USO DAS UNIDADES HOUNSFIELD NO PLANEJAMENTO DA CIRURGIA ESPINHAL: REVISÃO SISTEMÁTICA E META-ANÁLISE

Bazán, Pedro Luis; Jordan, Ricardo Cepeda; Cevallos, Juan Romel Medina; Adaro, Alfredo Osvaldo Godoy; Adaro, José Carlos Soria

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Review Article, Degenerativa • Coluna/Columna. 21 (3) • 2022 • https://doi.org/10.1590/S1808-185120222103264579 copiar

USO DAS UNIDADES HOUNSFIELD NO PLANEJAMENTO DA CIRURGIA ESPINHAL: REVISÃO SISTEMÁTICA E META-ANÁLISE

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo:

A densidade mineral óssea é um fator crucial no sucesso ou falha da osteossíntese na cirurgia da coluna vertebral; isso mostra o aparecimento da osteoporose e complicações relacionadas a ela. Sua avaliação é verificada por absorptiometria de raios-X de dupla energia (DEXA) e medição da Unidade Hounsfield (HU) por tomografia. Objetivo: Determinar o uso do HU no planejamento cirúrgico; comparar utilidade no diagnóstico de osteoporose pelo DEXA; e avaliar a sensibilidade na previsão de complicações. Método: Foi realizada uma revisão de literatura sistêmica no PubMed, em consonância com a metodologia PRISMA. Incluindo aqueles que justificaram o uso do planejamento pré-cirúrgico, comparou o HU/DEXA e avaliaram complicações. Para a análise estatística, o χ² foi usado. Resultados: Inicialmente foram identificados 57 artigos por meio da seleção de nove que atenderam aos critérios de inclusão. Em pacientes submetidos à cirurgia espinhal para fixação e fusão por patologia degenerativa, a medição do HU apresentou prevalência de osteoporose de 58,5% (sensibilidade 93,26%; especificidade 90,22%), complicações associadas à osteoporose de 24,5%, diagnóstico adequado de 71,98% e taxa de liberação de parafusos de 82,31%. Conclusões: A medição da UH para o diagnóstico da osteoporose acaba sendo mais sensível, específica e preditiva em relação ao DEXA, principalmente em pacientes idosos; representa uma ferramenta útil no planejamento da cirurgia espinhal, minimizando o risco de complicações como liberação de parafusos, fraturas, pseudoartrose, subsidência de dispositivos intersomáticos e cifose da junção proximal. Nível de evidência II; Revisão Sistemática e meta-análise.

Descritores:
Absorciometria de Fóton; Densidade Óssea; Osteoporose; Parafusos ósseos; Tomografia; Cifose

Author (Year)	Patients (n)	Approach	Conclusions	Type
Kim⁽²¹⁾ (2019)	503	Comparative study of HU vs. DEXA.	Significant correlation between HU and BMD. HU is considered a predictive factor for osteoporosis.	R
St Jeor17 (2020)⁾	140	Comparative study under evaluation of BMD, HU, and DEXA to determine complications associated with osteoporosis	HU is a predictive factor of complications of osteoporosis.	R
Ullrich ¹⁸18 Matsukawa K, Abe Y, Yanai Y, Yato Y. Regional Hounsfield unit measurement of screw trajectory for predicting pedicle screw fixation using cortical bone trajectory: a retrospective cohort study. Acta Neurochir (Wien). 2018;160(2):405-11. https://doi.org/10.1007/s00701-017-3424-5. https://doi.org/10.1007/s00701-017-3424-... (2018)	81	Evaluate the HUs for possible determination of the risk of subsidence of the boxes.	HU measurement is recommended in pre-surgical planning.	R
St Jeor ¹⁹19 Berger-Groch J, Thiesen DM, Ntalos D, Grossterlinden LG, Hesse E, Fensky F, et al. Determination of bone density in patients with sacral fractures via CT scan. Orthop Traumatol Surg Res. 2018;104(7):1037-41. https://doi.org/10.1016/j.otsr.2018.07.022. https://doi.org/10.1016/j.otsr.2018.07.0... (2020)	244	Compare DEXA and HU, a study in patients with degenerative spinal pathology.	Extension of the concept of spinal osteoporosis for patients with poor bone quality.	R
Matsukawa ²⁰20 Bredow J, Boese CK, Werner CML, Siewe J, Löher L, Zarghooni K, et al. Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg. 2016;136(8):1063-7. https://doi.org/10.1007/s00402-016-2487-8. https://doi.org/10.1007/s00402-016-2487-... (2018)	92	Demonstrate the usefulness of HU in the screw path to predict the primary and long-term fixing force of the pedicle screws.	The regional HU values of the screw path could strongly predict both primary and long-term live screw fixation.	R
Berger-Groch²¹21 Xu F, Zou D, Li W, Sun Z, Jiang S, Zhou S, et al. Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery. Neurosurg Focus. 2020;49(2):E10. https://doi.org/10.3171/2020.5.FOCUS20249. https://doi.org/10.3171/2020.5.FOCUS2024... (2018)	531	Collect information on BMD by HT in CT of patients with sacral fractures.	HU is a simple procedure to further assess bone quality in patients with pelvic ring fractures.	R
Bredow ²²22 Ponnusamy KE, Iyer S, Gupta G, Khanna AJ. Instrumentation of the osteoporotic spine: biomechanical and clinical considerations. Spine J. 2011;11(1):54-63. https://doi.org/10.1016/j.spinee.2010.09.024. https://doi.org/10.1016/j.spinee.2010.09... (2016)	365	UH was evaluated in 365 patients to determine the BMD of each vertebral body.	The determination of bone density by pre-operative computed tomography can predict the risk of loosening the screws and inform the decision to use magnification cement to reduce the incidence of loosening the screws.	R
Xu ²³23 Duan PG, Mummaneni PV, Rivera J, Guinn JMV, Wang M, Xi Z, et al. The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up. Neurosurg Focus. 2020;49(2):E7. https://doi.org/10.3171/2020.5.FOCUS20192. https://doi.org/10.3171/2020.5.FOCUS2019... (2020)	143	UH, values of the vertebral body and pedicle as predictors of post-surgical pedicular screw loosening.	The HUs of the vertebral body alone are not enough to accurately assess the risk of loosening the pedicle screw.	R
Zou D ⁸8 Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, et al. Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease. Osteoporos Int. 2007;18(9):1219-24. https://doi.org/10.1007/s00198-007-0370-8. https://doi.org/10.1007/s00198-007-0370-... (2020)	503	The loosening rate of the pedicular screw at 12 months of follow-up was 30.0%.	The HU value measured on CT was an independent predictor of pedicular screw loosening; low HU values correlate significantly with an increased risk of screw loosening.	R

n (patients with osteoporosis)		DEXA study		Total
n (patients with osteoporosis)		N (patients without osteoporosis)		Total
Hounsfield Units	n (patients with osteoporosis)	484	36	520
Hounsfield Units	n (patients without osteoporosis)	35	332	367
Total		519	368	887

Patients with osteoporosis		Diagnosis by Tomographic HU		Total
Patients with osteoporosis		Patients without osteoporosis		Total
Complications	Patients with osteoporosis	255	83	338
Complications	Patients without osteoporosis	588	1469	2057
Total		843	1552	2395

Patients with osteoporosis		Diagnosis by Tomographic HU		Total
Patients with osteoporosis		Patients without osteoporosis		Total
Pedicle screw loosening	Patients with osteoporosis	237	69	306
Pedicle screw loosening	Patients without osteoporosis	4	1052	1056
Total		241	1121	1362

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[1] Correspondence: Pedro Luis Bazán. HIGA San Martín de La Plata, Hospital Italiano de La Plata and Instituto de Diagnóstico 51, La Plata St, Apt 1725, Buenos Aires, Argentina. 1900. pedroluisbazan@gmail.com