Original article
Results to 4-year follow-up of the treatment of the cervical stenosis by corpectomy, titanium mesh cage and anterior plate fixation
Resultados a 4 años de seguimiento del tratamiento del conducto cervical estrecho mediante corpectomía, malla de titanio y fijación anterior con placa
Alejandro Antonio Reyes Sánchez
, Luis Alberto Gameros Castañeda, Claudia Obil Chavarría, Armando Alpizar Aguirre, Barón Zárate Kalfópulos, Luis Miguel Rosales-Olivares
Corresponding author
alereyes@inr.gob.mx
areyes@vertebrae.com.mx
Corresponding author at: Av. Paseo de la Reforma 155 1.er piso, Col. Lomas de Chapultepec, Del. Miguel Hidalgo, C.P., 11000 Mexico City, Mexico. Tel.: +55 2623 0130ext.0285/86.
areyes@vertebrae.com.mx
Corresponding author at: Av. Paseo de la Reforma 155 1.er piso, Col. Lomas de Chapultepec, Del. Miguel Hidalgo, C.P., 11000 Mexico City, Mexico. Tel.: +55 2623 0130ext.0285/86.
División de Cirugía de Columna Vertebral, Instituto Nacional de Rehabilitación, Secretaria de Salud, Ciudad de México, Mexico
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Paseo de la Reforma 155 1.<span class="elsevierStyleSup">er</span> piso, Col. Lomas de Chapultepec, Del. Miguel Hidalgo, C.P., 11000 Mexico City, Mexico. Tel.: +55 2623 0130ext.0285/86." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados a 4 años de seguimiento del tratamiento del conducto cervical estrecho mediante corpectomía, malla de titanio y fijación anterior con placa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 837 "Ancho" => 1505 "Tamanyo" => 123618 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Immediate postoperative X-ray. (B) X-ray at 4 years postoperatively.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term cervical spondylosis encompasses degenerative changes to the spine.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cervical spondylosis is a sequence of changes to the intervertebral discs, the vertebrae and the joints, associated with degenerative changes caused by ageing or secondary to trauma. The main symptom is neck pain that is frequently associated with pain in the shoulder region.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Cervical spondylotic myelopathy is a degenerative process caused by stenosis of the cervical canal and is the primary cause of functional disability in adults.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4,5</span></a> For this reason, efforts have been made internationally to find appropriate treatment for this disorder. There are currently many surgical treatments for the condition that have been standardised over time.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">6–9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although anterior cervical discectomy and fusion has been the gold standard in the treatment of cervical canal stenosis, techniques have been described to treat multilevel disease under the premise that the use of an implant reduces morbidity since it does not require taking a graft.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10–12</span></a> Using a cervical mesh as an anterior support when performing a corpectomy, has the advantage over 2-level discectomy of creating a wider decompression window, and the same bone tissue from the corpectomy is used as the graft.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">13–15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatment is controversial, since subsidence of the cage is still the main limitation of this procedure.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">16–20</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Anterior discectomy and arthrodesis with tricortical graft is currently the most commonly used technique to treat cervical radiculopathy and myelopathy. For placement of the tricortical graft, in biomechanical studies there is no statistical relevance of the height of the graft with application of distractive force.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a> The use of cervical mesh cages started in 1986.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> Titanium mesh cages are rigid cylindrical implants which fill with spongy bone to provide anterior support and facilitate intervertebral arthrodesis.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21,22</span></a> Their advantages are reduced morbidity at the donation site and their fusion rate; their disadvantages are their cost, determining radiographic union, revision surgery and migration.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">18,20,23–25</span></a> The indications for corpectomy are: multilevel disease, compression at the level of the posterior wall, anterior osteophytes, and deformity of the vertebral body.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Nürick<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a> introduced a scale for assessing the gait of patients with spondylotic cervical myelopathy, consisting of 6 grades (grade 5 being the most serious): radicular symptoms with no myelopathic signs (0), normal gait with myelopathic signs (1), mild gait involvement (2), ataxic gait (3), assisted gait (4) and wheelchair-bound (5). The neck disability index<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">27,28</span></a> is a self-administered questionnaire with 10 sections. Each of the sections (pain intensity, personal care, lifting, headache, concentration, work, driving, sleep and recreation) offer 6 possible responses that represent 6 progressive levels of functional capacity, and are scored from 0 to 5. The total score is expressed as a percentage of the maximum possible score.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There are international articles that cover the treatment of multilevel cervical canal stenosis by corpectomy and titanium mesh placement plus anterior fixation, the outcomes vary according to the authors. We found no literature at a national level when we performed a search in the Pub Med, Scielo, Scielo México, MD Consult, Science Directo and Ovid search engines using the keywords titanium mesh, cervical corpectomy and myelopathy and anterior fixation. We found 0 references containing reports on clinical and radiological evaluations of patients with this disorder in Mexican publications, using the abovementioned technique.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore, the general aim was to establish an association between titanium mesh cage subsidence and clinical and functional outcomes at 4-year follow-up. The specific objectives were to assess subsidence of the mesh cage in millimetres by X-ray, classifying the grade of union by X-ray and clinical assessment using Nürick's classification for cervical myelopathy and the pre-and post-operative neck disability index (NDI).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0050" class="elsevierStylePara elsevierViewall">This was a prospective, observational, longitudinal, open, non-randomised, deliberate intervention study with 4-year follow-up of 7 patients from our outpatients’ department with a diagnosis of cervical canal stenosis, aged over 40 years, who underwent corpectomy and placement of titanium mesh cage and one-level anterior cervical plate. The mesh cage was filled with autologous graft.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Demographic variables such as sex and age were assessed and intervening variables such as corpectomy levels, transoperative bleeding volume, surgical technique (mesh and anterior plate placement), grade of union, trans- and post-operative complications. Cervical lordosis was assessed and compared preoperatively and at 4-year follow-up. The dependent variable was the functional outcome assessed using the NDI and the Nürick functional scale, and mesh cage subsidence was the independent variable, assessed by digital X-rays and measured in millimetres in the DICOM<span class="elsevierStyleSup">®</span> system.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The statistical analysis consisted of descriptive statistics estimating frequencies, percentages, measures of central tendency and dispersion. Paired <span class="elsevierStyleItalic">t</span>-tests and/or Wilcoxon signed Rank test, and Pearson and Spearman correlation tests were undertaken, as appropriate. A <span class="elsevierStyleItalic">p</span> value of <0.05 was accepted as statistically significant and the software packages Excel and SPSS v. 21 were used.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">From January 2009 to December 2011, 13 patients were found with a diagnosis of cervical canal stenosis, who were treated surgically by corpectomy and placement of titanium mesh cage and one-level anterior cervical plate. Six of the patients were eliminated from the study: one died and the other 5 decided not to participate.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 7 remaining patients in the study, 2 were male and 5 female, with a percentage of 28.6% and 71.4% respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The levels resected were C5 in 4 cases (57.1%), C6 in 2 cases (6.9%) and C4 in 1 case (14.3%). Minimum surgery time was 100<span class="elsevierStyleHsp" style=""></span>min and maximum 210<span class="elsevierStyleHsp" style=""></span>min, with a mean of 153.57±40.28. Minimum transoperative bleeding was 150<span class="elsevierStyleHsp" style=""></span>ml and maximum 300<span class="elsevierStyleHsp" style=""></span>ml, with a mean of 200±57.73. The days of hospital stay were a minimum of 5 and maximum of 11, the mean was 7.57±2.43 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Union of grade 1 was found in all patients at 4-year follow-up (remodelling and trabeculae) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0080" class="elsevierStylePara elsevierViewall">The presurgical NDI was a minimum of 0 and a maximum of 77.7, with a mean of 30.01±24.32. The post-operative NDI at 4 years was a minimum of 0 and a maximum of 52, with a mean of 32.05±6.90. The correlation of the preoperative NDI and the postoperative NDI at 4 years was <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.801, with 95% CI −21 at 16.91 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0085" class="elsevierStylePara elsevierViewall">A minimum Nürick grade of 3 and a maximum of 4 were obtained, with a mean of 3.28±0.48. The postoperative Nürick at 4 years was a minimum of 1 and a maximum of 4, with a mean of 3.14±1.21. The correlation of the preoperative Nürick and the postoperative Nürick at 4 years was <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.766, with 95%CI −.98 to 1.26 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0090" class="elsevierStylePara elsevierViewall">A minimum of 3 degrees of preoperative lordosis was encountered and a maximum of 27 degrees, with a mean of 14.42±8.03. Postoperative–operative lordosis at 4 years was a minimum of 3 degrees and a maximum of 39, the mean was 17±11.67. The correlation between the preoperative and postoperative lordosis at 4 years was <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.660, with 95% CI −16.18 to 11.04 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0095" class="elsevierStylePara elsevierViewall">The minimum immediate postoperative subsidence was 0<span class="elsevierStyleHsp" style=""></span>mm and the maximum was 8.21<span class="elsevierStyleHsp" style=""></span>mm, the mean was 2.69±2.80. Postoperative subsidence at 4 years was a minimum of 4.35<span class="elsevierStyleHsp" style=""></span>mm and a maximum of 9.18<span class="elsevierStyleHsp" style=""></span>mm, the mean was 6.11±1.61. In this correlation there was a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001 with 96%CI −4.57 to −2.28 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Five patients were found with immediate postoperative subsidence; the patient with the most subsidence at 8.21<span class="elsevierStyleHsp" style=""></span>mm had a total subsidence at 4 years of 9.18<span class="elsevierStyleHsp" style=""></span>mm, the difference was only 0.97<span class="elsevierStyleHsp" style=""></span>mm and their Nürick grade was 4, with no changes during the preoperative period or at 4 years. Three of the patients had an initial subsidence of 2.4, 1.8 and 3<span class="elsevierStyleHsp" style=""></span>mm, and a final subsidence of 6, 6 and 5.6<span class="elsevierStyleHsp" style=""></span>mm, respectively, and had improved Nürick grades of 3 to 1, 4 to 3 and 3 to 2, respectively, and only one of them, with immediate postoperative subsidence went from 3.84 to 7.3<span class="elsevierStyleHsp" style=""></span>mm in 4 years, with a poorer Nürick grade of 3. No immediate postoperative subsidence was found in 2 patients; however, their subsidence at 4 years was 4.7<span class="elsevierStyleHsp" style=""></span>mm and 4.5<span class="elsevierStyleHsp" style=""></span>mm, and both Nürick grades increased by one point, from 3 to 4. Using Spearman's test, a relationship was observed between postoperative subsidence at 4 years and Nürick grade at 4 years, but was not statistically significant.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">It was found in this study that most of the patients studied were female (71.4%), in contrast to the study undertaken by Chen et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> who found that most of their patients were male (57.66%).</p><p id="par0110" class="elsevierStylePara elsevierViewall">However, we coincide with these authors in that the most common level for corpectomy was C5: 57.1% of the patients in our study and 49.33% of those in the study by Chen et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The only complication was the formation of a haematoma in the surgical approach in one patient, which was surgically drained, with a favourable outcome. This complication is reported by Paradells et al.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> as very rare in this type of approach.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Bone union outside the mesh cage was observed in all cases, especially in the portion posterior to it and its lateral areas. But we were not able to observe the same inside the mesh cages, due to the disadvantage of assessment by X-ray alone. We consider, therefore, that a weakness of our study is that the patients were not assessed by CAT scan at the end of the study, unlike Lee and Sung<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">30</span></a> who used CAT and x-ray assessment for a comprehensive evaluation.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The mean surgery time was 153.57±40.28 and the mean transoperative bleeding was 200±57.73, equivalent to the meta-analysis by Wen et al.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> who compare anterior discectomy with corpectomy, with similar results to ours in these parameters.</p><p id="par0130" class="elsevierStylePara elsevierViewall">On comparing the preoperative NDI, with a mean of 30.01±24.32, and the postoperative NDI at 4 years with a mean of 32.05±16.90, a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.801 was observed, which is not significant. This is explained because the NDI essentially assesses axial pain and not functional status, which is given on the Nürick myelopathy scale.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Correlation of the myelopathic assessment with preoperative Nürick had a mean of 3.28±0.48 and at 4-year follow-up presented a mean of 3.14±1.21, with a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.766, without being statistically significant, unlike that found by Bilbao et al.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> who found in a study of 71 patients an improvement of 62% on the Nürick scale, and observed that while the Nürick grade was lower, the patients achieved greater improvement. The patients in our study had severe myelopathic disorders, which would explain why they did not achieve significant improvement.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Preoperative cervical lordosis, with a mean of 14.42±8.03, correlated with the mean at 4 years of 17±11.67, with a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.666; although this is not statistically significant, we can assume that with a small sample size (7 patients) the difference would have to be very high to have any significance. In their study, Jang et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">33</span></a> observed an increase in lordosis at the end of their follow-up compared to the immediate postoperative period. This indicates that subsequent subsidence of the mesh cage causes an increase in lordosis.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The immediate postoperative subsidence, with a mean of 2.69±2.80, correlated with the subsidence at 48 months, with a mean of 6.11±1.61, a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001 was obtained, a similar result to that of Chen et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> who obtained an incidence of subsidence of 79.7%. Likewise, Jang et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">33</span></a> obtained a subsidence of 93.3% in the patients in their study.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Chen et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> also mention that the patients with moderate subsidence (60.7%) presented no significant clinical changes, but the group of patients with severe subsidence (19%) correlated with unfavourable neurological outcomes and complications associated with the subsidence.</p><p id="par0155" class="elsevierStylePara elsevierViewall">We observed subsidences in the immediate postoperative period, which suggests to us that there was a fracture of the platforms that would encourage immediate subsidence in all the patients.</p><p id="par0160" class="elsevierStylePara elsevierViewall">It was observed that the patients who had no immediate postoperative subsidence had depression of the platform of 4<span class="elsevierStyleHsp" style=""></span>mm at the final 4-year follow-up, so we can assume that initial subsidence of the mesh cage does not affect its progress, and also has no probable relationship with the cause of symptoms or predisposition for the subsidence to increase.</p><p id="par0165" class="elsevierStylePara elsevierViewall">There is an association between the Nürick grade at 4 years and postsurgical subsidence at 4 years. However it is not statistically significant, since the sample size is very small, and this is a problem in statistics. We observed a good outcome in 3 patients with an improved Nürick grade, with no relationship with immediate postoperative subsidence. The 2 patients with no initial subsidence had a worse grade by one point at the end of the follow-up period. One patient with initial subsidence also had negative changes by one point on the scale, and the patient who presented the most initial subsidence had no changes in their Nürick grade.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Furthermore, the satisfactory or unfavourable outcomes of the patients relate to the time of onset of the myelopathy, as Tetreault et al.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a> mention in their study, the probabilities of a successful outcome reduce the longer the symptoms progress. It was a weakness of our study not to have covered this parameter, since it would be important to consider the duration of the myelopathy prior to surgery due to the presence of irreversible lesions. Other weaknesses of the study are that the sample was small and the variability in brand of material used. However some reports in the international literature have similar samples.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0175" class="elsevierStylePara elsevierViewall">Subsidence of the mesh cage is a common phenomenon in this type of procedure, despite the small sample size.</p><p id="par0180" class="elsevierStylePara elsevierViewall">We observed no statistically significant changes between the preoperative and the 4-year postoperative comparisons in lordosis, or Nürick scale and NDI.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres986527" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec954125" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres986526" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec954124" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-12" "fechaAceptado" => "2016-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec954125" "palabras" => array:4 [ 0 => "Cervical spine" 1 => "Corpectomy" 2 => "Subsidence" 3 => "Titanium mesh cage" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec954124" "palabras" => array:4 [ 0 => "Columna cervical" 1 => "Corpectomía" 2 => "Hundimiento" 3 => "Malla de titanio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cervical spondylotic myelopathy is caused by cervical stenosis. Several techniques have been described for the treatment of multilevel disease, such as the anterior corpectomy with titanium mesh cage and anterior cervical plate placement, which has the advantage of performing a wider decompression and using the same bone as graft. However, it has caused controversy since the collapse of the mesh cage continues being a major limitation of this procedure.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective 4-year follow-up study was conducted in 7 patients diagnosed with cervical stenosis, who were treated surgically by one level corpectomy with titanium mesh cage and anterior cervical plate placement, evaluating them by radiographs and clinical scales.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">7 patients, 5 women and 2 males were studied. The most common level was C5 corpectomy (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4). The Neck Disability Index (NDI) preoperative average was 30.01±24.32 and 4-year postoperative 16.90±32.05, with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.801. The preoperative and 4-year postoperative Nürick was 3.28±0.48 and 3.14±1.21 respectively, with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.766. Preoperative lordosis was 14.42±8.03 and 4-year postoperative 17±11.67 degrees, with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.660. The immediate postoperative and 4-year postoperative subsidence was 2.69±2.8 and 6.11±1.61<span class="elsevierStyleHsp" style=""></span>mm respectively, with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the small sample, the subsidence of the mesh cage is common in this procedure. No statistically significant changes were observed in the lordosis or Nürick scale and NDI.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La mielopatía cervical espondilótica es ocasionada por un conducto cervical estrecho. Se han descrito varias técnicas para el tratamiento multinivel, como la corpectomía anterior más colocación de malla y placa anterior, que tiene la ventaja de realizar una descompresión más amplia y utilizar el mismo tejido óseo como injerto; sin embargo, es causa de controversia, ya que el hundimiento de la malla sigue siendo la mayor limitación que tiene este procedimiento.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio prospectivo con seguimiento a 4 años, en 7 pacientes con diagnóstico de conducto cervical estrecho que fueron tratados quirúrgicamente mediante corpectomía de un nivel, colocación de malla de titanio y placa cervical anterior, evaluándolos mediante radiografías y escalas clínicas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se estudió a 5 pacientes femeninos y 2 masculinos. El nivel más común de corpectomía fue C5 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4). El índice de discapacidad cervical (IDC) prequirúrgico media de 30.01±124.32 y posquirúrgico a 4 años 32.05±16.90, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.801. El Nürick prequirúrgico y posquirúrgico a 4 años fue 3.28±0.48 y 3.14±1.21, respectivamente, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.766. La lordosis prequirúrgica fue de 14.42±8.03 y la posquirúrgica a 4 años 17±11.67 grados, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.660. El hundimiento posquirúrgico inmediato y posquirúrgico a 4 años fue de 2.69±2.8 y 6.11±1.61 mm, respectivamente, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A pesar de lo pequeño de la muestra, el hundimiento de la malla es común en este procedimiento. No se observaron cambios estadísticamente significativos en la lordosis ni en la escala de Nürick ni en el IDC.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Reyes Sánchez AA, Gameros Castañeda LA, Obil Chavarría C, Alpizar Aguirre A, Zárate Kalfópulos B, Rosales-Olivares LM. Resultados a 4 años de seguimiento del tratamiento del conducto cervical estrecho mediante corpectomía, malla de titanio y fijación anterior con placa. Cir Cir. 2017;85:381–386.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 837 "Ancho" => 1505 "Tamanyo" => 123618 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Immediate postoperative X-ray. (B) X-ray at 4 years postoperatively.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Union at 4 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative NDI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-operative NDI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative Nürick \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nürick 4 years postoperatively \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative lordosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lordosis 4 years postoperatively \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Immediate post-operative subsidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subsidence at 4 years \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">[0.5–6]<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.801</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">[0.7–8]<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.766</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">[0.9–10]<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.660</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">[0.11–12]<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1675303.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Outcomes per patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Degenerative cervical spinal estenosis: current strategies in diagnosis and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. 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Massicotte" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2106/JBJS.L.01323" "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg Am" "fecha" => "2013" "volumen" => "95" "paginaInicial" => "1659" "paginaFinal" => "1666" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24048553" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24440507/0000008500000005/v2_201802210427/S2444050717300748/v2_201802210427/en/main.assets" "Apartado" => array:4 [ "identificador" => "44603" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24440507/0000008500000005/v2_201802210427/S2444050717300748/v2_201802210427/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050717300748?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 30 | 4 | 34 |
| 2024 September | 83 | 11 | 94 |
| 2024 August | 53 | 15 | 68 |
| 2024 July | 45 | 6 | 51 |
| 2024 June | 29 | 5 | 34 |
| 2024 May | 28 | 8 | 36 |
| 2024 April | 44 | 5 | 49 |
| 2024 March | 40 | 5 | 45 |
| 2024 February | 74 | 2 | 76 |
| 2024 January | 35 | 5 | 40 |
| 2023 December | 35 | 13 | 48 |
| 2023 November | 52 | 5 | 57 |
| 2023 October | 51 | 11 | 62 |
| 2023 September | 37 | 4 | 41 |
| 2023 August | 42 | 5 | 47 |
| 2023 July | 87 | 6 | 93 |
| 2023 June | 63 | 12 | 75 |
| 2023 May | 93 | 13 | 106 |
| 2023 April | 103 | 19 | 122 |
| 2023 March | 113 | 23 | 136 |
| 2023 February | 66 | 25 | 91 |
| 2023 January | 51 | 23 | 74 |
| 2022 December | 39 | 26 | 65 |
| 2022 November | 56 | 23 | 79 |
| 2022 October | 49 | 16 | 65 |
| 2022 September | 55 | 23 | 78 |
| 2022 August | 61 | 7 | 68 |
| 2022 July | 48 | 16 | 64 |
| 2022 June | 38 | 11 | 49 |
| 2022 May | 37 | 13 | 50 |
| 2022 April | 32 | 9 | 41 |
| 2022 March | 63 | 12 | 75 |
| 2022 February | 96 | 8 | 104 |
| 2022 January | 92 | 7 | 99 |
| 2021 December | 59 | 11 | 70 |
| 2021 November | 50 | 11 | 61 |
| 2021 October | 70 | 10 | 80 |
| 2021 September | 31 | 8 | 39 |
| 2021 August | 44 | 8 | 52 |
| 2021 July | 34 | 12 | 46 |
| 2021 June | 23 | 15 | 38 |
| 2021 May | 31 | 8 | 39 |
| 2021 April | 84 | 24 | 108 |
| 2021 March | 41 | 17 | 58 |
| 2021 February | 29 | 8 | 37 |
| 2021 January | 35 | 16 | 51 |
| 2020 December | 45 | 11 | 56 |
| 2020 November | 70 | 10 | 80 |
| 2020 October | 25 | 12 | 37 |
| 2020 September | 17 | 9 | 26 |
| 2020 August | 40 | 12 | 52 |
| 2020 July | 30 | 6 | 36 |
| 2020 June | 25 | 6 | 31 |
| 2020 May | 32 | 17 | 49 |
| 2020 April | 16 | 12 | 28 |
| 2020 March | 38 | 6 | 44 |
| 2020 February | 39 | 5 | 44 |
| 2020 January | 46 | 4 | 50 |
| 2019 December | 38 | 10 | 48 |
| 2019 November | 17 | 3 | 20 |
| 2019 October | 28 | 2 | 30 |
| 2019 September | 23 | 3 | 26 |
| 2019 August | 18 | 2 | 20 |
| 2019 July | 38 | 6 | 44 |
| 2019 June | 70 | 4 | 74 |
| 2019 May | 163 | 27 | 190 |
| 2019 April | 55 | 11 | 66 |
| 2019 March | 21 | 4 | 25 |
| 2019 February | 27 | 4 | 31 |
| 2019 January | 27 | 2 | 29 |
| 2018 December | 19 | 0 | 19 |
| 2018 November | 25 | 1 | 26 |
| 2018 October | 41 | 5 | 46 |
| 2018 September | 32 | 5 | 37 |
| 2018 August | 9 | 1 | 10 |
| 2018 July | 15 | 0 | 15 |
| 2018 June | 13 | 0 | 13 |
| 2018 May | 7 | 0 | 7 |
| 2018 April | 11 | 0 | 11 |
| 2018 March | 8 | 0 | 8 |
| 2018 February | 16 | 4 | 20 |
| 2018 January | 13 | 4 | 17 |
| 2017 December | 8 | 4 | 12 |
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