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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_2 | Pages 10 - 10
2 Jan 2024
Martínez T Mariscal G Hevia E Barrios C
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The multimodal management of canal stenosis is increasing, and inhibitors of central sensitization are playing a crucial role in central sensitization processes. Pregabalin and gabapentin are antiepileptic drugs that reduce presynaptic excitability. The objective of this study was to investigate whether the use of pregabalin and gabapentin is effective in the symptomatic management of canal stenosis.

A literature search was conducted in four databases. The inclusion criteria were studies that compared pregabalin or gabapentin with a control group in lumbar canal stenosis. Randomized clinical trials and a comparative retrospective cohort study were included. The main clinical endpoints were VAS/NRS, ODI, and RDQ (Roland Morris Disability Questionnaire) at 2, 4, 8 weeks, and 3 months, adverse events, and walking distance were also collected. Data were combined using Review Manager 5.4 software.

Six studies and 392 patients were included. The mean age was 60.25. No significant differences were observed in VAS at 2, 4, and 8 weeks: (MD: 0.23; 95% CI: −0.63-1.09), (MD: −0.04; 95% CI: −0.64 to −0.57), and (MD: −0.6; 95% CI: −1.22 to 0.02). Significant differences were observed in favor of pregabalin with respect to VAS at three months: (MD: −2.97; 95% CI: −3.43 to −2.51). No significant differences were observed in ODI (MD: −3.47; 95% CI: −7.15 to −0.21). Adverse events were significantly higher in the pregabalin/gabapentin group (OR 5.88, 95%CI 1.28-27.05). Walking distance and RDQ could not be compared, although the results were controversial.

Gabapentinoids have not been shown to be superior to other drugs used in the treatment of LSS or to placebo. However, they have shown a higher incidence of adverse effects, improved results in VAS at 3 months, and a slight improvement in ambulation at 4 months in combination with NSAIDs compared to NSAIDs in monotherapy.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_1 | Pages 2 - 2
2 Jan 2024
Mariscal G Burgos J Antón-Rodrigálvarez L Hevia E Barrios C
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In healthy subjects, respiratory maximal volumes are highly dependent on the sagittal range of motion of the T7-T10 segment. In AIS, the abolition of T7-T10 dynamics related to the stiffness induced by the apex region in Lenke IA curves could harm ventilation during maximal breathing. The aim of this study was to analyze the dynamics of the thoracic spine during deep breathing in AIS patients and in healthy matched controls. This is a cross-sectional, case-control study. 20 AIS patients (18 girls, Cobb angle, 54.7±7.9°; Risser 1.35±1.2) and 15 healthy volunteers (11 girls) matched in age (12.5 versus 15.8 yr. mean age) were included. In AIS curves, the apex was located at T8 (14) and T9 (6). Conventional sagittal radiographs of the whole spine were performed at maximal inspiration and exhalation. The ROM of each spinal thoracic functional segment (T1-T7, T7-T10, T10-T12) and the global T1-T12 ROM were measured. In healthy subjects, the mean T1-T12 ROM during forced breathing was 16.7±3.8. AIS patients showed a T1-T12 ROM of 1.1±1.5 (p<0.05), indicating a sagittal stiffness of the thoracic spine. A wide T7-T10 ROM (15.3±3.0) was found in healthy controls (91.6% of the T1–T12 ROM). AIS patients showed only 0.4±1.4 ROM at T7-T10 (36.4% of the T1-T12 ROM) (p<0.001). There was a significant positive correlation between the magnitude of T7-T10 kyphosis in maximal exhalation and both FVC (% of predicted FVC) and FEV1. In conclusion, Lenke 1A AIS patients show a restriction of the thoracic spine motion with an almost complete abolition of T7-T10 ROM, a crucial segment for deep breathing. T7-T10 stiffness could explain the ventilatory limitations found in AIS patients.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_1 | Pages 24 - 24
2 Jan 2024
Burgos J Mariscal G Antón-Rodrigálvarez L Sanpera I Hevia E García V Barrios C
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The aim of this study was to report the restauration of the normal vertebral morphology and the absence of curve progression after removal the instrumentation in AIS patients that underwent posterior correction of the deformity by common all screws construct whitout fusion. A series of 36 AIS immature patients (Risser 3 or less) were include in the study. Instrumentation was removed once the maturity stage was complete (Risser 5). Curve correction was assessed at pre and postoperative, before instrumentation removal, just post removal, and more than two years after instrumentation removal. Epiphyseal vertebral growth modulation was assessed by a coronal wedging ratio (WR) at the apical level of the main curve (MC). The mean preoperative coronal Cobb was corrected from 53.7°±7.5 to 5.5º±7.5º (89.7%) at the immediate postop. After implants removal (31.0±5.8 months) the MC was 13.1º. T5–T12 kyphosis showed a significant improvement from 19.0º before curve correction to 27.1º after implants removal (p<0.05). Before surgery, WR was 0.71±0.06, and after removal WR was 0.98±0.08 (p<0.001). At the end of follow-up, the mean sagittal range of motion (ROM) of the T12-S1 segment was 51.2±21.0º. SRS-22 scores improved from 3.31±0.25 preoperatively to 3.68±0.25 at final assessment (p<0.001). In conclusion, fusionless posterior approach using a common all pedicle screws construct correct satisfactory scoliotic main curves and permits removal of the instrumentation once the bone maturity is reached. The final correction was highly satisfactory and an acceptable ROM of the previously lower instrumented segments was observed.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_8 | Pages 121 - 121
11 Apr 2023
Mariscal G Burgos J Antón-Rodrigálvarez L Hevia E Barrios C
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To analyze the dynamics of the thoracic spine during deep breathing in AIS patients and in healthy matched controls.

Case-control cross-sectional study. 20 AIS patients (18 girls, Cobb angle, 54.7±7.9°; Risser 1.35±1.2) and 15 healthy volunteers (11 girls) matched in age (12.5 versus 15.8 yr. mean age) were included. In AIS curves, the apex was located in T8 (14) and T9 (6). Conventional sagittal radiographs of the whole spine were performed at maximal inspiration and expiration. The ROM of each spinal thoracic functional segment (T1-T7, T7-T10, T10-T12), the global T1–T12 ROM were measured. Respiratory function was assess by forced vital capacity (FVC), expiratory volume (FEV1), FEV1/FVC, inspiratory vital capacity (IVC) and peak expiratory flow (PEF).

In healthy subjects, the mean T1–T12 ROM during forced breathing was 16.7±3.8. AIS patients showed a T1-T12 ROM of 1.1±1.5 (p<0.05) indicating a sagittal stiffness of thoracic spine. A wide T7–T10 ROM (15.3±3.0) was found in healthy controls (91.6% of the T1–T12 ROM). AIS patients showed only 0.4±1.4 ROM at T7-T10 (36.4% of the T1–T12 ROM) (p<0.001). There was a significant correlation between T7-T10 ROM and IVC.

Lenke 1A AIS patients show a restriction of the thoracic spine motion with an almost complete abolition of T7-T10 ROM, a crucial segment participating in the deep breathing. T7-T10 stiffness could explain the ventilatory limitations found in AIS patients.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_9 | Pages 90 - 90
1 May 2017
Hevia E Solaz J Barrios C Caballero A Burgos J
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Background

Oblique implantable total disc replacements (TDR) have been developed in an attempt to partially resect the anterior longitudinal ligament (ALL), together with additional partial resection of lateral annulus fibres. To date, the literature has not addressed the impact of the TDR oblique implantation on the lumbar spine sagittal alignment. The hypothesis of this study was that TDR at the L4-L5 level does not change the sagittal alignment and the range of motion of the lumbar spine when the implant is placed in accurate position.

Methods

Prospective single-center radiological investigation of L4/5 TDR inserted through an oblique approach for the treatment of disc disease. A series of 52 patients with a minimum of 2-year FU after oblique TDR at L4/L5 level was analysed for radiological changes in sagittal alignment and range of motion of the lumbar spine. The total sagittal lumbar lordosis (TSLL), the segmental sagittal lumbar lordosis (SSLL) of the operated level, and the range of motion of the TDR implant were determined in pre- and postoperative functional X-rays. The accuracy of the implant position was also evaluated.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_8 | Pages 59 - 59
1 Apr 2017
Hernandez C Burgos J Antón L García V Hevia E Barrios C
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Background

The improvement of the rib cage deformity (RCD) after surgery correction has not been correlated in detail with the correction of vertebral axial rotation (AR). The loss of at the rib cage after correction has been never monitored. The hypothesis of this work was that the aesthetic improvement of RCD in adolescent idiopathic scoliosis (AIS) does not follow completely the reduction of thoracic AR after correction surgery. Moreover, lesser correction of thorax deformity could be expected in mature patients with more rigid curves.

Methods

Multicenter prospective study of the modifications of the rib cage deformity in 24 patients operated because of AIS Lenke type 1A. RDC was assessed in the preoperative MRI exams including the thoracic perimeter. Vertebral AR was quantified by the RaSac angle. Anterior and posterior rib hump, and the translation of the sternum were measured in mm according to standard protocols. All these parameters were assessed in the immediate post-op period and 2-years after surgery using CT-scan axial slides. In all cases, a vertebral derotation technique performed by asymmetric rod bending was used. Immature (Risser 0–2) and mature (Risser 3–4) patients were compared.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_8 | Pages 61 - 61
1 Apr 2017
Antón-Rodrigálvarez LM Flores JB Cabanes L Barrios C Hevia E de Blas G García V
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Background

The overall incidence of neurological symptoms attributed to lumbar misplaced screws has been described to occur in 3.48% of patients undergoing surgery. These lumbar radicular neurological lesions are undetected with conventional intraoperative neurophysiological and radiological controls. The hypothesis of this study was that direct stimulation of the pedicle screw after placement in the lumbar spine may not work as well as for screws placed in the thoracic pedicles. A more suitable method for the lumbar spine could be the stimulation of the pedicle track with a ball-tipped probe.

Methods

Comparative observational study on the detection of malpostioned lumbar pedicle screws using two different techniques in two different periods: t-EMG screw stimulation (2011–2012) and track stimulation (2013–2014). A total of 1440 lumbar pedicle screws were placed in 242 patients undergoing surgery for vertebral deformities in the last four years (2011–2014). In the first two years, 802 lumbar screws were neuromonitored using t-EMG during. In the last two years, 638 screws were placed after probe stimulation of the pedicle track. Standardised t-EMG conventional registration and fluoroscopy were afterwards performed in all cases.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_8 | Pages 60 - 60
1 Apr 2017
Hevia E Paniagua A Barrios C Caballero A Chiaraviglio A Flores J
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Background

Recently, some studies have focused attention on the possibility that anaerobic pathogens of low virulence could constitute an etiological factor in disc herniation. There have been isolated such strains, predominantly Propionibacterium acne, between 7 and 53% of patients undergoing surgery for disc pathology. According to these studies, patients with anaerobic infections of the disc are more likely to develop Modic changes in the adjacent vertebrae. The aim of this work was to test this hypothesis by growing in specific media the disc material extracted in a series of lumbar discectomy and relating this factor with the presence of pre-intervention Modic changes.

Methods

A total of 22 consecutive patients undergoing primary unisegmental discectomy for lumbar disc herniation (77.2% male, mean age 40.1 ± 9.1 years) were included. All patients were immunocompetent and none had previously received an epidural steroid injection prior surgery. MRI study confirmed the disc herniation. Following strict antiseptic protocols, the extracted disc material was sent for slow-growth anaerobic enriched culture (>10 days).


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_8 | Pages 57 - 57
1 Apr 2017
Aragonés M Hevia E Caballero A Barrios C
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Background

The controversy concerning the benefits of unisegmental cervical disc arthroplasty (CDA) over anterior cervical discectomy and fusion (ACDF) is still open because some randomised clinical trial (RTC) comparing ACDF with CDA have been highly inconclusive. Most of these studies mixed disc prosthesis with dissimilar kinematic characteristics. To date, a compilation of the clinical and radiologic outcomes and adverse events of anterior cervical discectomy and fusion (ACDF) compared with a single cervical disc arthroplasty (CDA) design, the Bryan disc has partially accomplished.

Methods

This is a systematic review of RCTs with level I-II evidence. Only RCTs reporting clinical outcomes were included in this review. After a search on different databases including PubMed, Cochrane Central Register of Controlled Trials, and Ovid MEDLINE, a total of 10 RCTs out of total 51 studies were entered in the study. RTC's were searched from the earliest available records in 2005 to December 2014.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_8 | Pages 58 - 58
1 Apr 2017
Lorente R Fernández-Pineda L Burgos J Antón-Rodrigálvarez L Hevia E Pérez-Encinas C Barrios C
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Background

After surgical correction of thoracic scoliosis, an improvement in the cardio-respiratory adaptation to exercise would be expected because of the correction of the rib cage associated with the spinal deformity. This work intended to evaluate the physiologic responses to incremental exercise in patients undergoing surgical correction of adolescent idiopathic scoliosis (AIS). The hypothesis of this study was that the exercise limitations described in patients with AIS could be related with the physical deconditioning instead of being linked to the severity of the vertebral deformity.

Methods

Cross-sectional study of the exercise tolerance in a series of patients with AIS type Lenke 1A, before and 2 years after surgical correction. Twenty patients with AIS and 10 healthy adolescents aged between 12 and 17 years old were evaluated. The average magnitude of the curves was 60.3±12.9 Cobb. Cardio-respiratory function was assessed before surgery and at 2-year follow-up by maximal exercise tolerance test on treadmill following a Bruce standard protocol. Maximal oxygen uptake (VO2), VCO2, expiratory volume (VE), and VE/VO2 ratio were registered.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_11 | Pages 297 - 297
1 Jul 2014
Barrios C Montes E Burgos J de Blas G Antón-Rodrigálvarez M Hevia E Correa C
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Summary Statement

The spinal cord showed marked sensibility to acute compression causing complete and irreversible injury. On the contrary, the spinal cord has more ability for adaptation to slow progressive compression mechanisms having the possibility of neural recovery after compression release.

Introduction

The aim of this experimental study was to establish, by means of neurophysiologic monitoring, the degree of compression needed to cause neurologic injury to the spinal cord, and analyze whether these limits are different making fast or slow compression.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 395 - 395
1 Sep 2012
Sánchez Ruas JJ Burgos Flores J Aranda Romero F Del Olmo Hernández T De Blas G Barrios C Hevia E Regidor I Correa Gorospe C Ruíz Ibán M Díaz Heredia J López Mondéjar J Berrendero L
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Introduction

A new triggered electromyography test for detection of stimulus diffusion to intercostal muscles of the contralateral side during thoracic pedicle screw placement was evaluated. Experimental research was carried out in order to determine if, using this test, neural contact at different aspects of the spinal cord and nerve roots could be discriminated.

Methods

Nine industrial pigs (60–75 kg) had 108 pedicle screws placed bilaterally in the thoracic spine (T8–T13). Neural structures were stimulated under direct vision at different anatomic locations from T9 to T12. Recording electrodes were placed over the right and left intercostal muscles. Increasing intensity of the stimulus was applied until muscle response was detected at the contralateral side (diffusion phenomenon). After this first experiment, the thoracic spine was instrumented. Screws were placed in the pedicle in two different positions, the anatomic intrapedicular location and with purposeful contact with the neural elements.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 397 - 397
1 Sep 2012
Sánchez Ruas JJ Burgos Flores J Aranda Romero F Del Olmo Hernández T Piza Vallespir G De Blas G Montes E Caballero García A Barriga Martín A Collazo J Hevia E Correa Gorospe C Barrios C
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Objectives

To determine the limits of spinal displacement before the onset of neurophysiological changes during spinal surgery. Assessing if the type of force applied or the section of the adjacent nerve roots increases the tolerance to displacement.

Methods

Experimental study in 21 domestic pigs. Three groups were established according to the displacing force applied to the cord: separation (group 1, n=7), root stump pull (group2, n=7) and torque (group3, n=7). Successive records of cord-to-cord motor evoked potential were obtained. The displacing force was removed immediately when neurophysiological changes observed. The experiment was repeated after sectioning the adjacent nerve roots.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 453 - 453
1 Sep 2009
Barrios C Riquelme O Burgos J Hevia E Gonzalez-Lopez J Correa C
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This work was aimed at study the role of paraspinal muscles on spinal tensegrity. Four different models of spinal tensegrity breakage with and without injury of the posterior spinal muscle were investigated.

Fifteen minipigs (mean age 6-week) underwent costotransversectomy (CTT) at 5 consecutive vertebral segments. In 4 animals ribs and transverse processes (T7–T11) were removed through a posterior midline approach with complete desinsertion of paraspinal muscles. In other 3 animals, CTT was performed by a posterolateral approach (T6–T10) without detachment of paraspinal muscles. Other 4 minipigs underwent rib resection (T7-T11) throughout a thoracoscopic approach avoiding damage of posterior spinal muscles. A final group of 4 animals, a complete detachment of the paraspinal muscles was performed from T7 to T11 without removing bony structures and leaving in deep surgical wax attached to the spinous and transverse processes to avoid reinsertion of the muscles after surgery. Anatomic specimens were radiologically and macroscopically studied just at sacrifice 5 months after surgery

All 4 animals operated on of CTT by midline posterior approach developed structural spinal deformity with curve convexity at the side of rib removal (mean Cobb angle 34,6°). Animals undergoing CTT by posterolateral approach without paraspinal muscle detachment did not develop any significant spinal deformity. Absence of spinal deformity was also found in those animals in which rib resection was performed by thoracoscopy without injury of the posterior spinal muscles. All 4 animals undergoing detachment of the paraspinal muscles without CTT and application of the surgical wax developed scoliotic curves (mean Cobb angle of 28°).

In conclusion, a new insight on the underlying pathogenic mechanisms of scoliotic curves is given by using this spinal tensegrity model. Isolated damage of the posterior muscle-ligamentous structures around the costotransverse joints breaking muscles spine tensegrity seems to be mandatory to induce scoliotic deformity. Rib removal alone appeared to have less scoliotic inductive implication. The finding questions previous knowledge on scoliosis etiopathogeny.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 246 - 246
1 Jul 2008
DOMÉNECH P GUTIERREZ P BURGOS J PIZA G HEVIA-OLAVIDE E ROCA J FENOLLOSA J
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Purpose of the study: Fixing the pedicles can be difficult to achieve during surgical treatment of scoliosis involving the thoracic spine because of the vertebral rotation raising the risk of neurological and vascular disorders. Use of extrapedicular thoracic screws has been proposed for more adapted and safe fixation. No clinical data has been published concerning the safety of these screws.

Material and methods: This multicentric retrospective clinical and radiological study included 467 thoracic screws in 34 patients operated for scoliosis. Neurophysiological monitoring was used for all procedures. Screws were positioned free hand without radioscopic control. Pedicular screws were inserted in T10, T11, T12. Extra-pedicular screws were inserted for thoracic vertebrae above T10 to T4. Correction was achieved with rods bent in situ. The purpose of this study was to evaluate the position of the thoracic screws within the vertebral body and in relation to the great vessels and the cord. The position of the screws in the thoracic spine was studied by two independent observers reading multiple thin-slice CT images. The observers noted malposition as: 1) penetration into the canal more than 2 mm, 2) less than 1 cm hold in the vertebral body, 3) screw protrusion more than 2 mm beyond the vertebral cortical.

Results: Screw malposition was observed for 9 of 161 pedicular screws (5.4%) and for 21 of 306 (6.8%) thoracic screws. None of the screw malpositions had a clinical expression. There was one episode of thoracic effusion associated with thoracoplasty. Two patients required revision (one for poor indication and one for disincarceration). There were no postoperative deep infections. Three cases of intercostals neuralgia subsided within three months.

Conclusion: Insertion of thoracic screws for fixation and correction is a useful technique with few complications. It enables better 3D correction and better control of the deformation. Screw malposition in this series was similar to that observed with classical pedicular techniques. There was no major complication associated with thoracic screws.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 324 - 324
1 May 2006
Burgos J Castrillo-Amores M Hevia E Sanpera I Piza G Lopez-Mondejar J Amaya S
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Introduction and purpose: We present the results of our surgical method involving nerve decompression, reduction and circumferential spinal fusion via posterior approach for severe spondylolisthesis.

Materials and methods: We studied 14 patients with spondylolisthesis and slippage greater than 50%; mean age 24. Mean slip angle 37° and mean preoperative slip 74%.

Procedure: Via a posterior approach we performed neural decompression and placed pedicle screws in L5-S1 (in one case we instrumented L4 for associated L4-L5 spondylolisthesis) and iliac screws (except in three cases). We removed the annulus fibrosus, the L5-S1 disc and the rounded proximal edge of the sacrum. Following distraction of L5-S1 we inserted bone graft cages (from 3 to 5). We adjusted the bars with spanners to reduce slippage and achieve final curvature of the spine.

The cases were monitored with evoked potentials and epidural catheter.

We studied preoperative, postoperative and final check X-rays. The clinical histories were also reviewed.

Results: One rupture of the dura. Two patients with anterior slippage of a cage. One posterior slippage of L5 screws, without revision surgery. One postoperative infection resolved by surgical cleaning and antibiotic therapy.

After mean follow-up of 32 months the radiographic study showed no pseudoarthrosis. Final mean slippage was 15% and slip angle 5°. Ten patients had no pain or physical limitations. Two presented mild lumbar discomfort and occasional limitation.

Conclusions: The procedure we used was shown to be effective in correcting the deformity with excellent clinical results.