Posterior Route Research Articles

Gastric endoscopic submucosal dissection via gastrostoma before the second operation for esophageal perforation: A case report

A 69-year-old man with advanced esophageal cancer and 2 early gastric cancers received chemoradiotherapy and was scheduled to undergo subtotal esophagectomy after gastric endoscopic submucosal dissection (ESD). However, left lower esophageal perforation induced by vomiting suddenly occurred, and he urgently underwent esophago-proximal gastrectomy and gastrostomy without reconstruction. The resected specimen showed a complete response of pretreatment for the esophageal cancer and radical resection of one gastric cancer. Radical resection of the other gastric lesion was necessary before reconstruction. The fistula of gastrostoma was gradually dilated from 6.7 to 9.3 mm in order to pass the endoscope. At nine months after emergent operation, gastric ESD was performed via only the gastrostoma. A hemoclip with thread was attached to the specimen, and the thread was pulled out of the gastrostoma. The specimen was able to be removed en bloc, resulting in radical resection. Gastric tube reconstruction through the posterior sternal route was performed at six months after the ESD. He has not developed recurrence of the esophageal or gastric cancer in the two years since the emergent operation.

Air Bubble Sign: A New Screening Method for Anastomotic Leakage After Esophagectomy for Esophageal Cancer.

Contrast esophagography often is performed to screen for anastomotic leakage (AL) after esophagectomy. However, its sensitivity remains low. Adverse events also have been reported. This report describes a new screening method to detect AL on computed tomography (CT) after esophagectomy. From January 2012 to December 2015, 185 patients with esophageal cancer underwent surgical resection at the authors' institution. The study comparatively reviewed patient characteristics, surgical outcomes, and findings from postoperative CT images and contrast esophagrams of 142 patients who underwent esophagectomy followed by primary gastric conduit reconstruction through a posterior mediastinum route. In this study, 24 patients (15.5%) had AL (leakage-positive group), and 120 patients (84.5%) did not (leakage-negative group). Both groups had comparable backgrounds. The number of air bubbles around the anastomotic site and the mediastinal space on postoperative CT images were significantly greater in the leakage-positive group than in the leakage-negative group. The cutoff value for the number of air bubbles required for a positive diagnosis of AL ("air bubble sign") was calculated to be 3 by receiver operating characteristic curve. Compared with contrast esophagography, the air bubble sign on CT demonstrated a significantly higher sensitivity (86.4 vs. 50.0%) and an equivalent specificity (95.8 vs. 100.0%). Contrast esophagography altered the postoperative management of only five patients (3.5%). A positive air bubble sign on CT is an objective and noninvasive screening method for AL after esophagectomy for esophageal cancer and may replace contrast esophagography as a screening test for AL.

SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS.

ABSTRACTObjective:The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver.Study design:Report of a case series with description of a new surgical technique.Methods:The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used.Results:In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively).Conclusion:The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.

Columnar metaplasia in the remnant esophagus is a long-term indicator for pneumonia after radical esophagectomy.

This study investigated the long-term risk factors for pneumonia after esophageal reconstruction using a gastric tube via the posterior mediastinal route following esophagectomy for esophageal cancer. The influence of columnar metaplasia in the remnant esophagus was specifically assessed. Among 225 patients who underwent esophagectomy between January 2004 and December 2010, the subjects were 54 patients who could be followed up for more than 5years. Routine oncologic follow-up consisted of CT scanning of the abdomen and chest every 4-6months and annual endoscopy. Data on the occurrence of pneumonia were collected by retrospective review of chest CT scans. Risk factors for pneumonia investigated by univariate and multivariate analyses included the age, gender, diameter of the stapler, length of the intrathoracic remnant esophagus, anastomotic stricture, and presence of columnar metaplasia in the remnant esophagus. The median age was 62.4years (interquartile range: 55.8-68.0years). Forty-three patients were men. Pneumonia was detected in 39 patients (72.2%). The incidence of columnar metaplasia in the remnant esophagus increases with time. Anastomotic stricture was significantly related to the absence of columnar metaplasia on endoscopy in the first year after esophagectomy (p=0.013). Univariate analysis showed that the frequency of pneumonia was significantly related to the intrathoracic remnant esophagus length ≥4.4cm (p=0.014), age over 65years (p=0.014), and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy (p=0.005). Among them, age over 65years and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy were found to be independent indicators of the postoperative pneumonia by multivariate analysis. Pneumonia occurred in 72.2% (39/54) of patients after esophagectomy for esophageal cancer. The presence of columnar metaplasia after esophagectomy is an indicator for pneumonia over the long term.

Advance in screws fixation in posterior route pedicle on lower cervical spine

With the continuously exploration, in recent years, further understanding of anatomical characteristics of the cervical pedicle brings great breakthrough in cervical pedicle screw implantation. In addition, pedicle screw implantation in cervical spine is considered as a technique with high safety and reliability, which can be widely used in cervical trauma fracture, cervical instability, degenerative, inflammatory, benign or malignant tumor, deformity and other neck diseases. Because of the tremendous differences between upper cervical spine (C1, C2) and lower cervical spine (C3-7) in anatomical morphology, cervical pedicle screw implantation in C1 and C2 differs from in lower cervical spine. Due to the similar structure of C3-7, pedicle screw implantation methods are based on the same principle and sharing a few points in common. The pedicle screw technique can be classified in two groups according to the practice methods: navigation technology and manual placement of cervical pedicle screw. Navigation nailing is considered as reliable, easy handing, and with clear operative vision, however, with disadvantages as complex procedures, highly cost operation equipment, and risk in navigation draft. Therefore, manual placement of pedicle screw is more reasonable and practical comparing with the former. In this study, it analyzed anatomical characteristics of lower cervical pedicle and the measurement of pedicle structure, discussed technique of manual placement of pedicle screw in lower cervical spine and biomechanical study of pedicle screw, and summed up the comparison of the advantages and disadvantages of current representative manual placement technology.

Superior Thoracic Aperture Size is Significantly Associated with Cervical Anastomotic Leakage After Esophagectomy.

The size of the superior thoracic aperture (STA) may be associated with the incidence of cervical anastomotic leakage after esophagectomy. Using computed tomography (CT) images, we retrospectively investigated relationships between the size of the STA and anastomotic leakage following esophagectomy using the retrosternal or posterior mediastinal reconstruction routes. Patients who underwent cervical esophagogastrostomy after esophagectomy between 2009 and 2015 were enrolled in this retrospective study (n=326). The size of the STA was measured at the level of the sternal notch using preoperative CT images, and it was determined as the anteroposterior diameter of the STA minus the diameter of the trachea. Associations between clinical factors, including the size of the STA, and anastomotic leakage were determined. Anastomotic leakage occurred in 44 patients (13.5%). The size of the STA ranged from 0 to 49mm (median, 16mm). In univariate analyses, the duration of the operation, tumor location, anastomotic procedure, and the size of the STA were significantly associated with anastomotic leakage. In multivariate analysis, only the size of the STA was independently related to leakage (odds ratio 1.05; 95% confidence interval 1.002-1.107; p=0.027). The size of the STA affected the incidence of leakage more frequently with the posterior mediastinal route than with the retrosternal route. The size of the STA was significantly associated with the incidence of anastomotic leakage after esophagectomy, especially when using the posterior mediastinal route.

Clinical Assessment of Reconstruction Involving Gastric Pull-Up Combined with Free Jejunal Graft After Total Pharyngolaryngoesophagectomy.

Total pharyngolaryngoesophagectomy (PLE) is used as a curative treatment for synchronous laryngopharyngeal and thoracic esophageal cancer or for multiple cancers in the cervical and thoracic esophagus. Gastric pull-up is commonly used after PLE, but postoperative complications are common. The present study evaluated these procedures in patients with esophageal cancer. Fourteen patients (7 with synchronous pharyngeal and thoracic esophageal cancer, 4 with synchronous cervical and thoracic esophageal cancer, and 3 with cervicothoracic esophageal cancer) underwent reconstructive surgery after PLE involving gastric pull-up combined with free jejunal graft between 2004 and 2015. Esophagectomy via right thoracotomy was performed in 9 patients, and transhiatal esophagectomy was used in 5. The posterior mediastinal route was used in 13 patients, excluding one patient with early gastric cancer. Interposition of a free jejunal graft included microvascular anastomosis using two arteries and two veins in all patients. Anastomotic leakage and graft necrosis did not occur in any of the 14 patients who underwent the above surgical procedures. Tracheal ischemia close to the tracheostomy orifice occurred in 4 patients (28.6%), but none of these patients developed pneumonia. No hospital deaths were recorded. The results indicate that gastric pull-up combined with free jejunal graft is a feasible reconstructive surgery after PLE. This procedure is a promising treatment strategy for synchronous pharyngeal and thoracic esophageal cancer or multiple cancers in the cervical and thoracic esophagus. Larger series are needed to show the distinct advantages of this procedure in comparison with conventional methods of reconstruction after PLE.

食道癌後縦隔経路再建後に横隔膜ヘルニアを来した2例

食道癌後縦隔経路再建後に横隔膜ヘルニアを来した2例

Endoscopic occlusion with silicone spigots for the closure of refractory esophago-bronchiole fistula after esophagectomy.

A 65-year-old man with cT1bN0M0 stage I middle thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the posterior mediastinal route after preoperative carbon-ion radiotherapy and chemotherapy in a clinical trial. Anastomotic leakage occurred, but it spontaneously improved. At six months after the operation, he was rehospitalized with a cough and dysphagia. An esophago-bronchiole fistula and stenosis of the gastric tube were observed. He first underwent stent placement in the gastric tube. Two weeks later, the syringeal epithelium was burned by argon plasma coagulation after stent removal. Endoscopic occlusion was then performed for the fistula with two guidewire-assisted silicone spigots. Two weeks later, he was discharged on an oral diet, and he has not developed recurrence of the fistula or cancer for three years. This is the first report of endoscopic occlusion with a guidewire-assisted silicone spigot through the esophagus.

Revisiting the differences between irreducible and reducible atlantoaxial dislocation in the era of direct posterior approach and C1-2 joint manipulation.

OBJECTIVE The current management of atlantoaxial dislocation (AAD) focuses on the C1-2 joints, commonly approached through a posterior route. The distinction between reducible AAD (RAAD) and irreducible AAD (IrAAD) seems to be less important in modern times. The roles of preoperative traction and dynamic radiographs are questionable. This study evaluated whether differentiating between the 2 groups is important in today's era. METHODS Ninety-six consecutive patients with congenital AAD (33 RAAD and 63 IrAAD), who underwent surgery through a posterior approach alone, were studied. The preoperative and follow-up clinical statuses for both groups were studied and compared using Japanese Orthopaedic Association (JOA) scores. The radiological findings of the 2 groups were compared, and the intraoperative challenges described. RESULTS A poor preoperative JOA score (clinical status) was seen in one-fifth of patients with IrAAD, although the mean JOA score was nearly similar in the RAAD and IrAAD groups. There was significant improvement in follow-up JOA score in both groups. However, segmentation defects (such as an assimilated arch of the atlas and C2-3 fusion) and anomalous vertebral arteries were found significantly more often in cases of IrAAD compared with those of RAAD. Os odontoideum was commonly seen in the RAAD group. The C1-2 joints were acute in IrAAD compared with RAAD. Preoperative traction in IrAAD resulted in vertical distraction and improvement in clinical and respiratory status. Surgery for IrAAD required much more drilling and manipulation of the C1-2 joints while safeguarding the anomalous vertebral artery. CONCLUSIONS Bony and vascular anomalies were much more common in patients with IrAAD, which made surgery more challenging than it was in RAAD despite similar approaches. An irreducible dislocation seen on preoperative radiographs made surgeons aware of difficulties that were likely to be encountered and helped them to better plan the surgery. Distraction achieved through preoperative traction reaffirmed the feasibility of intraoperative reduction. This made the differentiation between the 2 groups and the use of preoperative traction equally important.

Assessment of spontaneous correction of lumbar curve after fusion of the main thoracic in Lenke 1 adolescent idiopathic scoliosis

ObjectiveTo evaluate the clinical and radiographic response of the lumbar curve after fusion of the main thoracic, in patients with adolescent idiopathic scoliosis of Lenke type 1. MethodsForty-two patients with Lenke 1 adolescent idiopathic scoliosis who underwent operations via the posterior route with pedicle screws were prospectively evaluated. Clinical measurements (size of the hump and translation of the trunk in the coronal plane, by means of a plumb line) and radiographic measurements (Cobb angle, distal level of arthrodesis, translation of the lumbar apical vertebral and Risser) were made. The evaluations were performed preoperatively, immediately postoperatively and two years after surgery. ResultsThe mean Cobb angle of the main thoracic curve was found to have been corrected by 68.9% and the lumbar curve by 57.1%. Eighty percent of the patients presented improved coronal trunk balance two years after surgery. In four patients, worsening of the plumb line measurements was observed, but there was no need for surgical intervention. Less satisfactory results were observed in patients with lumbar modifier B. ConclusionsIn Lenke 1 patients, fusion of the thoracic curve alone provided spontaneous correction of the lumbar curve and led to trunk balance. Less satisfactory results were observed in curves with lumbar modifier B, and this may be related to overcorrection of the main thoracic curve.

Plunging Ranulas Revisited: A CT Study with Emphasis on a Defect of the Mylohyoid Muscle as the Primary Route of Lesion Propagation.

ObjectiveThe purpose of this study was to clarify the pathogenesis of plunging ranulas in regard of the pathway of lesion propagation using CT scans.Materials and MethodsWe retrospectively reviewed CT scans of 41 patients with plunging ranula. We divided plunging ranulas into two types: type 1 was defined as those directly passing through a defect of the mylohyoid muscle with the presence (type 1A) or absence (type 1B) of the tail sign and type 2 as those through the traditional posterior route along the free edge of the mylohyoid muscle. Images were also analyzed for the extent of the lesion in respect to the spaces involved. As for type 1 lesions, we recorded the location of the defect of the mylohyoid muscle and the position of the sublingual gland in relation to the defect.ResultsCT scans demonstrated type 1 lesion in 36 (88%), including type 1A in 14 and type 1B in 22, and type 2 lesion in 5 (12%). Irrespective of the type, the submandibular space was seen to be involved in all cases either alone or in combination with one or more adjacent spaces. Of the 36 patients with type 1 lesions, the anterior one-third was the most common location of the defect of the mylohyoid muscle, seen in 22 patients. The sublingual gland partially herniated in 30 patients.ConclusionOur results suggest that the majority of plunging ranulas take an anterior shortcut through a defect of the mylohyoid muscle.

Spontaneous rupture of the lens capsule in hypermature cataract: presentations and outcomes

AimTo describe the occurrence of spontaneous rupture of the lens capsule in patients with hypermature cataract.Study designConsecutive case series.MethodsThe records of patients with hypermature cataract and spontaneous capsular dehiscence seen...

Avaliação da correção espontânea da curva lombar após a fusão da torácica principal na escoliose idiopática do adolescente Lenke 1

ObjectiveTo evaluate the clinical and radiographic response of the lumbar curve after fusion of the main thoracic, in patients with adolescent idiopathic scoliosis of Lenke type 1. MethodsForty‐two patients with Lenke 1 adolescent idiopathic scoliosis who underwent operations via the posterior route with pedicle screws were prospectively evaluated. Clinical measurements (size of the hump and translation of the trunk in the coronal plane, by means of a plumb line) and radiographic measurements (Cobbangle, distal level of arthrodesis, translation of the lumbar apical vertebral and Risser) were made. The evaluations were performed preoperatively, immediately postoperatively and two years after surgery. ResultsThe mean Cobb angle of the main thoracic curve was found to have been corrected by 68.9% and the lumbar curve by 57.1%. Eighty percent of the patients presented improved coronal trunk balance two years after surgery. In four patients, worsening of the plumb line measurements was observed, but there was no need for surgical intervention. Less satisfactory results were observed in patients with lumbar modifier B. ConclusionsIn Lenke 1 patients, fusion of the thoracic curve alone provided spontaneous correction of the lumbar curve and led to trunk balance. Less satisfactory results were observed in curves with lumbar modifier B, and this may be related to overcorrection of the main thoracic curve.

Surgical Treatment of Degenerative Disc Disease of L5/S1 with ALIF only (Standalone) versus Posterior Approach Pedicle Fixation: Comparative Retrospective Study

Introduction In the surgical treatment of degenerative disc disease, specifically in L5/S1 segment have been proposed various treatment modalities, the most used is posterior arthrodesis considered nowadays as the current gold standard. Objective This study aims to compare the results of two groups of patients with degenerative disc disease in terms of improvement in pain, functional scale, functional recovery time, and radiological lumbar lordosis correction. Material and Methods Two groups of patients diagnosed with degenerative disc disease (adult patients, chronic low back pain of more than 6 months duration, with failed previous treatment without radicular component, decreased height of intervertebral space, studies were compared retrospectively with plain X-ray, CT and MRI), operated from April 2009 to April 2014, with a minimum follow-up of 6 months and maximum of 4 years. A group of 25 patients was treated with arthrodesis using a posterior approach with fixation with pedicle screws and bone graft posterolateral from bone bank, while the second group of 22 patients was treated with technique ALIF with PEEK cage via anterior approach (standalone), with fixing screws to the platforms and bone grafting from bone bank. Pain and Oswestry functional index plus functional recovery time and return to work, as well as changes in radiological lumbar lordosis were compared. Operative time, bleeding, and hospitalization time were also compared. Statistics included measures of central tendency, and standard deviation for continuous variables, and frequencies and proportions for categorical variables were used. Student t-test was used to compare both groups to perform simultaneous and multivariate analysis clinical measures. Results We found improvement on the pain intensity visual analog scale, at least 50% of the intensity of initial pain, and in regard to functional scale ( p > 0.01), it was possible to improve the overall height of the intervertebral space the anterior approach which was not achieved by the posterior route. Moreover, significant differences of less surgical time, less bleeding, shorter hospital stay, and were found by the anterior approach to the posterior approach. Conclusion In this study was found for degenerative disc disease of L5/S1, a better surgical outcome by the anterior approach than the posterior approach in terms of pain and functional recovery in an average follow-up of 2 years.

Traumatic spondyloptosis: a series of 20 patients

OBJECT Spondyloptosis represents the most severe form of spondylolisthesis, which usually follows high-energy trauma. Few reports exist on this specific condition, and the largest series published to date consists of only 5 patients. In the present study the authors report the clinical observations and outcomes in a cohort of 20 patients admitted to a regional trauma center for severe injuries including spondyloptosis. METHODS The authors performed a retrospective chart review of patients admitted with spondyloptosis at their department over a 5-year period (March 2008-March 2013). Clinical, radiological, and operative details were reviewed for all patients. RESULTS In total, 20 patients with spondyloptosis were treated during the period reviewed. The mean age of the patients was 27 years (range 12-45 years), and 17 patients were male (2 boys and 15 men) and 3 were women. Fall from height (45%) and road traffic accidents (35%) were the most common causes of the spinal injuries. The grading of the American Spinal Injury Association (ASIA) was used to assess the severity of spinal cord injury, which for all patients was ASIA Grade A at the time of admission. In 11 patients (55%), the thoracolumbar junction (T10-L2) was involved in the injury, followed by the dorsal region (T1-9) in 7 patients (35%); 1 patient (5%) had lumbar and 1 patient (5%) sacral spondyloptosis. In 19 patients (95%), spondyloptosis was treated surgically, involving the posterior route in all cases. In 7 patients (37%), corpectomy was performed. None of the patients showed improvement in neurological deficits. The mean follow-up length was 37.5 months (range 3-60 months), and 5 patients died in the follow-up period from complications due to formation of bedsores (decubitus ulcers). CONCLUSIONS To the authors' best knowledge, this study was the largest of its kind on traumatic spondyloptosis. Its results illustrate the challenges of treating patients with this condition. Despite deformity correction of the spine and early mobilization of patients, traumatic spondyloptosis led to high morbidity and mortality rates because the patients lacked access to rehabilitation facilities postoperatively.

Uso do ácido tranexâmico no controle do sangramento em cirurgias de escoliose toracolombar com instrumentação posterior

ObjectiveScoliosis surgery involves major blood loss and frequently requires blood transfusion. The cost and risks involved in using allogeneic blood have motivated investigation of methods capable of reducing patients’ bleeding during operations. One of these methods is to use antifibrinolytic drugs, and tranexamic acid is among these. The aim of this study was to assess the use of this drug for controlling bleeding in surgery to treat idiopathic scoliosis. MethodsThis was a retrospective study in which the medical files of 40 patients who underwent thoracolumbar arthrodesis by means of a posterior route were analyzed. Of these cases, 21 used tranexamic acid and were placed in the test group. The others were placed in the control group. The mean volumes of bleeding during and after the operation and the need for blood transfusion were compared between the two groups. ResultsThe group that used tranexamic acid had significantly less bleeding during the operation than the control group. There was no significant difference between the groups regarding postoperative bleeding and the need for blood transfusion. ConclusionsTranexamic acid was effective in reducing bleeding during the operation, as demonstrated in other studies. The correlation between its use and the reduction in the need for blood transfusion is multifactorial and could not be established in this study. We believe that tranexamic acid may be a useful resource and that it deserves greater attention in randomized double‐blind prospective series, with proper control over variables that directly influence blood loss.

Use of tranexamic acid for controlling bleeding in thoracolumbar scoliosis surgery with posterior instrumentation

ObjectiveScoliosis surgery involves major blood loss and frequently requires blood transfusion. The cost and risks involved in using allogeneic blood have motivated investigation of methods capable of reducing patients’ bleeding during operations. One of these methods is to use antifibrinolytic drugs, and tranexamic acid is among these. The aim of this study was to assess the use of this drug for controlling bleeding in surgery to treat idiopathic scoliosis. MethodsThis was a retrospective study in which the medical files of 40 patients who underwent thoracolumbar arthrodesis by means of a posterior route were analyzed. Of these cases, 21 used tranexamic acid and were placed in the test group. The others were placed in the control group. The mean volumes of bleeding during and after the operation and the need for blood transfusion were compared between the two groups. ResultsThe group that used tranexamic acid had significantly less bleeding during the operation than the control group. There was no significant difference between the groups regarding postoperative bleeding and the need for blood transfusion. ConclusionsTranexamic acid was effective in reducing bleeding during the operation, as demonstrated in other studies. The correlation between its use and the reduction in the need for blood transfusion is multifactorial and could not be established in this study. We believe that tranexamic acid may be a useful resource and that it deserves greater attention in randomized double-blind prospective series, with proper control over variables that directly influence blood loss.

Tracheobronchial fistula during the perioperative period of esophagectomy for esophageal cancer.

Tracheobronchial (TB) injury and fistula formation during the perioperative period of esophagectomy is a rare but life-threatening complication. We examined the development of intraoperative TB injury and postoperative TB fistulas in consecutive 763 patients with esophageal cancer who underwent esophagectomy, including 494 patients who underwent transthoracic subtotal esophagectomy. TB injury and fistulas developed in two (0.4 %) and four patients (0.8 %), respectively, who received transthoracic esophagectomy. TB injury developed during the dissection of a tumor invading a major airway. Direct suturing of the laceration and covering it using a muscle flap was effective for one patient, while additional repair with a major pectoral muscle flap was needed in another patient. Postoperative TB fistulas developed due to peri-tracheal infection in two patients, and conservative treatment with drainage was performed. In another two patients, gastro-tracheal fistulas developed due to mechanical compression of staplers on the gastric tube, which was elevated via the posterior mediastinal route. The direct repair of the gastric tube and covering it with a major pectoral muscle flap resulted in the resolution of these fistulas. Careful dissection with direct vision of the esophagus, as well as oversewing of the staplers on the gastric tube, is mandatory for preventing TB injury and fistula formation. Appropriate drainage is effective in cases with peri-tracheal abscesses. If the TB fistula fails to heal within a 4- to 6-week period, conservative management should be abandoned. Direct surgical intervention with coverage by a muscle flap is important for TB fistulas.

Nível de dor no pós‐operatório imediato de artrodese lombar após infiltração epidural com sulfato de morfina

ObjectiveTo evaluate the pain level in patients treated with epidural infusion of morphine sulfate in a single dose, after a surgical procedure to perform lumber arthrodesis. MethodsForty patients underwent posterolateral lumbar arthrodesis or intersomatic lumbar arthrodesis via a posterior route at one, two or three levels. They were prospectively randomized into two groups of 20. In the first group (study group), 2mg of morphine sulfate diluted in 10mL of physiological serum was infiltrated into the epidural space, through the laminectomy area. The second group (controls) did not receive analgesia. The patients were asked about their pain levels before and after the operation, using a visual analogue scale (VAS). ResultsIt was found that the patients presented a significant diminution of pain as shown by the VAS. From before to after the operation, it decreased by an average of 4.7 points (p=0.0001), which corresponded to 53.2% (p=0.0001). ConclusionApplication of 2mg of morphine sulfate in a single epidural dose was sown to be a good technique for pain therapy following lumbar spinal surgery.