Effects of indirect foraminal decompression during anterior cervical disc fusion procedure: preliminary results of a prospective study with clinical and radiological outcomes.

INTRODUCTION: The respective effects of direct and indirect decompression in the clinical outcome after anterior cervical disc fusion (ACDF) is still debated. The main purpose of this study was to analyze the effects of indirect decompression on foraminal volumes during ACDF performed in patients suffering from cervico-brachial neuralgias due to degenerative foraminal stenosis, i.e. to determine whether implant height was associated with increased postoperative foraminal height and volume. METHODS: A prospective follow-up of patients who underwent ACDF for cervicobrachial neuralgias due to degenerative foraminal stenosis was conducted. Patient had performed a CT-scan pre and post-operatively. Disc height, foraminal heights and foraminal volumes were measured pre and post operatively. RESULTS: 37 cervical disc fusions were successfully performed in 20 patients, with a total of 148 foramina studied. Foraminal height and volume were measured bilaterally on the pre- and post-operative CT scans (148 foramina studied). After univariate analysis, it was found a significant improvement for every radiological parameter, with a significant increase in disc height, foraminal height and foraminal volume being respectively +3,22 mm (p < 0,001), +2,12 mm (p < 0,001) and +54 mm3 (p < 0,001). Increase in disc height was significantly associated with increase in foraminal height (p < 0,001) and foraminal volume (p < 0,001). At the same time, increase in foraminal height was significantly correlated with foraminal volume (p < 0,001), and seems to be the major component affecting increasing in foraminal volume. CONCLUSION: Indirect decompression plays an important part in the postoperative foraminal volume increase after ACDF performed for cervicobrachial neuralgias.

2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults.

These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.

Tomodensitometric bone anatomy of the intervertebral foramen of the lower cervical spine: measurements and comparison of foraminal volume in healthy individuals and patients suffering from cervicobrachial neuralgia due to foraminal stenosis.

PURPOSE: Degenerative foraminal stenosis of the cervical spine can lead to cervicobrachial neuralgias. Computed tomography (CT)-scan assists in the diagnosis and evaluation of foraminal stenosis. The main objective of this study is to determine the bony dimensions of the cervical intervertebral foramen and to identify which foraminal measurements are most affected by degenerative disorders of the cervical spine. These data could be applied to the surgical treatment of this pathology, helping surgeons to focus on specific areas during decompression procedures. METHODS: A descriptive study was conducted between two groups: an asymptomatic one (young people with no evidence of degenerative cervical spine disorders) and a symptomatic one (experiencing cervicobrachial neuralgia due to degenerative foraminal stenosis). Using CT scans, we determined a method allowing measurements of the following foraminal dimensions: foraminal height (FH), foraminal length (FL), foraminal width in its lateral part ((UWPP, MWPP and IWPP (respectively Upper, Medial and Inferior Width of Pedicle Part)) and medial part (UWMP, MWMP and IWMP (respectively Upper, Medial and Inferior Width of Medial Part)), and disk height (DH). Foraminal volume (FV) was calculated considering the above data. Mean volumes were measured in the asymptomatic group and compared to the values obtained in the symptomatic group. RESULTS: Both groups were made up of 10 patients, and a total of 50 intervertebral discs (100 intervertebral foramina) were analyzed in each group. Comparison of C4C5, C5C6 and C6C7 levels between both groups showed several significant decreases in foraminal dimensions (p < 0.05) as well as in foraminal volume (p < 0.001) in the symptomatic group. The most affected dimensions were UWPP, MWPP, UWMP, MWMP and FV. The most stenotic foraminal areas were the top of the uncus and the posterior edge of the lower plate of the overlying vertebra. CONCLUSION: Using a new protocol for measuring foraminal volume, the present study refines the current knowledge of the normal and pathological anatomy of the lower cervical spine and allows us to understand the foraminal sites most affected by degenerative stenosis. Those findings can be applied to foraminal stenosis surgeries. According to our results, decompression of the foramen in regard of both uncus osteophytic spurs and inferior plate of the overlying vertebra might be an important step for spinal nerves release.

Post-traumatic Curvularia sp. arthritis in an immunocompetent adult.

A 44-year-old woman, victim of a road accident in Mali was diagnosed with left knee arthritis. Joint effusion aspiration and subcutaneous surgical biopsies were positive for a melanized asexual ascomycete. Using microscopy and molecular biology, the fungus was identified as Curvularia sp. In vitro antifungal susceptibility was determined by the EUCAST broth microdilution reference technique and by E-test. The patient was treated with liposomal amphotericin B before posaconazole relay. Mycological samples obtained 10 days after starting the antifungal therapy by liposomal amphotericin B were negative in culture. Curvularia spp. are environmental fungi which can under certain conditions be pathogenic for humans.

Thromboembolic risk after lumbar spine surgery: a cohort study on 325 000 French patients.

Essentials The risk of venous thromboembolism (VTE) after lumbar spine surgery (LBS) is not precisely known. More than 320 000 patients who underwent LBS in France between 2009 and 2014 were followed-up. The overall risk of VTE after LBS is less than 1% but modulated by patient and procedural factors. Surgical device implantation, anterior approach and complex surgery increase the risk of VTE. SUMMARY: Background Postoperative venous thromboembolism (VTE) is a severe complication, the risk of which after lumbar spine surgery (LBS) is not precisely known. Objective To estimate the incidence of VTE after LBS, and to identify individual and surgical risk factors. Methods All patients aged >18 years who underwent LBS in France between 2009 and 2014 were identified. Among 477 024 patients screened, exclusions concerned recent VTE or surgery, and multiple surgeries during the same hospital stay. Results In 323 737 patients (mean age 52.9 years, 51.4% male), we observed 2911 events (0.91%) after a median time of 12 days (Q1-Q3: 5-72 days). The multivariate adjusted Cox model showed increased risks associated with age (4% per year of age; 95% confidence interval [CI] 3.8-4.3), obesity (hazard ratio [HR] 1.32, 95% CI 1.18-1.46), active cancer (HR 1.65, 95% CI 1.5-1.82), previous thromboembolism (HR 5.41, 95% CI 4.74-6.17), severe paralysis (HR 1.47, 95% CI 1.17-1.84), renal disease (HR 1.28, 95% CI 1.04-1.6), psychiatric disease (HR 1.21, 95% CI 1.1-1.32), use of antidepressants (HR 1.13, 95% CI 1.03-1.24), use of contraceptives (HR 1.56, 95% CI 1.19-2.03), extended surgery for scoliosis (HR 3.61, 95% CI 2.96-4.4), implantation of pedicular screws with a 'dose-effect' association, and an anterior approach (HR 1.97, 95% CI 1.6-2.43) or a combined approach (HR 2.03, 95% CI 1.44-2.84). Conclusions The overall VTE risk after LBS is moderate (< 1%) but is widely modulated by several easily identifiable risk factors. The surgical community should be aware of this heterogeneity, adapt prevention according to patients and to the procedure, and use drug prophylaxis in the event of a high risk being present.

Evolution and complications after surgery for spine deformation in patients with Parkinson's disease.

INTRODUCTION: Surgical treatment of spinal deformity is high risk in patients suffering from Parkinson's disease (PD). Several series have already reported a high rate of complications. However, none of these studies included more than 40 patients and none of the risk factors of complications were described. The aim of this study was to describe the rate and risk factors of revision surgery as well as the clinical outcome at the last visit in a large multicenter study of PD patients operated for spinal deformities. METHODS: A multicenter retrospective study included arthrodesis for spinal deformity in patients with PD. Clinical and surgical data including revision surgeries were collected. Assessment of functional outcomes at last follow-up was classified in 3 grades and spinal balance was assessed on anteroposterior and lateral plain X-rays of the entire spine. RESULTS: Forty-eight patients were included. Median age was 67 years old (range 41-80). Median follow-up was 27 months. The rate of surgical revision was 42%. Eighty per cent of revisions were performed for chronic mechanical complication. Global results were considered to be good in 17 patients (35%), doubtful in 17 patients (35%) and a failure in 14 patients (30%), for the whole series. CONCLUSIONS: The results of surgery for spinal deformities in patients with Parkinson disease vary with a high rate of complications and revisions. Nevertheless, these results should be seen in relation to the natural progression of these spinal deformities once spinal imbalance has developed. The association between preoperative clinical balance and final outcome suggests that early surgery can probably play a role in treatment. LEVEL OF EVIDENCE: Level IV (e.g. case series).

Neurological deficit secondary to a pre-sacral abscess with epidural extension up to L3: A case report and literature review.

Isolated epidural abscesses are uncommon lesions. Surgical treatment may be difficult due to the extension of these lesions. We present a case of a pelvic abscess spreading along the path of the sciatic nerve to the gluteus muscles and the lumbar canal, causing neurological compression; requiring surgical treatment with three simultaneous approaches.

Mid-term survivorship of Mini-keel™ versus Standard keel in total knee replacements: Differences in the rate of revision for aseptic loosening.

INTRODUCTION: To reduce the size of the surgical incision, modular mini-keel tibial components have been developed with or without extensions for the Nexgen™ MIS Tibial Component. Although a smaller component could theoretically result in defective fixation, this has never been evaluated in a large comparative series. Thus, we performed the following case control study to: (1) evaluate intermediate-term survival of a modular "mini-keel" tibial component compared to a reference standard keel component from the same line of products (Nexgen LPS-Flex Tibial Component, Zimmer); (2) to identify any eventual associated factors if the frequency of loosening was increased. HYPOTHESIS: The rate of revision for aseptic tibial loosening is comparable for both components. MATERIALS AND METHODS: This comparative, retrospective, single center series of 459 consecutive total knee arthroplasties (TKA) was performed between 2007 and 2010: with 212 modular "mini-keel" (MK) tibial components and 247 "standard" (S) components. Survival, rate of revision for aseptic tibial loosening and identification of a radiolucent line were analyzed at the final follow-up. RESULTS: After a median follow-up of 5years, the rate of revision for tibial aseptic loosing was significantly higher in the MK group with 12 cases (5.7%) and 4 cases in the S group (1.6%) (P=0.036). The use of the MK component appears to be a prognostic factor for surgical revision (hazard ratio=3.86 (1.23-11.88), P=0.02) but not for the development of a radiolucent line (HR=1.75 (0.9-3.4), P=0.097). The mean delay before revision was 38months (8-64) in the MK group and 15.2months (8-22) in the S group (P=0.006). Individual factors, such as gender, body mass index (BMI) and pre- or postoperative alignment were not prognostic factors for revision or radiolucent lines. CONCLUSION: The modular "mini-keel" tibial component was associated with a greater risk of revision for tibial component loosening. LEVEL OF EVIDENCE: Case control study, III.

Surgery in vertebral fracture: epidemiology and functional and radiological results in a prospective series of 518 patients at 1 year's follow-up.

INTRODUCTION: Recent epidemiological data for spinal trauma in France are sparse. However, increased knowledge of sagittal balance and the development of minimally invasive techniques have greatly improved surgical management. OBJECTIVES: To describe the epidemiology and management of traumatic vertebral fracture, and to analyze evolution and risk factors for poor functional outcome at 1 year's follow-up. MATERIALS AND METHODS: A prospective multicenter French cohort study was performed over a 6-month period in 2011, including all cases of vertebral fracture surgery. Data were collected by online questionnaire over the Internet. Demographic characteristics, lesion type and surgical procedures were collected. Clinical, functional and radiological assessment was carried out at 1 year. RESULTS: Five hundred and eighteen patients, with a mean age of 47 years, were included. Sixty-seven percent of fractures involved the thoracic or lumbar segment. Thirty percent of patients had multiple fractures and 28% neurological impairment. A minimally invasive technique was performed in 20% of cases and neurological decompression in 25%. Dural tear was observed in 42 patients (8%). Seventy percent of patients were followed up at 1 year. Functionally, SF-36 scores decreased on all dimensions, significantly associated with age, persistent neurological deficit and previous spine imbalance. Thirty-eight percent of working patients had returned to work. Radiologically, sagittal balance was good in 74% of cases, with fracture consolidation in 70%. DISCUSSION: Despite progress in management, spinal trauma was still a source of significant morbidity in 2011, with pronounced decrease in quality of life. Conserved sagittal balance appeared to be associated with better functional outcome.

Spinal cord compression due to undiagnosed thoracic meningioma following lumbar surgery in an elderly patient: a case report.

As spinal surgery in elderly patients is becoming increasingly frequent, comorbidities likely to be decompensated after such procedures must be kept in mind. We report here the case of an 82-year-old woman who presented rapidly progressive spinal cord compression following lumbar surgery for radiculopathy. Investigations showed a thoracic intradural extramedullary compressive lesion, which after removal turned out to be a meningioma. We suggest that radiculopathy and non-specific degenerative modifications partially masked this lesion, and that lumbar surgery caused this acute neurological deterioration. Therefore, we advice caution in older patients among whom such ambiguous clinical presentation is frequent.

Recurrent solitary fibrous tumour of the thoracic spine. A case-report and literature review.

Solitary fibrous tumours (SFTs) are rare tumours originating in the soft tissues. SFT development in the spine is an exceedingly rare event about which little is known. We describe a case of SFT of the thoracic spine in a 56-year-old woman. She presented with neurological deficits that required emergency resection, which was incomplete. Two subsequent local recurrences prompted further surgical procedures. At last follow-up, 12 months after the last procedure, function was satisfactory and there was no evidence of tumour recurrence. The management of SFTs is not well standardised, and no proven adjuvant treatments are available to date. Complete excision is effective in controlling disease progression. Prolonged follow-up is mandatory.