Lumbar disc herniation is the most common diagnosis among the degenerative abnormalities of the lumbar spine (affecting 2 to 3% of the population), and is the principal cause of spinal surgery among the adult population. The typical clinical picture includes initial lumbalgia, followed by progressive sciatica. The natural history of disc herniation is one of rapid resolution of the symptoms (four to six weeks). The initial treatment should be conservative, managed through medication and physiotherapy, sometimes associated with percutaneous nerve root block. Surgical treatment is indicated if pain control is unsuccessful, if there is a motor deficit greater than grade 3, if there is radicular pain associated with foraminal stenosis, or if cauda equina syndrome is present. The latter represents a medical emergency. A refined surgical technique, with removal of the extruded fragment and preservation of the ligamentum flavum, resolves the sciatic symptoms and reduces the risk of recurrence over the long term.
RESUMOA hérnia discal lombar é o diagnóstico mais comum dentre as alterações degenerativas da coluna lombar (acomete 2 a 3% da população) e a principal causa de cirurgia de coluna na população adulta. O quadro clínico típico inclui lombalgia inicial, seguida de lombociatalgia e, finalmente, de dor ciática pura. A história natural da hérnia de disco é de resolução rápida dos sintomas (quatro a seis semanas). O tratamento inicial deve ser conservador, com manejo medicamentoso e fisioterápico, podendo ser acompanhado ou não por bloqueios percutâneos radiculares. O tratamento cirúrgico está indicado na falha do controle da dor, déficit motor maior que grau 3, dor radicular associada à estenose óssea foraminal ou síndrome de cauda equina, sendo esta última uma emergência médica. Uma técnica cirúrgica refinada, com remoção do fragmento extruso, e preservação do ligamento amarelo, resolve a sintomatologia da ciática e reduz a possibilidade de recidiva em longo prazo. descritores - Keywords -Lumbar disc herniation; Ligamentum flavum; Sciatica; Surgical treatment INTRODUçãOA hérnia discal lombar consiste de um deslocamento do conteúdo do disco intervertebral -o núcleo pulposo -através de sua membrana externa, o ânulo fibroso, geralmente em sua região posterolateral. Dependendo do volume de material herniado, poderá haver compressão e irritação das raízes lombares e do saco dural, representadas clinicamente pela dor conhecida como ciática. Essa dor é conhecida desde a Antiguidade, mas a sua relação com a hérnia discal não foi descoberta até o início do século 20, quando Mixter e Barr a descreveram (1) . Atualmente, a hérnia discal lombar é o diagnóstico mais comum dentre as alterações degenerativas da coluna lombar e a principal causa de cirurgia de coluna. Fatores como maior acesso a cuidados médicos, precocidade na solicitação de exames de imagem e segurança dos procedimentos cirúrgicos levam a altas taxas de cirurgia, condição que é geralmente autolimitada.O tratamento da hérnia discal lombar evoluiu das ressecções transdurais para a abordagem convencional (2,3) , seguida da microcirurgia até a cirurgia endoscópica e percutânea. Atualmente. a hérnia discal lombar é a condição que mais leva à cirurgia de coluna, principalmente em homens ao redor dos 40 anos de idade (4) . Esta revisão visa discutir os principais aspectos de epidemiologia, diagnóstico e tratamento da hérnia discal lombar.
This study quantified the relative stress induced on the spinal cord and spinal nerves for different correction maneuvers using a novel hybrid patient-specific model. Of the three maneuvers studied, the Harrington distraction maneuver induced the most important stresses over the thoracolumbar region.
Scoliosis is a 3D deformation of the spine and rib cage. For severe cases, surgery with spine instrumentation is required to restore a balanced spine curvature. This surgical procedure may represent a neurological risk for the patient, especially during corrective maneuvers. This study aimed to computationally simulate the surgical instrumentation maneuvers on a patient-specific biomechanical model of the spine and spinal cord to assess and predict potential damage to the spinal cord and spinal nerves. A detailed finite element model (FEM) of the spine and spinal cord of a healthy subject was used as reference geometry. The FEM was personalized to the geometry of the patient using a 3D biplanar radiographic reconstruction technique and 3D dual kriging. Step by step surgical instrumentation maneuvers were simulated in order to assess the neurological risk associated to each maneuver. The surgical simulation methodology implemented was divided into two parts. First, a global multi-body simulation was used to extract the 3D displacement of six vertebral landmarks, which were then introduced as boundary conditions into the personalized FEM in order to reproduce the surgical procedure. The results of the FEM simulation for two cases were compared to published values on spinal cord neurological functional threshold. The efficiency of the reported method was checked considering one patient with neurological complications detected during surgery and one control patient. This comparison study showed that the patient-specific hybrid model reproduced successfully the biomechanics of neurological injury during scoliosis correction maneuvers.
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