Neurocirugía Abril 2014 (Vol 23)

Campos Hidrocefalia en pacientes…..
Neurocirugía-Neurocirurgia / Vol 22/ 2012
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Neurocirugía-Neurocirugía / Vol. 23 / 2014
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N E U R O C I R U G I A – N E U R O C I R U R G I A
Órgano Oficial de la Federación Latinoamericana de Sociedades de Neurocirugía (F LANC)
EDITOR DE PUBLICACIONES FLANC
GERMAN POSADAS NARRO
Oficina Editorial: Jr. Camilo Carrillo 225 - 602
Jesús María, Lima-PERU
Correo electrónico: neurogw@gmail.com
Edición: David Urquizo Sánchez
Email: durquizos@yahoo.com
COMITE EDITORIAL
MADJID SAMII (Alemania) ERNESTO HERRERA (El Salvador)
CARLOS GAGLIARDI (Argentina) JOSE MARTIN RODRIGUEZ (España)
JACQUES BROTCHI (Bélgica) TETSUO KANO (Japón)
MILTON SHIBATA (Brasil) ENRIQUE VEGA (Nicaragua)
HILDO AZEVEDO (Brasil) FREDDY SIMON ( Paraguay )
LEONIDAS QUINTANA (Chile ) HUGO HEINICKE ( Perú )
REMBERTO BURGOS (Colombia) ALVARO CORDOVA (Uruguay)
OSSAMA AL-MEFTY (EE.UU.) ALFONSO GUZMAN (Venezuela)
EDWARD LAWS (EE.UU) JESUS VAQUERO (España)

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FEDERACION LATINOAMERICANA DE SOCIEDADES DE NEUROCIRUGIA (FLANC)
DIRECTORIO
Presidente ROBERTO SANTOS (Ecuador)
Presidente Anterior ROGELIO REVUELTA (México)
Vicepresidente EDGARDO SPAGNUOLO (Uruguay)
Secretario General SERGIO VALENZUELA (Chile)
Tesorero OSCAR APONTE (Colombia)
Editor de Publicaciones GERMAN POSADAS (Perú)
Editor de Internet CLAUDIO YAMPOLSKY (Argentina)
Historiador PATRICIO TAGLE (Chile)
Parlamentario FERNANDO RUEDA (México)
Secretario Ejecutivo MARIO IZURIETA (Ecuador)
Presidente CLANC MANUEL ROJAS (Venezuela)
PRESIDENTES DE SOCIEDADES LATINOAMERICANAS DE NEUROCIRUGIA
ARGENTINA Abraham Campero GUATEMALA Erny Leal
BOLIVIA Hernan Jemio HONDURAS Osly Vásquez
BRASIL-SOCIEDAD Sebastiao Gusmao MEXICO Blas Lopez
BRASIL-ACADEMIA Paulo Pires de Aguiar NICARAGUA Marvín Salgado
CHILE Marcos Baabor PANAMA Avelino Gutiérrez
COLOMBIA Hernando Sifuente PARAGUAY Ramón Migliosiri
COSTA RICA José Pérez PERU Jesús Felix
CUBA Enrique de Jongh R. DOMINICANA Luis Suazo
ECUADOR Julio Enriquez URUGUAY Pablo Hernández
EL SALVADOR Guillermo Lara VENEZUELA José Finoccho
E. UNIDOS-CANADÁ Fernando Díaz
PRESIDENTES HONORARIOS
Dr. A .Krivoy (Venezuela) Dr. L. Ditzel (Brasil)
Dr. M. Loyo (México) Dr. U. Rocca (Perú)
Dr. J. Mendoza (Colombia) Dr. H. Giocoli (Argentina)
Dr. J. Méndez (Chile) Dr. M. Molina (Honduras)
Dr. F. Rueda (México) Dr. N. Renzi (Argentina)
Dr. T. Perilla (Colombia) Dr. M. Masini (Brasil)
Dr. R. Burgos (Colombia) Dr. A. Basso (Argentina)
Dr. L. Quintana (Chile) Dr. R. Revuelta (México)
Dr. E. Herrera (El Salvador) Dr. J. Landeiro (Brasil)

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DELEGADOS ANTE WFNS
Marco Molina 2º VICEPRESIDENTE REGIONAL
Roberto Santos DELEGADO SENIOR
Edgardo Spagnuolo SEGUNDO DELEGADO
Sergio Valenzuela DELEGADO ALTERNO
PRESIDENTES SOCIEDADES FEDERADAS REGIONALES
Rafael de la Riva ASOCAN
Ramiro Alvarado CONO SUR
PRESIDENTES SOCIEDADES ADHERENTES EXTRACONTINENTALES
Enrique Urculo ESPAÑA
Marco Barboza PORTUGAL
Massimo Collice ITALIA
Marc Sindou LENGUA FRANCESA
COMITÉS
EDUCACIÓN
Dr. Leonidas Quintana
Dr. Rodrigo Ramos
Dr. Alfredo Pedroza
Dr. Paulo E. Pires de Aguilar
CANDIDATURAS:
Dr. Marco Molina
Dr. Ernesto Herrera
Dr. Oscar Aponte
ESTATUTOS
Dr. Marco Molina
Dr. Fernando Rueda
Dr. Nestor Renzi
MEDALLAS
Dr. Marcos Masini
Dr. Rogelio Revuelta
FINANZAS
Dr. Eduardo Spagnuolo
Dr. Marcos Masini
Dr. Himmler Serato
Dr. Ricardo Lungo Esquivel
Dr. César Yano
ÉTICA
Comité Administrativo en pleno

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____________________________________________________________________________________________
CAPITULOS
1.-CIRUGÍA
CEREBROVASCULAR
Dr. Edgardo Sapgnuolo
2.-COLUMNA VERTEBRAL
Dr. José Soriano
3.-CIRUGÍA ESTEROTORÁXICA
Y FUNCIONAL
Dr. Jairo Espinoza
4.- NEUROCIRUGÍAPEDIÁTRICA
Dr. Guzmán Aranda
5.- NEURO ONCOLOGÍA
Dra. Alejandra Rabadan
6.-NEUROTRAUMATOLOGIA Y
TERAPIA INTENSIVA
Dr. Enrique Guzmán
7.- NERVIOS PERIFERICOS
Dr. Fernando Guedes
8-. BASE DE CRÁNEO
Dr. Gustavo Isolan

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REVISTA LATINOAMERICANA DE NEUROCIRUGIA
Abril, 2014. Volúmen 23
Contenido
Editorial
Dr. Remberto Burgos de la Espriella. ………………..….……….……………….……..7
Página del Presidente
La FLANC en el Contexto Mundial.
Dr. Efraín Ernesto Herrera Magaña………….………...………………...….…...…….10
Artículos Originales
Treatment of thoracolumbars spine fractures and dislocations Its influence on the
rehabilitation process.
Dr. Masini M…….……………………………………………………………..............12
Hidrocefalia en paciente pediátricos con tumor de fosa posterior: Propuesta de
escala predictiva.
Hydrocephalus in pediatric patients with posterior fossa tumor: Proposed
predictive scale.
Drs. Campos D., García J., Zopfi A, Toledo M., Ramírez A., Solis F,.………..............46
Artículo de Revisión
Absceso cerebral: Rol del neurocirujano.
Brain Absces to the work concerning the neurosurgeon.
Drs. Navas M., Alvis M., Gutierrez P., Alcala C., Moscote S……….……...……..…...57
Miscelánea en Neurociencias
Enfermedades prevalentes, valoración funcional y situación socio-familiar del adulto
mayor región callao 2006.
Prevalent diseases functional assessment, and social family situation in older adults
attending primary health care centers, Callao 2006.
Drs. Ruiz L., Campos M, Peña N., …...…………..…..…...…………..….…...………..70
Ciencia y Arte
Poemas: Rubén Darío………………………….………………….…………………83
Semblanza
Atos Alves de Sousa
Sebastião Gusmão …………….…………..…………………….………..….………..85
Reglamento de Publicaciones………………………………………….…..………..…….87

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Editorial
Remberto Burgos de la Espriella
INSTRUIR, ENSEÑAR Y EDUCAR
n Colombia, que lleva casi 20 años un sistema salud que ha alcanzado cerca
del 100% en cobertura en salud a los colombianos, se discute una
modificación estructural de esa ley, la cual es conocida como Ley 100 de
1993. La nueva reforma, pretende corregir sus defectos: la intermediación, la
integración vertical y el modelo de salud que ha estado centrado en la atención de la
enfermedad. Quedó en el olvido la prevención y sus medidas .Estas - las más eficaces-
cuando miramos los resultados en costo efectividad.
El Gobierno Nacional, bien intencionado, pero errado, buscando facilitar y agilizar la
oportunidad para la atención de los especialistas, ha propuesto en el nuevo proyecto de
Ley que hospitales con “experiencia” y sin control universitario, puedan otorgar títulos
de Especialistas a Médicos que durante un periodo de tiempo hayan trabajado como
hospitalarios en esa institución. Así, se aumentan en un periodo corto el número de
”especialistas” y se satisface la demanda.
¿Estamos preparados en Latinoamérica para que hospitales de tercer nivel, sin aval
universitario, otorguen Título de Neurocirujano a Médicos hospitalarios que durante 5
años han trabajado como “médicos de planta” en un servicio de neurocirugía?
Más allá de la pregunta planteada, llegamos al punto de la oferta y en esta la
distribución y concentración de los especialistas en nuestros países. Tenemos casi en
todos los países latinos 1 neurocirujano por 100.000 habitantes y esta cifra se aproxima
a los estándares de la distribución adecuada que la WFNS sugiere. Pero si detallamos
esta distribución, vemos que en las grandes ciudades se concentran y alcanzan casi
cifras del 20/100.000. Los especialistas que se radican en las grandes ciudades
encuentran oportunidades de trabajo asistencial y remuneración que apenas alcanza
para los gastos esenciales de una familia. El sueño de hacer los grandes casos no existe,
la ilusión del consultorio es una quimera y el horario de las grandes ciudades, donde el
día tiene 18 horas (transporte, movilización,), solo permite trabajos en dos instituciones
con cargas laborales de 8 horas que copan nuestra capacidad física.
E

8
La carga asistencial los asfixia; cuando desean asistir a Jornadas de Actualización la
responsabilidad laboral no se los permite y la fatiga del turno de la noche anterior los
obnubila.
Estos especialistas atiborrados en grandes capitales se frustran; nada más peligroso que
especialistas fracasados, amargados y desconsolados que se han movilizado
descrestados por las “luces académicas” que aparentemente ofrecen las grandes
ciudades.
La primera tarea como institución continental es facilitar la distribución de los
especialistas en neurocirugía para que la densidad de nuestra especialidad no tiña
solamente la ubicación geográfica de las grandes ciudades.
Debemos llegar a las ciudades intermedias y como centro de pensamiento recomendar
a nuestros gobiernos actualizar los recursos físicos para que el Medico Neurocirujano en
esa región pueda solucionar el 90% de la patología que aqueja a esa comunidad. Esta es
la neurocirugía general y básica.
Así, podemos atender desde el tumor supratentorial, el aneurisma simple y la estenosis
cervical. El tumor petroclival, el aneurisma de la basilar y la escoliosis compleja deben
ser remitidos a centros altamente calificados en las ciudades, donde la experticia se
nutre de la frecuencia y los resultados de calidad compensan los altos costos.
¿Cuál es el médico neurocirujano que necesita Latinoamérica?
Detengámonos en el currículo; tengo la convicción que no hay un centro en América
Latina que reúna las condiciones ideales para formar el neurocirujano integral.
Necesitamos abolir las fronteras y fomentar los currículos flexibles para que el
neurocirujano en formación se beneficie de las grandes oportunidades que nuestro
continente ofrece.
Hay centros en todos los países fuertes en áreas específicas y si nosotros en un gesto de
madurez (dejemos ese prurito latino tonto: “me las se todas”) reconocemos sus
bondades, podemos ofrecer a nuestros residentes y neurocirujanos este escenario
autóctono de aprendizaje. Estos compensan el anhelo escondido de capacitación y
prevenimos así esa migración triste a las grandes ciudades donde la frustración empaña
la belleza del ejercicio de una elite privilegiada, como los neurocirujanos de un
continente, donde el 50% de sus habitantes están clasificados como pobres.
La pobreza no son los recursos materiales; la peor de las pobrezas es la indigencia
intelectual: la ignorancia.
Afligido vive el país con “pobres de bolsillo”; sin futuro la nación con “pobres de mente”
y sin sueños la patria con “pobres de corazón”.

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Aquí es donde la FLANC y sus sociedades federadas tienen que jugar el partido de su
vida. Estimular los procesos de capacitación independientemente de quién los
promueva, fomentar el desarrollo de más y mejores escenarios de formación. Apoyar
liderazgos proactivos y ayudar a los servicios débiles para que crezcan sanos y se
robustezcan. Llevar las experiencias exitosas para quienes se inician en estas actividades
no repitan los mismos errores y sobretodo tener como punto diana el neurocirujano de
provincia para que no se sienta distante de sus pares y pueda desde las regiones,
convertirse en agente de cambio que promueva la salud integral de sus conciudadanos.
Hacer fuerte a los débiles; debe ser el primer postulado en nuestros reglamentos y
convicciones.
Remberto Burgos de la Espriella

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Página del Presidente
Dr. Efrain Ernesto Herrera Magaña
Presidente Honorario FLANC.
La FLANC en el Contexto Mundial.
n el inicio del siglo XX las ciencias en general inician un crecimiento exponencial
en áreas como la Anatomía, la Fisiología y la Patología. Esto aunado al interés,
perseverancia y afán investigativo de muchos hombres, promueve el desarrollo
de muchas áreas como las Neurociencias. Indiscutiblemente el desarrollo
tecnológico que acompaña a esta época permitió que los limitados recursos fuesen cada
vez un menor impedimento para el desarrollo y crecimiento.
A nivel mundial hombres como Cushing, Egaz Moniz, Olivecrona, Asenjo y una selecta
lista de precursores de la Cirugía Neurológica abrieron las puertas para que se sentarán
las bases de lo que hoy conocemos como la Neurocirugía Moderna, la cual continúa
teniendo sus bases en aquellas investigaciones iniciales de la Anatomía, Fisiología y
Patología.
La epidemiologia de la patología Neuroquirúrgica ha ido cambiando de acuerdo a
diferentes variables, dentro de las cuales el desarrollo no solo tecnológico sino también
económico social que cada una de las regiones ha presentado ha influido definitivamente
en estos cambios. Es indiscutible que en países desarrollados como Estados Unidos,
Alemania, Japón, Francia o Inglaterra entre otros, las investigaciones y recursos
tecnológicos se orienten en primera fila a la patología oncológica o cerebro vascular y es
muy cierto que al igual que ellos en muchos países de América Latina dicha patología
ocupa una ubicación entre sus primeras causas de muerte tal como sucede en países
como Brasil, Argentina, México, Costa Rica o Cuba entre otras, y si revisamos en las
estadísticas nacionales de países que se encuentran en "vías de desarrollo" como la
región Centroamericana, encontraremos que también ocupan un sitial muy importante
dentro de sus estadísticas de morbimortalidad. Por eso es muy importante conocer el
aporte que estas Naciones nos ofrecen y poderlo brindar a nuestros pacientes. De allí la
importancia del intercambio de conocimientos y experiencias que la FLANC ofrece a
través de sus Congresos Latinoamericanos, cursos, becas a Neurocirujanos jóvenes o
E

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Residentes de Neurocirugía. La Revista de la FLANC es probablemente uno de los
elementos más valiosos con los que contamos para lograr ese intercambio regional de
experiencias que enriquecen nuestro Servicio a los Enfermos. La creación de los diferentes
Capítulos Académicos es sin duda una de las ideas de mayor valor, ya que de una forma
más definida se tiene la oportunidad de abordar diferentes temáticas, ya sea espinal,
trauma, Oncología, vascular entre otras.
Uno de los Capítulos que en mi opinión alcanza una relevancia muy especial en América
Latina, es el Capítulo de Neurocirugía Pediátrica.
Al revisar la Neuro epidemiologia Pediátrica, es muy fácil de apreciar la enorme brecha
existente (al hablar de patología congénita) entre los países desarrollados y los llamados
en vías de desarrollo. La presencia de una enorme estadística en patologías que se
acompañan de disrafismo espinal y/o hidrocefalia en países del África o de América
Latina al compararla con la de los países desarrollados, nos muestra (entre otras cosas)
del enorme problema socio económico que invade estas regiones y que acompañan a
nuestras poblaciones.
Hablar de Investigación en América Latina resulta usualmente muy poco alentador. Sin
embargo uno de los objetivos de la FLANC es promoverla y lograr a través de ella
propuestas que incidan en el bienestar de aquellos a quienes nos debemos.
Afortunadamente tenemos una organización académica activa y pujante. Cooperemos
con la FLANC para que la investigación, propuestas y ejecución de las mismas se hagan
realidad. América Latina tiene frente a sí, un enorme reto. Enfrentémoslo.

Masini Treatment of Thoracolumbar……
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Artículo Original
Tratamiento de la Columna Toracolumbar Fracturas y
Dislocaciones y su Influencia en el Proceso de Rehabilitación
Treatment of Thoracolumbar Spine Fractures and Dislocations
Its Influence on the Rehabilitation Process
Marcos Masini, MD, M. Sc., Ph. D
Faculdade de Medicina do Planalto Central – FAMEPLAC
Hospital Lago Sul, Brasília.
Instituto Quéops Millennium, Neuroscience and Neurosurgery, Brasília, Brazil.
ABSTRACT
The author conducts a retrospective analysis of 121 patients suffering from fracture
and/or dislocation of the thoracolumbar spine treated within the protocol and
undergoing surgery between 1988 and 1995, with long outpatient monitoring
treatment.
An operative protocol and subsequent rehabilitation program were utilized in all
patients. Ninety-five patients were men, in their third and fourth decades of life. Fifty-
seven patients presented injuries caused by traffic accidents: forty-one by falls and
twenty-three by local traumas. Eighty-eight bone injuries were located at the T11, T12
and L1 transition and 75 patients presented paraplegia upon hospital admission. All of
them were classified by Frankel/ASIA scale at admission, discharge and last outpatient
follow up. All patients underwent plain x-rays of the spine. Seventy-one examinations
were complemented with computerized tomography and 50 with magnetic resonance.
All of them received rectangle rods and segmental sublaminar wire fixation with bone
graft fusion. Eighty-five patients needed concomitant decompression of the spinal
canal due to associated neurological deficit.
Patients admitted with a complete neurological deficit had no improvement during
follow up, however 70 percent of patients with partial neurological injuries improved
at least one Frankel/ASIA grade by the end of follow up. Lumbar injuries improved the
neurological grade 5 times more than localized thoracic injuries. Antero-posterior
dislocations of the vertebral body were corrected in average from 37 to 16 percent,
lateral dislocations from 27 to 19 percent and anterior angulation from 21 to 12
degrees. The loss due to angulation in the 43 patients examined after discharge did not
affect the functional independence. Patients’ functional independence measure
improved from an average of 29 points at the admission to an average of 79 points
after about 60 days in rehabilitation. Functional rehabilitation results in final
measurement were poor, however, when related with brain injury. The shorter the

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time between the injury and admission, the shorter the hospital stay, rehabilitation
period, and the better the final independence measure and hospital efficiency ratio as
well. The timing between injury and the surgical procedure did not influence the final
neurological recovery of patients and those patients having immediate post injury
surgery, however had better rehabilitation grade, i.e., the shorter the timing between
injury and surgical procedure, the shorter the hospital stay. The timing between the
injury and the surgical procedure also influences the efficiency ratio, i.e., the shorter
the timing between injury and surgery, the better the evaluation of the hospital
efficiency. Also, the shorter the timing between the injury and the patient admission,
the shorter the hospital stay, the better the evaluation in the FIM scale and the better
the Efficiency Ratio. The time patients waited for surgery, already at the hospital, also
did not increase the stay. The only factor delaying spine surgery was concurrent with
patients presenting thoracic, abdominal and brain injury. Burst fractures, differently
from dislocation, were found to be prone to late re-angulation due to impairment in
the anterior support of the spine. However, this did not influence the final functional
independence measure and did not cause neurological deficit.
The surgical technique used to treat patients with fractures and/or dislocation of
thoracolumbar spine is efficient. Although most thoracolumbar spine injuries are
statistically treated as non–surgical, the timing to conduct surgery must consider the
total clinical condition of the patient at admission.
Thus, the surgical procedure is elective. This method aims for concomitant spinal cord
and root decompression and spinal arthrodesis fixation of the spine. Decompression of
spinal cord and root should be always considered when deficit and misalignment on
the spine canal is recognized. The spinal stabilization is immediate and there is no need
for postoperative external immobilization. This method alleviates the pain and
stabilizes the deformity, enabling to continue the rehabilitation program.
Complications are similar to the ones of other methods and are treatable. The safety,
simplicity and economy of this system justify it as an option in this treatment.
Keywords: Thoracolumbar Spine Fractures and Dislocations, Neurosurgery, Surgical
Treatment, Posterolateral Decompression, Rectangular Rods, Sublaminar Segmental
Wires, Bone Graft. Rehabilitation.
INTRODUCTION
The spinal cord injury is one of the most devastating diseases for individuals of
modern society, affecting mainly young healthy and economically active people,
causing great economic and social impact¹. Estimates point out to more than 10,000
cases of spinal cord injury per year in Brazil. Trauma is the predominant cause. The

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numbers are alarming, exceeding most of the statistics published relating to the
incidence of spinal cord injuries in several countries. The United States and Japan, for
example, show rates of 40 new cases per every million of inhabitants per year. In
Brazil, the average rate in 1997, was 71 new cases per million of inhabitants.
Southwest and Northeast regions showed, respectively, rates of 71 and 91 new cases
per million. Half of the patients suffer from thoracolumbar spinal injuries 2, 3.This is a
problem that grows with Brazil, requiring much attention in addition to education and
prevention campaigns, as well as more efficient rehabilitation of the surviving
population, currently calculated at more than 180 thousand individuals.
In recent decades, there has been great progress in treatment practices for patients
with spinal cord injuries, and clinical evaluation has been systematized. Radiological
diagnosis methods have improved and the knowledge of spinal biomechanics has
enabled better identification of instability. Rescuing methods have been improved as
well as the clinical treatment of spinal cord injuries themselves and their
complications. Several fixation systems for the unstable spine have been developed
and the rehabilitation process has been systematized. Prevention programs have been
focused on causal factors and even the profile of spinal cord injuries has changed in
recent years, with the increase in spinal injuries due to aggression and the higher
incidence in the elderly population.
The thoracolumbar spine injuries have been the theme for a number of publications,
however, there were only a few prospective protocol works with sufficient amounts of
cases and monitored long enough to enable a statistical analysis with the use of
Methylprednisolone (NASCIS 1, 2 and 3), Ganglioside (SYGEN), Fampridine (SR) and
Cellular Therapy (Macrofage Trial)4. Thus, almost all aspects of treatment are still
surrounded with controversy. Knowledge of the problem and its dimensions has
become important to the surgeon once these patients require a multidisciplinary
approach, specialized care and rehabilitation.
Discussing technicalities such as fixation and arthrodesis of the thoracolumbar spine is
a detail that encourages a deeper investigation of the magnitude of the issue. The
monitoring of patients over time may enable a new clinical and psychological approach
and find new possibilities and solutions.
Our study on the topic began in January 1980. In the first 16 years of that period, we
treated 1,090 patients with thoracolumbar spine fractures and dislocations.
Considering those patients, 605 (55.5 percent) presented neurological deficit, 308 (28
percent) underwent surgery and 224 (73 percent) of them were instrumented by
posterior approach. In temporal sequence, 53 (24 percent) were treated with
Harrington instrumentation, 50 (22 percent) with Harrington-Luque instrumentation
and 121 (54 percent) with rectangular instrumentation. The last 121 patients are the

15
focus of our study. The Pedicle Fixation system with Rods and their variants have been
used in patients after the period of time of this study.
PATIENTS AND METHOD
This study includes 121 patients
suffering from thoracolumbar spine
fractures and dislocations who were
surgically treated (DOVE)64, analyzed
in 100 different items and monitored
for an average period of five (5) years
after the surgical procedure. This is a
protocol study where the identification
of the 121 patients was conducted
through hospital record. The analysis
period was from January 1988 to
December 1995. All patients, with
thoracic and lumbar spine injuries,
most of them concentrated between T-
11 and L-3, such region defined as
thoracolumbar transition. Based on the
information collected from the
admission protocol and the medical
records, the following patient data
were analyzed: gender, age, origin,
cause of injury, related injuries, dates
of fracture, hospital admission, surgery,
discharge, and date of the last
appointment at the hospital (base of
analysis: December 1996), neurologic
deficit on hospital admission, discharge
and follow up appointment, grade of
injury, grade fixed, number of grades
fixed, rod type, size of the rod used,
blood loss, surgery time, use or non-use
of blood or derivatives, procedure
details, date of deambulation after the
procedure (Frankel/ASIA - D and E)5,7
and date of rehabilitation
commencement (Frankel/ASIA-A, B and
C)5,7, neurological level at hospital
admission and discharge and number of
follow-up days after discharge.
Other records or procedures conducted
included: complications before and
after the surgical procedure at the
rehabilitation hospital and later
occurrences after hospital discharge,
classification on the FIM (functional
independence measure of the patient)
scale on admission and discharge, date
of the admission radiological study,
postoperative control and late control
conducted at discharge or in
ambulatory at the time of the last
appointment. During radiological
studies the following aspects were
analyzed: angulation, anteroposterior
and laterolateral traslation, scoliosis;
date of the computerized tomography
and magnetic resonance, with analysis
of the degree of commitment of the
spinal canal, classification of fractures
and dislocations by the MARGERL and
GERTZBEIN (6) system,
electrophysiological examinations
conducted as Electromyoneurography
and Evoked Potentials, graft removal
site (whether from the site of the
surgery or the iliac), bone healing and
details of the aspect of the system
along the radiological monitoring
during the Rehabilitation Program.

16
STATISTICS
We divided the database statistical
analysis in vertical and horizontal. In
the vertical statistical analysis, we
grouped the data of the columns and
showed the analysis in Graphs. We
analyzed gender, age range, origin,
causes, level of neurological injury at
hospital admission, level of
neurological injury at discharge, deficit
in the Frankel/ASIA scale5, 7 on
hospital admission, at discharge and on
outpatient evaluation, location of
fracture or dislocation, x-rays,
classification of fractures and
dislocations according to MARGERL and
GERTZBEIN6, number of spine levels
fixed, size of the rod used, blood loss
and use or non-use of blood, average
time of surgery, details of the
procedure (decompression, iliac or site
graft, use of single, double or
multifilament wire), anteroposterior
dislocation on hospital admission and
discharge, lateral dislocation on
hospital admission and discharge,
lateral inclination on hospital admission
and discharge, correction and loss of
angulation and time between
radiological checks, days between
fracture and hospital admission, days
between hospital admission and
surgery, months between fracture and
hospital discharged after rehabilitation,
days between the surgery and
discharge, semesters between the
discharge and the last outpatient
evaluation and the FIM (Functional
Independence Measure) scale
classification on hospital admission and
discharge.
In the horizontal statistical analysis, we
used the following tests: statistical
treatment of data involving descriptive
and inferential analysis, Chi-square Test
and Fisher's Exact Test when necessary,
in order to analyze the significance of
relations among the distributions of
variables. The difference among the
groups was tested through Variance
Analysis, by using the Kruska-Wallis
Test as well. We also evaluated the
Rehabilitation Efficiency Ratio, which is
equivalent to the Functional
Independence Measure obtained at the
end of the rehabilitation program
divided by the Length of Stay in the
Program.

17
DECOMPRESSION AND FIXATION TECHNIQUE FOR SPINAL ARTHRODESIS used in
these patients
FIGURE 1 - Patient positioning. Scheme of the posterolateral approach of spine with
preservation of lamina for anterolateral fixation and decompression of the spinal canal. Set with
10 cm, 15 cm and 20 cm rods. Application of Hartshill Rectangle and direction for the first and
second twist of Chanrley wires.
Summary of Case 1 - Female patient, 28 years old, victim of running over six days before.
Clinical condition of paraplegia (Frankel/ASIA A). Dislocation and fracture between L-1 and L-2.
Submitted to decompression, reduction and fixation with rectangle between T-11 and L-3.
Arthrodesis with grafts taken from the site of the surgery.
FIGURE 2 – Magnetic Resonance and Computed FIGURE 3 – Radiography showing
Tomography showing misalignment and the fracture and dislocation between L-1 and
compression. L-2 and the reduction.

18
FIGURE 4 – Decompression of Spinal Canal FIGURE 5 – Result of Fixation
and fusion after through posterolateral, fixation with the Hartshill 10 years.
Rectangular Rod System with grafts
The tables below refer to a vertical
statistical analysis of results. We
observed that 95 patients (78.5
percent) were male and 26 (21.5
percent) were female (Graph 1). The
predominant age group was between
20 and 29 years, in a group of 48
patients, followed by 30 and 39 years,
with 36 patients (Graph 2), with a single
occurrence under 9 years old and two
above 60 years old. The most common
cause was traffic accident in 57
patients, followed by fall in 41 and
direct trauma in 23 (Graph 4).
The level of neurological injury at
hospital admission was in T-12 (44),
followed by T-11 (23) and L-1 in 21
cases. The other levels were affected in
a proportion of less than four. The
spinal level of fracture and/or
dislocation enables to find most of the
injuries in the dorsal lumbar transition
between T-10 and L-2. The most
frequent location of injury was T-12
with 74 patients, L-1 with 68, T-11 with
27 and L-2 with 14. As the injury often
involves two segments, the numbers
added exceed the 121 cases analyzed.
The study of the neurological level of
injury at discharge enabled an analysis
of the neurological deficit evolution of
patients (Graph 6). The neurologic
deficit evaluation in the Frankel/ASIA
scale at fracture (admission), placed 75
with total injury in A, 9 in B, 20 in C, 4 in
D and 13 in A (Graph 7). The
comparison of this evaluation with the
one at the discharge and later with the
follow up evaluation enabled the
analysis of the neurological deficit
evolution among the various severities
of injury (Graph 8).
Concerning the radiological evaluation,
all patients underwent plain x-rays.
Seventy-one examinations were
complemented with computerized
tomography and 50 with magnetic
resonance. According to the
MARGERL/GERTZBEIN (6) classification,
most patients had C-1 type fractures in
72 cases and A-3 in 63 cases (Graph
12). In the analysis of the number of

19
levels fixed with the surgical procedure,
we observed that 42 were fixed in 5
levels, 38 in 4, 30 in 6, 6 in 7 and 5 in 8,
and two patients had fractures in two
distant spine levels (Graph 13). The size
of the rod is proportionally related with
the number of levels fixed in most
cases: there were 55 rods of 15 cm, 50
rods of 10 cm, 15 rods of 20 cm and
only one rod of 5 cm, used in children
and made according to the size
required (Graph 14). The blood loss was
registered by volume. We noticed that
93 patients had losses of less than
1,000 ml, 85 of them did not received
postoperative transfusion, 36 patients
received transfusion in volume less or
equal to 1,000 ml of blood during the
postoperative period (Graph 15). The
average time of surgery ranged
between 1 hour and 3 hours in 87
patients with prevalence between 2
hours and 3 hours in 49 cases. In 98
patients, the decompression of spinal
canal was conducted as part of the
procedure. Patients with no
neurological deficit were excluded from
this technique (18 cases), as well as 5
other cases in which the compression
was not considered significant in the
radiological evaluation. In 62 cases, the
graft was taken from the iliac by
conventional technique and, in 59
cases, only from the site of the surgery,
including the spinous apophyses, part
of the blade, facet and vertebral body
removed at decompression and
preparation of fusion. In 71 patients,
we used double wires and, in 46
patients, the single wire was used. In
four patients, flexible multifilament
cables were used.
All cases were x-rayed during
outpatient evaluation. A new x-ray
study was conducted in 43 patients,
among the 93 patients who returned
for a new evaluation after hospital
discharge. In 93 of them, with anterior
dislocation of the vertebra, we
observed a correction from 37 percent
to 16 percent of the dislocation. In the
laterolateral dislocation, the reduction
was decreased on average from 27
percent to 19 percent. The lateral
inclination was corrected from 11 to 8
degrees. The correction and loss of
angulation were 21 degrees before the
procedure, 12 degrees immediately
after the procedure and again 21
degrees on the late evaluation that was
conducted, on average, 624 days after
the second evaluation. In 56 patients,
the time between the fracture and the
admission was, at most, 14 days, in 28
patients, 329 days and in 23 patients,
44 days.
Thirty-two procedures were conducted
until the 6th day after hospital
admission, 23 between 7 and 13 days
and 26 between 14 and 20 days of
hospital admission. We analyzed the
time between the fracture and
discharge. Among 100 patients with
apparent neurologic deficit, in 68, the
time between the surgery and the
beginning of physical therapy was less
than 14 days. For the other 32 patients,
the time was longer than the period of
14 days. For the 18 patients who could
deambulate, the average time of
discharge for deambulation was
between the 3rd and 5th postoperative
day, i.e., half of the cases. Sixty-one

20
patients with neurologic deficit were
rehabilitated within the 60
postoperative days and 94 patients
returned for evaluation appointment
and functional revaluation. The average
MIF Scale evaluation on admission was
29 and at discharge 79. Only patients
with brain-related injury had delays or
low final grade.
Twenty-one patients had traumatic
brain-related injury, and one of them
evolved to death due to late
intracerebral frontal hematoma.
Sixteen suffered distal fractures
(superior or inferior limbs), 7 had
abdominal injury, 3 with thoracic injury
and 2 with pelvic injury. Two patients
had fractures in two levels distant from
the thoracolumbar spine. The
complications identified before the
surgery that justified its postponement,
in addition to related traumas, such as
brain, thoracic and abdominal/pelvic
injuries were the following: urinary
tract infection in 32 patients, bedsores
in 20, venous thrombosis in 3 and
pneumonia in 1.
Occurrences identified after surgery
and related to the rod and the wires
were classified into early and late
occurrences: EARLY OCCURRENCES –
wrong level of the procedure in 1 case,
superficial infection in 2 cases that
received clinical treatment; suture
dehiscence in 2 cases, local hematoma,
despite the drain. in 2 cases, deep
infection in 2 cases, one of them
evolving to meningitis and death; LATE
OCCURRENCES - bulging on the site in 3
patients, rod exchange due to local
pain, with placement of more grafts in
2 cases, broken wire in 10 cases, 2 of
them with multifilament wire, broken
rod with no need of intervention, 1
case with previous angulation above 20
degrees, late removal of the rod for
conducting DREZ in 2 cases. Concerning
pain and spasticity, we observed that 2
patients had pain above the injury,
related to joint pain, 7 had pain at the
level of the injury and fracture site,
which was related to instability, causing
the evaluation of 2 cases in which the
rod was replaced by a larger one and
more bone graft was placed. Eight
patients complained of intense pain
below the injury, which resulted in
clinical treatment and, in 2 cases, in
conduction of DREZ. Two patients
underwent pithing, for exaggerated
spasticity with no drug control.
After the surgery, and during the period
of hospital stay, 9 patients had urinary
infection, 7 developed bedsores
(usually sacral or trochanteric
bedsores), 1 had pneumonia, 1 had
deep vein thrombosis and another one
had myositis ossificans. Several
urological complications were
identified during the outpatient follow-
up period: vesical calculi in 3 patients,
demanding surgery, hydronephrosis in
2 and stenosis of urethra in 1. Eight
patients reported penile erection
dysfunction, with indication of
prosthesis to one of them. Another
patient enrolled in the program of
fertilization and managed to be a
parent. Likewise, a paraplegic patient of
group became pregnant, with medical
monitoring, giving birth to a healthy
child.

21
Gender – 121 cases Age Group – 121 cases
Women Men < 9 10 to 19 20 to 29 30 to 39 40
to 49 50 to 59 > 60
Graph 1 Graph 2
Fracture Deficit
Causes – 121 cases Frankel/ASIA Scale – 121 cases
Traffic Accident Fall Direct Trauma
Graph 4 Graph 7
Deficit on Discharge Classification of fractures and dislocations
Frankel/ASIA Scale – 121 cases Margerl/Gertzbein – 121 cases
A B C D E Death
Graph 8 Graph 12

22
Number of Fixed Spine Levels – 121 cases Blood Loss (ml) – 121 cases
Graph 14 Graph 15
HORIZONTAL STATISTICAL ANALYSIS
Does the time between fracture and
surgery influence the final rehabilitation
process of patient at discharge? In Graph
33, we observe that patients who
underwent early surgery obtained a
higher number of points on the FIM
Scale at hospital discharge. This means
that they took more advantage of time
for their rehabilitation and, at discharge,
they were better trained to perform
their activities. We observed that the
average classification in the FIM Scale,
when analyzing patients who underwent
surgery up to 31 days before (45
patients), was 57.6, while in those who
underwent surgery more than 31 days
before (52 patients), was 52.8 (x²,
p=0.010), which shows the significance
of the difference. For this analysis, we
excluded patients with no neurological
deficit. We concluded that patients who
underwent early surgery obtain better
results in the rehabilitation program.
Does the time between the fracture and
the surgery influence the length of stay
of the patient in the hospital for
rehabilitation? In Graph 34, we noticed
that the later the surgery, the longer is
the length of stay of the patient in the
hospital environment. We compared
patients who underwent surgery up to
31 days before inclusively (45 patients),
and those who underwent surgery more
than 31 days before (59 patients),
concluding that the average stay was
71.2 days in the first group, and 83 days
in the second one. The difference was
significant (x², p<0.026), which
authorizes us to assert that: the shorter
the time between the fracture and the
surgery, the shorter is the length of
hospital stay. For this analysis, we
excluded the patients with no
neurological deficit.

23
Average of Gain in FIM scores grouped by length of time between fracture and surgery
Average of Gain in FIM Scores
DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 >100
Graph 33
Length of stay grouped by length of time between fracture and surgery
Length of Stay in Days
Graph 34
Does the time between fracture and
surgery influence the efficiency ratio
(Functional Efficiency Measure gain
divided by the length of hospital stay)? In
Graph 35, we observed that there is a
direct relationship between these two
factors: the shorter the time between
fracture and surgery, the better the
efficiency ratio evaluation. We noticed
that 43 patients were grouped as up to
31 days before inclusively, and 50
patients as more than 31 days before
surgery. The analysis was significant with
x², p<0.005).
Does the time between the fracture and
admission at rehabilitation hospital
influence on treatment and
rehabilitation program of the patient? In
Graph 36, we noticed that the longer the
time between the fracture and its
admission, the lower is its evaluation in
the FIM Scale at discharge. Graph 37
shows that patients admitted up to 10
days after the fracture feature shorter
hospital length of stay. This ascends
progressively between 11, 20 days, 21,
and 30, of the fracture, indicating that
the length of stay increases, reducing
gradually later. In Graph 38, the
efficiency ratio is high for patients
admitted less than 10 days after fracture
and decreases in the following groups.

24
By the Table 20, 30 patients were
admitted less than 10 days inclusively
and 63 more than 10 days. The
comparison of efficiency rations of these
two groups was significant (x², p<0.02),
confirming that the shorter the time
between fracture and patient admission,
the shorter is the length of stay and the
better the FIM Scale evaluation and the
efficiency ratio.
Efficiency Ratio (MIF Gain/Length of Stay) grouped by length of time between fracture and surgery
Efficiency Ratio
Graph 35
Average Gain in FIM scores grouped by length of time between fracture and surgery
Average Gain in FIM Scores
DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 > 60
Graph 36
Length of Stay grouped by length of time between fracture and surgery
Length of Stay in Days
Graph 37

25
Efficiency Ratio (FIM Gain/Length of Stay) grouped by length of time between fracture and surgery
Efficiency Ratio
DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 >60
Graph 38
Does the waiting time of the patients for
surgery, when they are already admitted
in the institution where they will
undergo rehabilitation after surgery,
influence the rehabilitation program?
According to Graph, 39 patients were
divided into groups of 5 days, from the
date of admission to surgery, noticing
that 55 patients underwent surgery
before the 15th day of admission.
(Consider the analysis of other trauma-
related spine injuries and preoperative
complications.) In Graph 40, we may
notice that the MIF Scale gain of hospital
discharge was equal for all groups. This
indicates that the patients who waited
for surgery inside the rehabilitation
institution were included in the
rehabilitation program and could be
rehabilitated, not wasting time, even
waiting for surgery. Notice that when
comparing those patients who
underwent surgery in less than 15 days
inclusively, to those who underwent
surgery more than 15 days later, there
was no significance (x², p<0.48).
However, the length of stay of these
patients was significantly increased, as
demonstrated by Graph 41, in which the
average of stay for patients who
underwent surgery in less than 15 days
of admission inclusively was 66 days,
while those who underwent surgery
more than 15 days later was 90.7 days,
being the efficiency ratio x², p<0.000.
According to Graph 42, the efficiency
ratio decreases with the increased length
of hospital stay. It is noticed that, when
comparing 47 patients who underwent
surgery with less than 15 days of hospital
admission inclusively and 46 patients
with more than 15 days, the difference in
the efficiency ratio was highly significant
(x², p<0.005). Patients waiting for
surgical procedures of spine inside a
rehabilitation institution do not waste
time and participate in the rehabilitation
program before and after the procedure.
As the procedure is delayed, for the
treatment of other trauma-related spine
injuries, the length of hospital stay
increases, thus reducing the efficiency
ratio. (Consider the analysis of other
spine trauma related injuries and
preoperative complications.)

26
Number of cases grouped by length of time between admission and surgery
Number of cases
DAYS up to 05 06 to 10 11 to 15 16 to 20 21 to 25 26 to 30 31 to 35 36 to 40 41 to 45 >45
Graph 39
Efficiency Ratio (FIM Gain/Length of Stay) grouped by length of time between admission and surgery
Efficiency Ratio
DAYS up to 05 06 to 10 11 to 15 16 to 20 21 to 25 26 to 30 31 to 35
Graph 42
May the time between the fracture and the surgery be influenced by the presence of
severe traumatic injuries of other segments? In Graph 43, a significant amount of
traumatic injuries of other segments is evident in patients admitted in the acute phase.
Influences are expected once the spinal fracture occurs in polytrauma patients. In Graph
44, patients who had and did not have other related injuries are compared.
Cranioencephalic, thoracic, abdominal, pelvic and segment injuries are included here. It
was evident that the average time between fracture and surgery in the group with
trauma in other related organs decreased from 51 days to 36 days in the group that did
not have other trauma-related injuries. The difference was significant, with p<0.05. The
trauma related to other regions decreases the indication for the surgical procedure for
thoracolumbar spine fracture.
Number of cases grouped by length of time between fracture and surgery, separated between those who
had or did not have other trauma-related injuries
Number of Cases
Graph 43

27
Number of cases grouped by length of time between fracture and surgery, separated among those
who had or did not have other trauma-related injuries
Number of Cases
DAYS up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 > 100
With trauma-related injuries No trauma-related injuries
Graph 44
Is the type of fracture/dislocation related to recurring angulation in late evaluation?
According to Graph 22, we notice the angulation on admission, after surgery and in the
outpatient appointment. The difference was not as significant when conducted in group,
while, in the paired analysis, the difference was significant between fractures A-2 and C-1
(p<0.05). The average of angulation loss of the fracture Type A-2 was 11 degrees and the
average of angulation loss of fracture Type C-1 was 24 degrees. This loss occurred with
the reangulation in 43 patients evaluated after discharge (third measurement) did not
reflect in the individual evaluation of their Functional Independence.
May the time between fracture and surgery be influenced by preoperative complications
such as urinary tract infection, bedsores and venous thrombosis? In Graph 45, we may
notice that, when comparing the groups with and without this type of complication, there
was no difference. The average time of indication for surgery in both groups was 41 days,
and there was no significant difference with p<0.42.
Angulation Correction and Loss – 43 cases (Degrees)
1st
Measurement 2nd
Measurement 3rd
Measurement
Graph 22

28
Number of cases grouped by length of time between fracture and surgery, separated among those
who had or did not have complications
Number of Cases
With complications (average time for surgery =41 days) No complications (average time for surgery + 41 days -
There is no significant difference between average times for surgery (“t” with p.<0.42)
Graph 45
DISCUSSION
CONSERVATIVE TREATMENT OF
THORACOLUMBAR
FRACTURE/DISLOCATION
The treatment of fracture/dislocation
aims to preserve the residual function of
the spinal cord and roots and maximize
their recovery. It also aims to restore and
preserve the alignment of spinal
structures, obtain a consolidation free of
pain and instability and prevent the
occurrence of late neurologic deficit due
to angulation, also enabling to mobilize
the patient as early as possible in order
to complement the rehabilitation. Within
these principles, there is a real debate
about whether the goals preconized may
be reached with the conservative
treatment or if there is the need for
additional surgical treatment. Treatment
with postural reduction and dynamic
immobilization has been defended by
several authors with great experience8.
Laminectomy is absolutely
contraindicated in these cases, due to
the fact that it increases instability and
deformity of the spine, with late
damages9. Bed rest is recommended for
6 to 8 weeks, with use of vest for 16
weeks10. Patients with blast injury and
no deficit, or with minor deficit, may be
treated without surgery11, 12. Below
there is an example of reabsorption of
bone projection within the spinal canal
after six months of injury, where the
patient was treated without surgery
(Summary of Case 4).
The fact that those patients that
associate severe traumas of other
organs, such as skull, thorax and
abdomen, may not be treated surgically
during hospital stay, even when there is
indication for surgery, draws attention in
our casuistry. In this group, we observed
extension in the period of rehabilitation.
Those who have severe brain related
injury could not participate in the
rehabilitation program actively,
undergoing only family practice. Patients
with severe thoracic and abdomen
injuries, which prevent the conduction of

29
a major surgical procedure, were treated
conservatively within the
GUTTMANN13´s principles. It was
evidenced that the complications, which
occurred within the hospital
environment, did not extended the
length of time of the rehabilitation
program.
Computer Tomography conducted
after the injury.
Computed Tomography conducted
six months after injury. There was
no surgery in this case.
Summary of Case 4 - Male patient, 18
years old, running over victim when
cycling. Evolved with lumbar pain
presenting discreet dorsiflexion deficit of
the left foot with hypoesthesia in S-1. No
sphincter disorder. The computer
tomography at admission showed the
burst of L-1 with bone projection within
the canal that was treated. The
examination repeated six months after
the accident showed absorption of
anterior bone beam and progressive
remodeling of the spinal canal.
INDICATION FOR SURGERY
The indication for surgery in the spinal
cord injury has caused intense debates.
Several experimental models have been
developed over the years in an attempt
to clarify the issue. These models provide
rapid compression through bone
displacement, traction, torsion,
laceration and section, and also test the
elasticity by causing a small spinal
tension. Other models questioned the
application of compressive forces, the
kinetic energy involved, the
displacement and impulse. The results
were basically two classical models of
spinal cord injury: a dynamic model and
a static model. The dynamic model is
usually caused by rapid compression,
weight fall, application of clip or
extradural balloon. The static model uses
slow compression and constant speed,
usually caused by weight or extradural
balloon inflated slowly.
Studies such as the one by TARLOV and
KLINGER (17) used an extradural balloon
located in the lumbar region to compress
the cauda equina of dogs, causing partial
compression by 5 minutes, obtaining
recovery of neurologic deficit in 60
minutes after cessation of the
experiment. The studies by DOLAN and
TATOR (14), in addition to the one by
GUHA and TATOR (15), placed a
compression clip in the level of the first
thoracic vertebrae. Weights of 2.3g and
178g were used for 3 to 240 minutes.
The process concluded that the intensity

30
of the force applied and the compression
time on the injuries considered light
(between 2.3 and 16.9g) were important
factors for the recovery of neurologic
deficit. In experiments by NYSTROM and
BERGLUND (16), in which weights of 20,
35 and 50g were applied on the thoracic
spinal cord of rats, for 1 to 19 minutes, it
was observed that the time length was
not significant with 20g, but with weights
of 35 and 50g the recovery varied with
the time length of compression. TARLOV
and KLINGER (17) proved that recovery
varied depending on the force applied
(size of the balloon) and the compression
speed (minutes or hours).
In summary, the dynamic experimental
studies proved that the force of the
injury is the main determining factor of
the neurological deficit and the length of
time may be significant for weights
considered “light”. In addition, we
should add that in static models, the
length of time of the compression was
also significant, however, the relevance
to the acute spinal cord injury is
questionable, once it is difficult to
extrapolate it to the injury in humans.
The conclusion that the neurologic
deficit is defined by the initial trauma
generated two different lines of
indication for surgery in spinal cord
injury.
Not submitting patients to surgery is a
position defended until these days by the
British School12, which initially
condemned the laminectomy in the
acute phase, whose poor outcomes were
related to greater instability. According
to Guttmann, there is no indication for
surgery, once the injury occurs at the
moment of the impact and the
decompression of medulla has no effect
on recovery. Guttmann considered, in
the occasion, that the operative
morbidity and mortality superseded the
possible benefits. Guttmann blocked,
somehow, the development of surgical
treatment with that excellent effects
obtained through the rehabilitation of
patients13. Opposing to the experience,
there is indication for early surgery,
internal fixation and immediate
rehabilitation, positioning defended by
the American and European Continent
Schools, initially influenced by
experimental studies of ALLEN BOHLLER
(62), who planned the treatment of
spinal cord injury by posterior pithing for
drainage of the hematoma. At an early
stage, Allen abandoned the research that
already tended to demonstrate the
existence of secondary injury and, thus,
provided no guidance to those who, at
the time, based on his initial studies,
indicated the surgical treatment as an
option. Over time, the two lines
developed in different directions: the
first one, with rehabilitation techniques
and postural treatment of fractures and
the second one, questioning the
existence of the secondary spinal cord
injury and the best moment to submit
the patient to surgery, whether at an
early or late stage.
The latest experimental and clinical
research suggests that the
decompression in spinal cord injury may
improve neurological recovery,
demonstrating that time is a factor of
paramount importance. DELAMARTER
(18) applied a 50 percent compression

31
on the spine of the dog for a period of
one week. The recovery was observed in
those uncompressed within the first
hour. Recovery is the reverse of the
compressive force applied. It is difficult
to transfer the data to the human beings.
The force applied cannot be evaluated.
We do not know if only traction is
enough to align the canal, or whether we
should conduct the total decompression
of the canal to obtain the result desired.
JOHNSSON (19) monitored 17 patients
with decompression and stabilization of
the thoracolumbar spine. The measure
of the canal area postoperatively was 71
percent of normal, with an 86 percent
improvement in monitoring. A similar
finding was reported by LEVINE (20).
However, WILLEN (21), in a study of the
natural history of burst fracture between
T-12/L-1, described that bone fragments
that occupied more than 50 percent of
the canal were not reabsorbed and,
therefore, remained reducing and
compressing the spinal cord and roots.
WATERS (23) indicates that the recovery
is more pronounced in the first 6 months
after the injury. Twelve and 24 months
after the injury, however, little
improvement occurs. These are studies
based on the American Spinal Injury
Association6 standards and according to
serial evaluation and a manual of the
muscles chosen. Myometrial surveys
seem to demonstrate continuous
recovery after 1 year of injury. In
quadriplegics, the possibility of
functional recovery decreases with the
increased distance below the level of
injury. GRAZIANI (23) found 70 percent
of recovery on the level below the injury,
only 12 percent in the second level
below the injury and 0 percent at the
third level below the injury in
quadriplegics. Muscles with partial injury
recover better than those with total
injury, in a ratio of 90 percent versus 43
percent.
BRACKEN (24) NASCIS II information
concluded that 6.7 percent of the
patients admitted with total injuries
became incomplete injuries. From those,
only ¼ could recover the motor function.
In contrast, 37 percent of the patients
admitted into Frankel B improved. Half
of them recovered some function. Fifty-
three percent of patients admitted into
Frankel C improved to a functional level.
Young patients were more successful in
the recovery than elderly patients.
There are no randomized studies in
human beings on the effects of
decompression in neurological recovery.
Publications on the subject are a mere
collection of articles relating to
contemporary or historical control
groups, or even reports on cases with no
control groups. KIWERSKI (25) examined
1,761 patients, 798 of whom did not
undergo surgery. He reported that the
groups were not similar: 20 percent of
mortality in the group of patients who
did not undergo surgery, with 8.6
percent in the group who underwent
surgery. On complete injury, the
mortality was 36 percent in the group of
patients who did not undergo surgery,
against 19 percent in the group who
underwent surgery. The hospital stay
was 27 weeks for the group of patients
who did not undergo surgery and 17 for
the group who underwent surgery. The

32
average length of stay in both groups
was 9 to 12 weeks. It is worth
mentioning that surgery is delayed for
those with severe related-injury or
complications resulting from traumatic
injuries of other organs. BRUNETTE (26)
showed that the traumatic cervical
dislocation reduced by traction
immediately after the injury and
appropriate radiological control may
result in significant neurological
recovery. WEINSHEL (27) evaluated a
comparative study between groups of
patients only with arthrodesis and
fixation and another one related
decompression, not noticing substantial
difference. BOSE29 analyzed patients
with center cervical spinal syndrome and
obtained sensitive improvement in the
group who underwent surgery within the
20 initial days after the injury.
KRENGEL29 evaluated decompression in
incomplete thoracic paraplegia. The
recovery obtained greater success in
patients of the historical control group,
with 68 percent of recovery in
uncompressed and fixated patients, with
a 44 percent drop in those who
underwent only the fusion. HU30
evaluated the effect of decompression in
incomplete lumbar injuries. The average
improvement in the ASIA Scale for motor
deficit was 10 points. Those patients who
had fusion with no decompression
improved 4.2 points (p>0.05), achieving
significant statistical difference.
Evidence from the literature that
confirms decompression as efficient in
the SCI (spinal cord injury) is present in
studies of Level III, IV or V (C degree).
The same recommendation is made for
the removal of fragments of the canal.
There are also two level-III studies that
did not demonstrate benefits at
decompression and removal of
fragments.
Within the protocol we used, all the
patients underwent to surgery by using
the same technique with decompression,
fixation and arthrodesis. We were able
to observe, however, that patients with
total injury kept their injury
(Frankel/ASIA = A), while those with
partial injury tended to improve. This
improvement was more evident in those
patients with injury below or including
the level of L1. We observe in Table 26-A
that 85 percent of patients in C tend to
migrate to D and E and that 55 percent
of the patients classified in B tend to
migrate to C or D. On final evaluation
(Table 26-B), 70 percent of the patients
migrated at least one level on the
Frankel/ASIA Scale.

33
Chart 26-A
Comparative study on the evolution of patients according to the neurologic deficit at
admission and discharge
Discharge A B C D E
Admission 72 05 07 20 15
A 75
2 deaths
1B
B 09
+1 A
-5 B
C 20
+4 B – 2 E
17 C
D 04
+1 B
+15 C
E 13 +2 C
Outcome – There was migration of 55 percent of the cases from B to C and D and 85 percent from
C to D and E.
Chart 26-B
Comparative study on the evolution of patients according to the neurologic deficit at admission and
outpatient evaluation
Discharge A B C D E
Admission 56 03 04 17 14
A 72 0
B 05 -1 B
C 07 -2 C
D 20 -3 D +2 C
+1 B
E 15 +3 D

34
WHEN SURGERY IS RECOMMENDED
During the surgical study, the question of
when surgery is recommended is not
resolved. The use of a new classification
of the types of fractures, as in the item
above that deals with the indication for
(early or late) surgery, does not answer
this question either. We observed the
existence of experimental studies that
favor early surgery: TARLOV (13), DOLAN
and TATOR (14), GUHA and TATOR (34)
and also studies with clinical evidence
that any recovery occurs when the injury
occurred more than 24 hours before. The
question is: what about those between 1
and 23 hours? There is also no definitive
evidence for or against early surgery.
None of the two schools could refute
injury evidence. It is present in
experimental models characterized as:
late injury in the white and grey spinal
matter, glutamate-related calcium-
mediated injury, free radicals (lipid
peroxidation) and ischemic injury. There
is also, in the literature, clinical evidence
supporting surgery. MAIMAN (33)
evaluated 20 patients with
thoracolumbar injuries that had late
decompression through lateral cavity
and noticed that 17 patients improved.
WEINSHEL (27) examined 90 patients
with cervical spinal cord injury, classified
in Frankel A and B and noticed that 47 of
them recovered the root function below
the injury and 14 have recovered the
spinal function also below the injury. We
have to consider that, in thoracolumbar
transition (most frequent location of
these fractures), the injuries are a
mixture of spinal cord and root injuries
that have different clinical behaviors.
There is also clinical evidence in the
literature that does not support the
surgery as the study by TATOR (34),
which examined 208 patients with spinal
cord injury and cauda equina, 116 (56
percent) of which underwent surgery
with mortality of 6.1 percent, compared
to 15.2 percent of patients who did not
undergo surgery, being deep vein
thrombosis the most frequent problem.
Comparing the groups, there is no
evidence of neurological recovery.
FRANKEL (5) analyzed 612 patients with
closed spinal cord injury. All were
treated with postural reduction and only
4 needed surgery for spinal instability,
which occurred lately. In this group,
there were 2 percent of neurological
worsening in patients during treatment.
MARSHALL (35) conducted a prospective
study with 283 patients with spinal cord
injury, noticing patients worsening
related to early surgery. WILLEN (8)
stated there was no difference in the
result whether the patient undergoes
early or late surgery.
Studies with clinical evidence supporting
surgery: DUH (36) studies 187 patients
with spinal cord injury, based on data
from NASCIS II, being 56 through anterior
approach, 247 through posterior
approach and 38 patients with injuries
that occurred less than 25 hours before
and improvement of 17.8 percent,
compared to the group which did not
undergo surgery, in which there was 13.8
percent improvement. In this study, 105
patients underwent surgery more than
200 hours after injury, from which 16.4
percent improved. The author concluded

35
that the surgery is beneficial, regardless
of the time of its conduction.
There were differences in the analysis of
the surgery effects, including misdeeds
and even mortality. For WIMOT and
HALL (37) and TATOR (34), surgery
increases the complications. Both
MARSHALL (36), who evaluated surgeries
that occurred less than 5 days after
injury, and LEVI38, who analyzed
surgeries that occurred less than 24
hours after injury, adopt the same point
of view. The study by WILBERGER (63)
analyzes a group who underwent surgery
less than 24 hours after injury, admitting
that early surgery causes fewer
complications.
The conclusions that may be obtained
from these studies are that laboratory
tests enable the assurance that
decompression may have positive
aspects, however, they raise doubts as
regards the moment to conduct such
procedure. The positioning of
GUTTMANN (12) concerning
laminectomy was indeed valid, however,
it was not consistent with the current
methods of spine fixation. Those are
techniques that may be performed
safely, in specialized centers, at any time
of the occurrence of spinal cord injury.
Several small series of cases studied
suggest the benefit of surgical
decompression, however, in contrast,
three major series, such as MARSHALL
(35), TATOR (34) and DUH (36) failed to
demonstrate the beneficial aspects.
Over time, there have been
modifications of the process. HEIDEN
(40), for example, proved that patients
with spinal injuries who underwent
surgery in the first week after injury had
46 percent of complications and for
those who underwent surgery after
more than 1 week, the ratio dropped to
27 percent. MARSHALL (35) found 15
percent of neurological deterioration in
patients who underwent surgery less
than 5 days after injury. After this period,
there was no deterioration. This allows
us to assume that the evolution of the
secondary injury, in some patients, may
be confused or aggravated by surgical
procedure, considered an additional
injury in polytrauma patients. By
analyzing the thoracolumbar region
fractures, the Sociedade para Estudo da
Escoliose (1992) showed 25 percent of
complications in patients who
underwent surgery and 3 percent in
those who did not undergo surgery.
DICKSON (41) evaluated 49 patients with
thoracolumbar fractures and found the
same recovery in a period between 8 and
35 days among those who underwent
surgery less than 24 hours after injury.
BENZEL (42) conducted anterior
decompression in patients with more
than 19 days after injury, not having
found relation between recovery and the
moment of the surgery. CLOHISY (43)
monitored 20 patients with anterior
decompression and compared half of
them with decompression in less than 48
hours to the other half with an average
of 60 days after the injury. In this series,
patients with early decompression had
better neurological recovery in
comparison to those with late
decompression.

36
BRUNETTE (26) has an interesting work
that studies bilateral dislocation of facets
and its reduction time with neurological
recovery. The procedure relates the early
surgical treatment with recovery. It is
also possible to construe that the
reduction of a bilateral dislocation of
facets at cervical level withdraws the
continuous traction and compression
factor of the spin cord, preventing
aggravation of the secondary injury. The
analysis detailed at NASCIS II25 shows
that from the 487 patients included in
the study, only 295 underwent surgery.
From those, 38 underwent surgical
treatment less than 25 hours after injury
and 105 more than 200 hours after
injury. In our study, we concluded that
surgery does not increase the risk of
neurological worsening. The
complications and hospital stay are
reduced, however the effect about the
neurological deficit recovery is
inconclusive.
Even among those who believe that
surgery may improve the patient with
spinal cord injury, there is some
disagreement about the ideal moment to
conduct it. WAGNER (44) is contrary to
early surgery and MARSHALL (35)
believes it may worsen the condition of
the patient. Apologists of that modality
of surgery bet on canal decompression
and spinal immobilization as factors that
enable early mobilization, thus avoiding
prolonged bed rest with neurological
improvement and early physiotherapy.
MARSHALL (35) indicates caution, once
in a multicenter study with 283 patients,
from 134 patients who underwent
surgery, 4 had the condition deteriorated
after the procedure. They underwent
surgery within the first 5 days after
injury. HEIDEN (40) observed that those
who underwent surgery in the first week
had a higher number of pulmonary
complications than those who
underwent late surgery. Improvement
was found in 1.5 to 5 percent of the
cases of those who underwent surgery,
however the time of surgery was not
analyzed. ANDERSON and BOHLMAN
(32) recommend late decompression in
cervical injuries. Forty-nine percent of
the 51 patients who underwent surgery
between 1 month and 8 years of injury
improved at least one neurological level.
KATOH and MASRI (45) evaluated 53
patients with complete cervical spinal
cord injury that were treated
conventionally and from the 40 patients
monitored for 12 months, 19 recovered.
AEBI46 evaluated 100 patients with
cervical injury and concluded that 1/3 of
them improved neurologically and 75
percent had fractures that were reduced
either manually or surgically up to 6
hours after injuries. LEVI38 examined
103 patients treated with anterior
decompression retrospectively and no
difference was observed in the
neurological recovery of the patients
who underwent surgery within 24 hours
after surgery and those who underwent
to surgery after more than 24 hours.
The literature presents a mixture of
studies of level III and V, conflicting with
each other. Based on the evaluation of
the surgical indications by DONOVAN
(47), the idea that surgery improves the
neurological outcome could not be
confirmed, however, the evidence is not

37
as strong to the point of invalidating his
indication. In selected patients, where
there is spine cord and roots to be
preserved, early decompression seems
to have a theoretical potential for
improvement. It is not a riskless surgery.
The patient may occasionally
deteriorate. In order to solve the
question, more detailed studies are
necessary. Thus, the moment of surgery
is still controversial, requiring a
randomized study for further
clarification, including finding out
whether the surgery is beneficial or not
in the treatment of secondary injury.
Even in the face of those facts, several
authors are in favor of early surgery,
aiming at neurological improvement with
spine stabilization and reduction of
complications related to prolonged
immobilization in bed and early
commencement of the patient
rehabilitation, with resultant cost
reduction. Those are refutable
arguments, depending on the condition
of service for the patient. In our study,
we admitted most of the patients within
the first two weeks after injury, and also
most of them undergo surgery in the
following week. The time of surgery
depends on the severity of the trauma-
related injuries. In a service aimed at
rehabilitation, there seems to be no
increase in the rehabilitation time of the
patients that wait for surgery. This is our
experience. Such conclusion is curious,
once it shows that the ones who defend
early surgery in emergency are
somewhat correct. They aim, with this,
to reduce the waiting time of the patient
to be transferred to the rehabilitation
center. On the other hand, the clinician
responsible for patients is convinced
that, with or without surgery, the
moment of the procedure does not
change the length of hospital stay and
the end result of rehabilitation. Thus, we
may be in favor of both sides in a
recurrent discussion among experts. If
the service should indicate the patient
for rehabilitation in another department,
and this transfer depends on the spine
being stabilized or not, then the waiting
time may influence the increased total
time of hospital stay. In rare and
exceptional cases, there is indication for
emergency surgery in open dura mater
injuries, progressing neurologic deficit
caused by misalignment, great
angulation or progressive angulation and
pain related with severe spinal
instability.
With reference to the conduction of the
surgery, there is disagreement in the
literature. In patients with multiple
injuries, there are authors who tend to
conduct emergency surgery, once we
know, in the early hours after injury, that
the patient has more favorable
conditions, which we call Window of
Opportunity. This window occurs before
the development of systemic
complications. Patients with spinal cord
injury, particularly those with thoracic,
abdominal or high lesion, often develop
respiratory complications (atelectasis
and pneumonia) in the hours following
spinal injury, which makes immediate
surgery inconvenient. BRACKEN (24)
demonstrated the beneficial effect of
using Methylprednisolone in the early
hours after injury and was criticized and
discredited subsequently. YOUNG and

38
BRACKEN (48) defend the idea that the
same therapeutic window should be
used for surgery, to improve the
prognosis of spinal cord injury recovery.
The argument would be the observation
of improvement in microcirculation and
axonal compression. Therefore, the
purpose of emergency surgery has the
following advantages: 1- it would avoid
systemic complications, stabilizing the
spine at an early stage; 2- it would
restore normal anatomophysiological
conditions at the site of injury and early
would enable the early transfer of the
patient to the place of rehabilitation.
WHICH APPROACH SHOULD BE USED
FOR SURGERY – Before the various
alternatives, posterior instrumentation
and fusion related to decompression
were selected for treatment of injuries,
especially when the surgical approach
occurs later than the 5th day after injury
(which is more frequent in this casuistry),
when only the alignment of the spine
does not enable the expansion of the
canal. There are several alternatives
regarding the surgical route to be used in
the treatment of thoracolumbar
transition fractures: anterior
decompression and instrumentation;
posterior decompression and
instrumentation and those methods
combined. The most acceptable option is
controversial. Mc AFEE and BOHLMAN
(49) concluded that, with the anterior
decompression of thoracolumbar spine,
there was improvement of one level in
the Frankel Scale in 88 percent of
patients with incomplete neurological
injury. KANEDA (50) obtained, through
the same anterior route, an
improvement of one level in 70 percent
of patients. DICKSON and HARRINGTON
(51) obtained improvement of level in
the Frankel Scale in 75 percent of
patients who underwent surgery by
posterior approach. HARDAKER52
conducted bilateral pedicle trans
decompression and instrumented with
Harrington rods, obtaining improvement
of one level in 85 percent of cases.
EDWARDS (53) instrumented through
posterior approach and all of his patients
had neurological improvement. ESSES54
conducted a prospective study and
compared two groups, with no
difference between the anterior and
posterior approaches. GERTZBEIN (55)
did not notice statistical difference and
88 percent of patients who underwent
surgery through anterior approach
improved one level in the Frankel Scale,
while 83 percent of those who
underwent surgery through posterior
approach also improved one level. In our
study, we observed that 50 percent of
patients with partial deficit (Frankel/ASIA
B/C/D) migrated at least one level in the
clinical evaluation at discharge. Among
46 patients, 23 improved. In the
evaluation appointment after surgery,
other 6 patients of this group showed
upward migration in one level, increasing
the improvement ratio to 70 percent.
SHAFFREY and DANISA56 conducted a
prospective study with 130 patients,
from whom 49 underwent surgery, 27
through posterior approach, 16 through
anterior approach, and 6 through the
two routes. Among the items compared,
the blood loss, the hospital stay, the cost
of the procedure and the time of surgery
were higher in the anterior approach.

39
However, the correction of kyphosis and
the neurological improvement were not
significantly different among the groups.
In the posterolateral approach through
facetectomy, the fenestration enables
the removal of anterior bony projections
and disc material often herniated to the
inner part of the spinal canal. The
fixation system consisting of a rectangle
and sublaminar wires enables a rigid
construction, which provides fixation and
consolidation of arthrodesis. DOVE (64)
should include abundant amount of bone
graft on the entire region fixed and not
on the level fractured. This leads to a
lower stress on the system, reducing the
indication for late surgery to withdraw
the system due to fatigue or rupture. In
patients with persistent compression of
the spinal canal and with no
improvement of the neurological deficit
as expected, the anterolateral approach
in a second moment may be chosen. If
fusion through posterior approach has
already occurred, there is no need for
instrumentation, and only for
decompression with bone graft.
WHICH APPROACH SHOULD BE USED
FOR SURGERY
Before the various alternatives,
posterior instrumentation and fusion
related to decompression were selected
for treatment of injuries, especially when
the surgical approach occurs later than
the 5th day after injury (which is more
frequent in this casuistry), when only the
alignment of the spine does not enable
the expansion of the canal. There are
several alternatives regarding the
surgical route to be used in the
treatment of thoracolumbar transition
fractures: anterior decompression and
instrumentation; posterior
decompression and instrumentation and
those methods combined. The most
acceptable option is controversial. Mc
AFEE and BOHLMAN (49) concluded that,
with the anterior decompression of
thoracolumbar spine, there was
improvement of one level in the Frankel
Scale in 88 percent of patients with
incomplete neurological injury.
KANEDA50 obtained, through the same
anterior route, an improvement of one
level in 70 percent of patients. DICKSON
and HARRINGTON (51) obtained
improvement of level in the Frankel Scale
in 75 percent of patients who underwent
surgery by posterior approach.
HARDAKER52 conducted bilateral pedicle
trans decompression and instrumented
with Harrington rods, obtaining
improvement of one level in 85 percent
of cases. EDWARDS (53) instrumented
through posterior approach and all of his
patients had neurological improvement.
ESSES54 conducted a prospective study
and compared two groups, with no
difference between the anterior and
posterior approaches. GERTZBEIN (55)
did not notice statistical difference and
88 percent of patients who underwent
surgery through anterior approach
improved one level in the Frankel Scale,
while 83 percent of those who
underwent surgery through posterior
approach also improved one level. In our
study, we observed that 50 percent of
patients with partial deficit (Frankel/ASIA
B/C/D) migrated at least one level in the
clinical evaluation at discharge. Among

40
46 patients, 23 improved. In the e
valuation appointment after surgery,
other 6 patients of this group showed
upward migration in one posterior
approach, 16 through anterior approach,
and 6 through the two routes. Among
the items compared, the blood loss, the
hospital stay, the cost of the procedure
and the time of surgery were higher in
the anterior approach. However, the
correction of kyphosis and the
neurological improvement were not
significantly different among the groups.
In the posterolateral approach through
facetectomy, the fenestration enables
the removal of anterior bony projections
and disc material often herniated to the
inner part of the spinal canal. The
fixation system consisting of a rectangle
and sublaminar wires enables a rigid
construction, which provides fixation and
consolidation of arthrodesis. DOVE (64)
should include abundant amount of bone
graft on the entire region fixed and not
on the level fractured. This leads to a
lower stress on the system, reducing the
indication for late surgery to withdraw
the system due to fatigue or rupture. In
patients with persistent compression of
the spinal canal and with no
improvement of the neurological deficit
as expected, the anterolateral approach
in a second moment may be chosen. If
fusion through posterior approach has
already occurred, there is no need for
instrumentation, and only for
decompression with bone graft.
COMPLICATIONS
In the posterior and posterolateral
approach, there may be dural injury in
the preparation or placement of the
instruments and, whenever possible, it
should be repaired. The placement of
instrumental may compress the spinal
cord and/or roots, accentuating deficit
and pain. Adequate training for the use
of instrumentation and the preoperative
use of the evoked, and motor and
sensory potentials may be useful for the
prevention of this type of complication.
There may be bad reduction,
hypertraction, hyperextension or
rotation. We indicate the conduction of
radiological control during surgery. The
procedure is conducted with the
prophylactic use of antibiotics. The
patient preparation is important as well
as special attention to skin conditions in
the preoperative stage. Infection may
mean the withdrawal of the instruments,
which should be postponed to the
maximum, i.e. until spinal fusion. Major
bleeding is possible during the
procedure. It is a complication that must
and may be avoided by careful
dissection, ligation or protection of
vessels. The use of drains in the surgical
area and a routine, one drain in the
surgery site and another one in the side
of graft donation, when applicable.
In the anterior portion approach, there
may be a number of problems: injuries of
abdominal and thoracic organs, due to
proximity to the spine, bleeding by
laceration of the inferior vena cava,
aorta or smaller arteries, neurological
injury and liquoric fistula, in addition to
infectious complications, with formation
of pseudarthrosis. Special attention

41
should be given to dissection plans and
hemostasis. The great vessels should be
dissected, deviated or connected before
being sectioned.
Occasionally, there may be other distant
complications, as in the pneumothorax
due to trauma-related fracture of ribs,
pulmonary embolism and urinary
infection. Late complications may
happen with the disruption of the system
used for fixation, due to bending
strength. The postoperative pain may be
due to the deafferentation, when a few
patients may require the conduction of
DREZ (coagulation of posterior root
entry). This means later approach, with
removal of the entire system and
conduction of a broader laminectomy.
Such a procedure, if possible, should be
conducted later, after the occurrence of
the anterior fusion, once this may lead to
instability.
CONCLUSIONS
Patients with severe neurologic deficit
related to unstable thoracolumbar spine
injuries are potential candidates for
surgical procedures.
The moment to conduct the surgical
procedure should respect all clinical
conditions of the patient. Individuals
with injury related with skull, thorax and
abdomen should have their surgery
scheduled for the moment the general
condition is clinically balanced. The time
waiting for surgery does not influence
the outcome with regard to neurological
recovery and rehabilitation as
demonstrated in this study. It only
extends the length of hospital stay and
reduces the hospital efficiency ratio
which is a function based on the
rehabilitation time.
The method to be used should enable
the concomitant decompression of
neural elements with spinal fixation and
arthrodesis. The decompression of
neural elements should be considered
whenever there is deficit and/or
misalignment of the spinal canal. The
fact that lumbar injuries show recovery
potential five times higher than when
compared with thoracic and cervical
injuries justify this approach, since those
are mixed spinal root injuries.
The surgical stabilization of the spine
occurs immediately. The method relieves
pain and stabilizes the deformity,
enabling the complementation of the
rehabilitation program. Late evaluation
enabled to detect that patients admitted
with great dislocations and treated by
using this method evolve with
reangulation at the level of the injury
and it does not influence the final
outcome of treatment and rehabilitation.
Preoperative clinical complications did
not change the rehabilitation program of
the patient, but influenced in deciding
when to indicate the surgical procedure.
The postoperative complications are
similar to those of other methods, and
are treatable.
Safety, simplicity and economy are
factors that contribute to surgeons
continue using this method to treat
thoracolumbar spine fractures and/or
dislocations.

42
REFERENCES
1. Valli, D.; Fernandes, A.; Silva, M.; Key, F.;
Leopoldo e Silva, F.; Esteves, J. C.;
Milagres, A. C.; Walter, J.; Souza, A.;
Haddad, L.; Mudo, L. M.: Avaliação
epidemiológica dos pacientes com
traumatismo raquimedular operados no
Hospital Estadual "Professor Carlos da
Silva Lacaz". Coluna/Columna. 2010;
8(3):58-61.
2. Masini, M.: An Estimation of Incidence and
Prevalence of Spinal Cord Injury in Brazil.
J. Bras. Neurosurg. 12(2):97-100, 2001.
3. Botelho, R. V.; Fontoura, E. A. F.; Masini,
M.: Brazilian Epidemiology of Spine and
Spinal Cord Injury, Chapter 6 in
Epidemiology of Spinal Cord Injuries
Book. Editors: V. Rahimi-Movaghar; S. B.
Jazayeri at all, Nova Ciência Publishing
House, 2012.
4. Lammertse, D. P.: Clinical trials in spinal
cord injury: lessons learned on the path to
traslation. The 2011 International Spinal
Cord Society. Sir Ludwing Guttmann
Lecture. Spinal Cord. 2013; 51(1):2-9.
5. Frankel, H. L.; Hancock, D. O.; Hyslop, G.;
Melzak, J.; Michaelis, L. S.; Ungar, G. H.;
Vernon, J. D.; Walsh, J. J.: The value of
postural reduction in the initial
management of closed injuries of the
spine with paraplegia and tetraplegia. I.
Paraplegia, 7:179-92, 1969.
6. Magerl, F.; Harms, J.; Gertzbein, S. D.: A
new classification of spinal fractures.
Presented at the Société Internationale
Orthopedie et Traumatologie Meeting,
Montreal, Canada, September 9, 1990.
7.Guttmann, L.: Spinal cord injuries.
Comprehensive management and
research. Oxford: Blackwell, 1973.
8. Willen, J.; Dahllöf, A.; Nordwall, A.:
Paraplegia in unstable thoracolumbar
injuries: a study of conservative and
operative treatment regarding
neurological improvement and
rehabilitation. Scand. J. Rehab. Med.,
Supplement 9, 1983.
9 .Jones, R. F.; Snowdon, E.; Coan, J.:
Bracing of thoracic and lumbar spinal
fractures. Paraplegia, 25:386-93, 1987.
10. Cantor, J. B.; Lebwohl, N. H.; Garvey, T.:
Non-operative management of stable
thoracolumbar burst fractures with early
ambulation and bracing. Spine, 18:971-
976, 1983.
11. Mumford, J.; Weinstein, J. N.; Spratt, K.
F.: Thoracolumbar burst fractures: the
clinical efficacy and outcome of non-
operative management. Spine, 18:955-
70, 1993.
12 .Guttmann L.: Spinal cord injuries:
comprehensive management and
research. Oxford: Blackwel, 1976.
13. Tarlov, I. M.; Klinger, H.; Vitale, S.:
Experimental techniques to produce
acute and gradual compression.
Archives of Neurology and Psychiatry,
70:813-9, 1953.
14. Dolan, E. J.; Tator, C. H.; Endrenyi, L.:
The value of decompression for acute
experimental spinal cord compression
injury. J. Neurosurg., 53:749-55, 1980.
15. Guha, A.; Tator, C. H.; Endrenyi, L.;
Piper, I.: Decompression of the spinal
cord improves recovery after acute
experimental spinal cord compression
injury. Paraplegia, 25:324-39, 1987.
16. Nystrom, B.; Berglund, J. E.: Spinal cord
restitution following compression injuries
in rats. Acta. Neurol. Scand., 78:467-72,
1988.
17. Tarlov, I. M.; Klinger, H.: Time limits for
recovery after acute compression in
dogs: spinal cord compression studies.
Archives of Neurology and Psychiatry,
71:271-90, 1954.
18. Delamarter, R. B.; Sherman, J. E.; Carr,
J. B.: The pathophysiology of spinal cord
damage and subsequent recovery
following immediate or delayed

43
decompression. J. Am. Paraplegia Soc.,
17:105-9, 1994.
19 .Johnsson, R.; Herrlin, K.; Hagglund, G.;
Stromqvist, B.: Spinal canal remodeling
after thoracolumbar fractures with intra-
spinal bone fragments. 17 cases
followed 1-4 years. J. Ortho. Scand.,
62:125-9, 1991.
20. Levine, M.; Lin, S.; Balderston, R.; Cotler,
J.: Fate of residual retro-pulsed bone
fragments in surgically managed
thoracolumbar burst fractures. J. Am.
Paraplegia Soc., 17:98-106, 1994.
21. Willen, J.; Anderson, J.; Tomooka, K.;
Singer, K.: The natural history of burst
fractures at the thoracolumbar junction.
J. Spinal Discord., 3:39-43, 1990.
22. Waters, R. L.; Adkins, R. H.; Yakura, J.
S.; Sie, I.: Motor and sensory recovery
following incomplete tetraplegia. Arch.
Phys. Med. Rehabil., 75:306-17, 1994.
23. Graziani, V.; Crozier, K. S.; Herbison, G.
S.: Strength recovery in the three levels
of zone of partial preservation in motor
complete quadriplegia after one year
post-injury. J. Am. Paraplegia Soc.,
15:122-7, 1992.
24. Bracken, M. D; Shepard, M. J; Collins,
W. F.: A randomized, controlled trial of
methylprednisolone or naloxone in the
treatment of acute spinal-cord injury:
results of the second national acute
spinal cord injury study. N. Engl. J.
Med., 322:1405-11, 1990.
25. Kiwerski, J. E.: Neurological outcome
from conservative or surgical treatment
of cervical spinal cord injured patients. J.
Paraplegia, 31:192-6, 1993.
26. Brunette, D. D.; Rockswold, G. L.:
Neurologic recovery following rapid
spinal realignment for complete cervical
spinal cord injury. The Journal of
Trauma, 27:445-7, 1987.
27. Weinshel, S. S.; Maiman, D. J.; Baek, P.;
Scales, L.: Neurologic recovery in
quadriplegia following operative
treatment. J. Spinal Disord., 3:244-9,
1990.
28. Bose, B.; Northrup, B. E.; Osterholm, J.
L.: Reanalysis of central cervical cord
injury management. Neurosurgery.
15:367-71, 1984.
29. Krengel, W. F.; Anderson, P. A.; Henley,
M. B.: Early stabilization and
decompression for incomplete
paraplegia due to a thoracic-level spinal
cord injury. J. Spine, 18:2080-7, 1993.
30. Hu, S. S.; Capen, D. A.; Rimoldi, R. L.;
Zigle, J. E.: The effect of surgical
decompression on neurologic outcome
after lumbar fractures. J. Clin. Orthop.
Related. Res., 288:166-73, 1993.
31. Anderson, P. A.; Bohlman, H. H.: Anterior
decompression and Arthrodesis of the
cervical spine: long-term motor
improvement. Part II. Improvement in
complete traumatic quadriplegia. J.
Bone Joint Surg. Am., 74:683-692,
1992.
32. Bohlman, H. H.; Anderson, P. A.: Anterior
decompression and arthrodesis of the
cervical spine: long-term motor
improvement: part I - Improvement in
incomplete traumatic quadriparesis. J.
Bone Joint Surg. Am., 74:671-82, 1992.
33. Maiman, D. J.; Larson, S. J.; Benzel, E.
C.: Neurological improvement
associated with late decompression of
the thoracolumbar spinal cord.
Neurosurgery, 14:302-07, 1984.
34. Tator, C. H.; Duncan, E. G.; Edmonds,
V. E.; Lapczak, L. I.; Andrew, D. F.:
Comparison of surgical and conservative
management in 208 patients with acute
spinal cord injury. Can. J. Neurol. Sci.,
14:60-9, 1987.
35. Marshall, L. F.; Knowlton, S.; Garfin, S.
R.; Klauber, M. R.; Eisenberg, H. M.;
Kopaniky, D.; Miner, M. E.; Tabbador,
K.; Clifton, G. L.: Deterioration following
spinal cord injury. J. Neurosurg., 66:400-
4, 1987.

44
36. Duh, M. S.; Shepard, M. J.; Wilberger, J.
E.; Bracken, M. B.: The effectiveness of
surgery on the treatment of acute spinal
cord injury and its relation to
pharmacological treatment.
37. Wimot, C. B.; Hall, K. M.: Evaluation of
the acute management of tetraplegia:
conservative versus surgical treatment.
Paraplegia, 24:148-53, 1986.
38. Levi, L.; Wolf, A.; Rigamonti, D.; Ragheb,
J.; Mirvis, S.; Robinson, W. L.: Anterior
decompression in cervical spine trauma:
does timing of surgery affect the
outcome? Neurosurgery, 29:216-22,
1991.
39. Wilberg, J.; Hauge, H. N.: Neurological
outcome after surgery for thoracic and
lumbar spinal injuries. Acta Neurochir.,
91:106-12, 1988.
40. Heiden, J. S.; Wiss, M. H.; Rosenberg,
A. W.; Apuzzo, M. L.; Kurze, T.:
Management of cervical spinal cord
trauma in Southern California. J.
Neurosurg., 43:p.732-36, 1975.
41. Dickson, J. H.; Harrington, P. R.; Erwin,
W. D.: Reduction and stabilization of the
severely fractured thoracic and lumbar
spine. J. Bone Joint Surg., 60;799-805,
1978.
42. Benzel, E. C.; Larson, S. J.: Functional
recovery after decompressive operation
for thoracic and lumbar spine fractures.
43. Clohisy, J. C.; Akbarnia, B. A.; Bucholz,
R. D.; Burkus, J. K.; Backer, R. J.:
Neurologic recovery associated with
anterior decompression of spine
fractures at the thoracolumbar junction
(T12-L1). Spine, 17:325-30, 1992.
44. Wagner, F. C.; Chehrazi, B.: Early
decompression and neurologic outcome
in acute cervical spinal cord injuries. J.
Neurosurg., 56:669-72, 1982.
45. Katoh, S., Masri, W. S.: Neurological
recovery after conservative treatment of
cervical cord injuries. J. Bone Joint Surg.
(Br), 76:225-8, 1994.
46. Aebi, M.; Mohler, J.; Zach, G. A.;
Morsher, E.: Initiation, surgical technique
and results of 100 sequentially treated
fractures and fracture-dislocation of the
cervical spine. Clin. Orthop., 203:244-9,
1986.
47. Donovan, W. H.: Operative and non-
operative management of spinal cord
injury: a review. Paraplegia, 32:375-88,
1994.
48. Young and Bracken: Long-term
consequences of stable fractures of the
thoracic and lumbar vertebral bodies. J.
Bone Joint Surg. (Br)., 55:295-300,
1973.
49. McAfee, P. C.; Bohlman, H. H.; Yuan, H.
A.: Anterior decompression of traumatic
thoracolumbar fractures with incomplete
neurological deficit using retroperitoneal
approach. J. Bone Joint Surg., 67-A:89-
96, 1985.
50. Kaneda, K.; Kuniyoshi, A.; Fujiya, M.:
Burst fractures with neurologic deficits of
the thoracolumbar spine; results of
anterior instrumentation. Spine, 9:788-
92, 1984.
51. Dickson, J. H.; Harrington, P. R.; Erwin,
W. D.: Results of reduction and
stabilization of the severely fractured
thoracic and lumbar spine. J. Bone Joint
Surg., 60:799-805, 1978.
52. Hardaker: (no reference)
53. Edwards, C. C.; Levine, A. M.: Early rod-
sleeve stabilization of the injured
thoracic and lumbar spine. Orthop. Clin.
North Am., 17:121-45, 1986.
54. Esses, S. I; Botsford, D. J; Kostuik, J. P.:
Evaluation of surgical treatment for burst
fractures. Spine, 15:667-9, 1990.
55. Gertzbein, S. D.; Court-Brown, C. M.;
Marks, P.: The neurological outcome
following surgery for spinal fractures.
Spine, 13:641-4, 1988.

45
56. Danisa, O. A.; Shaffrey, C. I.: Surgical
approaches for the correction of
unstable thoracolumbar burst fractures:
a retrospective analysis of treatment
outcomes. J. Neurosurg., 83:977-83,
1995.
57. Masini, M.: Estabilização da Coluna no
Trauma Raquimedular. Neurocir. Cont.
Bras. 1:11, 1-6, 1991.
58. Masini, M.: Spinal Cord Injury: Patients,
who have accident, walk and paralysis.
Paraplegia in press.1991
59. Masini, M.; Freire, N. N. G.; Neves, E.
G. C.: Experience with a spinal injury
unit in Brasília. Paraplegia. 28:17-24,
1990.
60. Masini, M.; Freire, N. N. G.; Neves, E. G.
C.; Mello, P. A.; Nascimento, J. S.:
Tratamento de fraturas toracolombares
instáveis. Arq. Bras. Neurocir., 5:143-54,
1986.
61. Masini, M.; Moncada, G. H. O.:
Tratamento de fraturas e luxações
toracolombares com uso de hastes
retangulares e losangulares. J. Bras.
Neurocir., 2, 45-8, 1990.
62. Bohller, L.: Técnica del Tratamiento de
las Fracturas. 4th edition, Barcelona,
Editorial, P.57-97, 1934.
63. Wilberg J; Hauge H. N.: Neurological
Outcome after Surgery for Thoracic and
lumbar spine injuries. Acta Neurochir.,
91:106-12, 1988.
64. Dove J.: The Use of The Hartshill System
for Internal Fixation of spinal fractures
and tumors. Acta Belgium, 57
Suppl.1:163-4;1991.

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