifesting with gradual onset of symptoms, secondary to involvement of the spinal canal. Rarely, intracyst hemorrhage occurs, and may acutely present as radicular - or even spinal cord - compression syndrome. Synovial cysts are generally associated with degenerative facets, although the pathogenesis has not been entirely established. We report a case of bleeding complication in a synovial cyst at L2-L3, adjacent to the right interfacet joint, causing acute pain and radiculopathy in a patient on anticoagulation therapy who required surgical resection.
Cistos sinoviais da coluna lombar são uma causa incomum de dor na coluna e radiculopatia, geralmente com evolução gradual dos sintomas, que são secundários ao comprometimento do canal vertebral. Raramente, há hemorragia intracística, que pode se manifestar de forma aguda com síndrome compressiva radicular ou mesmo medular. Habitualmente, os cistos sinoviais associam-se a doença degenerativa facetária, embora a patogênese não esteja completamente estabelecida. Relatamos aqui um caso em que uma complicação hemorrágica em um cisto sinovial no nível L2-L3, adjacente à interfacetária direita, causou dor lombar e radiculopatia em um paciente em terapia anticoagulante, sendo necessária a ressecção cirúrgica.