Defining threshold for sagittal correction in lumbar fractures.

PURPOSE: Surgical indications for thoraco-lumbar fractures are driven both by neurological status, fractures instability and kyphotic deformity. Regarding kyphotic deformity, an angulation superior to 20° is considered by many surgeons as a surgical indication to reduce the disability induced by post-traumatic kyphosis. However, there is a lack of data reporting the ideal or theoretical lordosis that one must have in a particular lumbar segment on CT-scan. The main goal of this study was to determine the mean value for segmental lumbar lordosis according to pelvic incidence (PI) on a cohort of normal subjects. METHODS: The consecutive CT-scan of 171 normal adult subjects were retrospectively analyzed. The PI and the segmental lordosis (L4S1, L3L5, L2L4, L3L1, L2T12 and T11-L1) were measured on all CT-scan. The mean values were calculated for the global cohort and a sub-group analysis according to IP ranges (< 45°, 45 < IP < 60° and > 60°) was performed. RESULTS: The mean angular values for the whole cohort were IP: 54, 9°; L4S1: - 38, 1°; L3L5: - 30, 6°; L2L4: - 14, 1°; L1L3: - 4, 9°; T12L2: + 1, 9° and T11L1: + 5, 4°. The segmental values vary significatively with PI ranges, as for L3L5: - 26, 8° (PI < 45°); - 30° (45 < PI < 60°) and - 35, 1° (PI > 60°). CONCLUSION: These results provide a referential of theoretical values of segmental lordosis according to PI. This abacus may help spinal surgeon in their decision-making process regarding lumbar fractures, to determine the amount of sagittal correction needed, according to the PI range, to be adapted to the sagittal morphology of the patient. LEVEL OF EVIDENCE: III.

Initial experience, feasibility, and technical development with an electromagnetic navigation assistance in percutaneous pelvic bone cementoplasty: retrospective analysis.

OBJECTIVES: To assess the feasibility and technical outcomes of pelvic bone cementoplasty using an electromagnetic navigation system (EMNS) in standard practice. MATERIALS AND METHODS: Monocentric retrospective study of all consecutive patients treated with cementoplasty or reinforced cementoplasty of the pelvic bone with EMNS-assisted procedures. The endpoints were periprocedural adverse events, needle repositioning rates, procedure duration, and radiation exposure. RESULTS: A detailed description of the technical steps is provided. Thirty-three patients (68 years ± 10) were treated between February 2016 and February 2020. Needle repositioning was required for 1/33 patients (3%). The main minor technical adverse event was soft tissue PMMA cement leaks. No major adverse event was noted. The median number of CT acquisitions throughout the procedures was 4 (range: 2 to 8). Radiation exposure and mean procedure duration are provided. CONCLUSION: Electromagnetic navigation system-assisted percutaneous interventions for the pelvic bone are feasible and lead to low rates of minor technical adverse events and needle repositioning. Procedure duration and radiation exposure were low. KEY POINTS: • Initial experience for 33 patients treated with an electromagnetic navigation assistance for pelvic cementoplasty shows feasibility and safety. • The use of an electromagnetic navigation system does not expose to high procedure duration or radiation exposure. • The system is efficient in assisting the radiologist for extra-axial planes in challenging approaches.

The "Eiffel Tower" technique: novel long-axis sacroplasty under electromagnetic navigation assistance; feasibility and descriptive study.

OBJECTIVES: To describe a novel long-axis multimodal navigation assisted technique - the so-called Eiffel Tower technique - aimed at integrating recent technological improvements for the routine treatment of sacral insufficiency fractures. MATERIALS AND METHODS: The long-axis approach described in the present study aimed at consolidating the sacral bone according to biomechanical considerations. The purpose was (i) to cement vertically the sacral alae all along and within the lateral fracture lines, resembling the pillars of a tower, and (ii) to reinforce cranially with a horizontal S1 landing zone (or dense central bone) resembling the first level of the tower. An electromagnetic navigation system was used in combination with CT and fluoroscopic guidance to overtop extreme angulation challenges. All patients treated between January 2019 and October 2021 in a single tertiary center were retrospectively reviewed. RESULTS: A description of the technique is provided. Twelve female patients (median age: 80 years [range: 32 to 94]) were treated for sacral insufficiency fractures with the "Eiffel Tower" technique. The median treatment delay was 8 weeks (range: 3 to 20) and the initial median pain assessed by the visual analogue scale was 7 (range: 6 to 8). Pain was successfully relieved (visual analogue score < 3) for 9 patients (75%) and persisted for 2 patients (17%). One patient was lost during the follow-up. No complication was noted. CONCLUSION: The "Eiffel Tower" multimodal cementoplasty integrates recent technological developments, in particular electromagnetic navigation, with the purpose of reconstructing the biomechanical chain of the sacral bone. KEY POINTS: • Sacral insufficiency fractures are common and can be efficiently treated with percutaneous sacroplasty. • The long axis sacroplasty approach can be challenging given both the shape of the sacral bone and the angulation to reach the target lesion. • The "Eiffel Tower" technique is a novel approach using electromagnetic navigation to expand the concept of the long axis route, adding a horizontal S1 landing zone.

Extraction of cement leakages and malpositioned spindles complicating percutaneous interventions: why, when and how?

OBJECTIVES: Cement leakages in soft tissues are a common occurrence during cementoplasty. They may cause chronic pain, and thus treatment failure. Spindle malposition during reinforced cementoplasty may cause vascular, nerve or cartilage injury. Our goal was to evaluate the rate of cement leakage/spindle extraction and describe the techniques used. METHODS: This retrospective monocentre study included 104 patients who underwent reinforced cementoplasty and 3425 patients who underwent cementoplasty between 2012 and 2020. Operative reports and fluoroscopic images were reviewed to identify extraction attempts and their outcomes. RESULTS: Six patients (5.8%) had a malpositioned spindle, and all of them underwent spindle extraction during reinforced cementoplasty, with an 80% success rate. A total of 7 attempts were performed, using 2 different techniques. One thousand one hundred thirty patients (32%) had a cement leak in soft tissues, and 7 (0.6%) underwent cement leakage extraction during cementoplasty, with a 100% success rate. A total of 10 attempts were performed, using 3 different techniques. No major complication related to the extraction procedures occurred. CONCLUSIONS: Spindle malpositions and soft tissue cement leakages are not uncommon. We described 5 different percutaneous techniques that were safe and effective to extract spindles and paravertebral cement fragments. KEY POINTS: • Soft tissue cement leakages or spindle malpositions are a non-rare occurrence during cementoplasty, and may cause technical failure and/or chronic pain. • Most soft tissue cement fragments and malpositioned spindles can easily be extracted using simple percutaneous techniques.

Efficiency of a novel vertebral body augmentation system (Tektona™) in non-osteoporotic spinal fractures.

BACKGROUND: The restauration of the local kyphosis is crucial to thoracolumbar fractures outcomes. Recently, the Tektona™ (Spine Art) system, constituted by a flexible lamella for corporeal reduction has emerged as a promising solution for osteoporotic fractures. However, no study has yet focused on its results on traumatic fractures. METHODS: A retrospective longitudinal study on prospectively collected data was conducted on 53 patients that had a kyphoplasty by Tektona™, associated or not to percutaneous fixation. The data collected were clinical, surgical and scannographic (measurement of AVH, MVH and PVH (anterior/medium/posterior vertebral height), and RTA (regional traumatic angle) in°), preoperatively, post-operatively and at last follow-up. RESULTS: Fractures were mainly located at the upper lumbar spine and were AOSpine A3 type for 74%. The mean RTA was 12° in pre-operative, 4° in post-operative (p = 2e- 9), and 8° at the last follow-up (p = 0,01). The mean correction of RTA for the fixation group was - 10 ± 6° versus - 7 ± 4° for the kyphobroplasty alone group (p = 0,006). The mean correction for fractures located at T10-T12 was - 9 ± 3°, - 9 ± 5° for L1, - 8 ± 3° for L2 and - 5 ± 3° for L3-L5 (p = 0,045). CONCLUSIONS: The Tektona® system appears to be efficient for acute thoraco-lumbar fractures, comparable to other available systems, allowing a real intracorporeal reduction work. Its relevance, especially in the long term needs further investigation. The association of a percutaneous fixation allow to obtain a better correction of the RTA but did not seem to prevent the loss of correction at follow-up.

[Pathologies of the spine]. / Les pathologies du rachis.

Spinal pathology is a major public health problem. It is sometimes referred to as the "disease of the century" due to the increasing number of people affected. It can be low back pain or neck pain, but whatever the mechanism and the age of the patient, its consequences on the quality of life are undeniable. In the case of scoliosis, which can cause an alteration in body image in young patients, treatment requires, in addition to possible surgery, long-term support.

[The nurse and postoperative monitoring in spinal surgery]. / L'infirmière et les surveillances postopératoires en chirurgie rachidienne.

As after any surgical procedure, the spinal patient is transferred to the postoperative surveillance room. There, a nurse will closely monitor the patient's vital parameters. Particular vigilance is deployed to identify possible complications related to the operation, some of which are specific to scoliosis. The management of postoperative pain is also at the heart of the care.

Reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography in hypervascular spinal metastases prior embolization.

OBJECTIVES: Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization. METHODS: All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized "yes vs no" scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics. RESULTS: Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI [0.09-0.81]) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI [0.37-1.00]). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0). CONCLUSIONS: TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool. KEY POINTS: • TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases. • TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography. • TR-CE-MRA's spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.

Safety and effectiveness of cervical vertebroplasty: report of a large cohort and systematic review.

PURPOSE: To evaluate retrospectively safety and effectiveness of cervical vertebroplasty (cVP) based on a single-center large cohort. MATERIALS AND METHODS: All cVP performed at a single center from January 2001 to October 2014 were included and reviewed. Procedure-related complications (minor and major) were systematically recorded. Effectiveness in terms of analgesia was evaluated using a semi-quantitative grading scale at 1-month follow-up. Risk factors for the occurrence of a procedure-related complication or cement leakage, as well as factors influencing pain relief at 1-month follow-up, were evaluated using a multivariate analysis. RESULTS: One hundred and forty cVP procedures (176 vertebrae) were performed in 130 consecutive patients (88 female, 42 male; mean age = 56 years) during the inclusion period. Among the treated lesions, 80% were bone metastases (mostly from breast cancer), 8% were related to hematological malignancies, and 12% were non-malignant lesions. One fatal complication (0.7%) was related to cement migration in the vertebrobasilar system. Three cervical hematomas were recorded, one of them requiring prolonged oral intubation. The overall rate of major complications was 1.5%. At 1 month, pain reduction was observed in 76% of the cases. Additional surgical fixation was required in 6.1% of the cases. cVP of more than one vertebra during the same session was an independent risk factor for procedure-related complications. CONCLUSION: Cervical vertebroplasty is a safe technique with an acceptable major complication rate. Its effectiveness in terms of pain relief is good at mid-term follow-up. KEY POINTS: • Cervical vertebroplasty (cVP) is a safe procedure with a low rate of major complications (1.5%). • cVP provides pain relief in 76% of the cases. • Additional fixation surgery is rarely required after cVP (6.1% of the cases).

Long-term outcome of percutaneous alcohol embolization combined with percutaneous vertebroplasty in aggressive vertebral hemangiomas with epidural extension.

OBJECTIVES: To evaluate, on a long-term basis, the safety and effectiveness of percutaneous alcohol embolization (PAE) combined with percutaneous vertebroplasty (PVP) as a sole treatment for aggressive vertebral haemangiomas (AVHs) with epidural extension. METHODS: From 1996 to 2015, 26 consecutive patients (15 women [58%] and 11 men; mean age 51.8 years [range: 19-75 years]) underwent PAE combined with PVP (performed at day 15) for the treatment of 27 AVHs with epidural extension. Clinical outcome was evaluated with a mean delay of 88.3 ± 53.3 months (range: 22-217 months). The primary endpoint was pain relief evaluated with a visual analogue scale (VAS). RESULTS: Pre-procedure mean VAS score was 7.23 ± 1.3 and significantly improved at last follow-up (m = 3.11 ± 1.9; p < 0.001). Ten patients (38.5%) remained asymptomatic. Eighty-eight percent of the patients with neurosensory disorders had complete regression of these symptoms. Two of the three patients with motor deficit did not show any improvement. No major complication was recorded. CONCLUSIONS: PAE combined with PVP is a minimally invasive safe and effective therapeutic approach for AVH with epidural involvement, even on long-term clinical outcome. This technique appears mainly effective for pain and neurosensory symptoms, but seems less effective for motor deficit relief. KEY POINTS: • Combination of PAE with PVP is a safe technique. • PAE combined with PVP is an effective treatment for sensory symptoms. • This strategy seems less effective in patients with motor deficits.

Reinforced cementoplasty using dedicated spindles in the management of unstable malignant lesions of the cervicotrochanteric region.

OBJECTIVES: In long bones, cementoplasty alone does not provide sufficient stability, which may cause secondary fractures. This study reviewed the safety and efficacy of reinforced cementoplasty (RC) (percutaneous internal fixation using dedicated spindles combined with cementoplasty) for unstable malignant lesions of the cervicotrochanteric region (CTR) of the proximal femur. METHODS: Eighteen consecutive patients (nine women [50%] and nine men [50%]; mean age 55.1 ± 16.2 years; range 22-85) underwent RC for 19 unstable lesions of the CTR (16/19 [84.2%] bone metastases, 3/19 [15.8%] multiple myeloma lesions). All the patients were considered unsuitable for surgery. Clinical outcome was judged with a mean follow-up of 8.8 ± 7.2 months (range 1-27). The primary endpoints were occurrence of secondary fractures during the follow-up period and local pain relief measured by a visual analogue scale (VAS). RESULTS: No secondary fracture occurred. Mean VAS improved from 5.9 ± 3.1 (range 0-10) to 2.3 ± 2.4 (range 0-7) at 1 month (p = 0.001) to 1.6 ± 1.7 (range 0-5) at final follow-up (p = 0.0002). One symptomatic cement pulmonary embolism was recorded. CONCLUSION: RC is an original minimally invasive technique providing pain relief and effective bone stability for unstable malignant lesions of the cervicotrochanteric region in patients unsuitable for open surgery. KEY POINTS: • Reinforced cementoplasty (RC) combines intralesional spindling with cementoplasty. • RC provides effective bone stability and pain relief. • RC is a suitable minimally invasive option for patients in poor general condition.

Sacropelvic fixation with iliosacral screws: applications and results in adult spinal deformities.

STUDY DESIGN: Retrospective radiographic and clinical review. OBJECTIVE: To determine the feasibility of iliosacral screw fixation in adult spinal deformations. SUMMARY OF BACKGROUND DATA: Pelvic fixation is one of the most challenging instrumentation problems. The poor bone quality frequently found within the sacrum and the large lumbosacral loads with cantilever pullout forces across this region explain its frequent failure. METHODS: Fourteen adult patients undergoing pelvic fixation using iliosacral screws with a minimal follow-up of 24 months were analyzed for radiographic outcomes. Radiographic data included the localization of the spinal deformity, the Cobb angle, T4-T12 thoracic kyphosis, L1-S1 lumbar lordosis, the T9 tilt, the pelvic parameters, and the POA. Mechanical and infectious complications were also noted. RESULTS: The lumbo-pelvic correction was performed with a large reduction of the POA in every case. The frontal and sagittal corrections obtained with this procedure were considered as being effective. There were no mechanical complications due to failure of the instrumentation, loss of sacral fixation, or loss of lumbar lordosis at the time of the last follow-up. One patient experienced local infection on the left iliosacral screw without any residual functional sequel. DISCUSSION: Iliosacral screwing can offer a pelvic fixation reliable enough to allow restoration of 3-dimensional trunk balance. This technique has a quite short learning curve and adequately permits frontal and sagittal corrections, increases stability, and decreases instrumentation-related complications. Our observations suggest that it is applicable to pelvic fixation in adult surgery.

Malpractice litigation after spinal surgery: A review of allegations in France in 1990-2020.

OBJECTIVE: Spinal surgery is among the specialities with the highest rates of complications and of peri-operative morbidity and mortality. The number of spinal surgeries performed is rising year on year in France. The objectives of this study were to identify the main reasons for malpractice claims after spinal surgery in France, to evaluate the impact of avoidable errors, and to examine differences between civil lawsuits (private institutions) and administrative lawsuits (public institutions). HYPOTHESIS: The leading reasons for malpractice litigation are avoidable errors such as inadequate patient information, errors in indications, and inadequate post-operative monitoring. MATERIAL AND METHODS: We reviewed malpractice claims related to spinal surgery and recorded in two French databases (Legifrance and Doctrine) in 1990-2020. We combined the indexing term "surgery" with any of the following terms: "disc", "spine", "cervical", "vertebral", "lumbar", "scoliosis", "disc replacement", and "fusion". The search was performed by three orthopaedic surgeons who were blind to patient data and recorded the allegations, verdicts, and pay-outs. RESULTS: We included 275 claims. The main plaintiff allegations were inadequate information (34.5%), infection (22%), spinal-cord injury (17%), and errors in indication (13%). Among these reasons, 56.7% may have been partly avoidable. In private institutions, claims for infection and for erroneous indication were significantly more common than in public institutions (p=0.02 for both), whereas the opposite was true for spinal-cord injury (p<0.001). CONCLUSION: After spinal surgery in France, the most common malpractice allegation was inadequate information. Over half the claims were related to potentially avoidable factors. Among allegations, errors in indication were significantly more common in civil than in administrative lawsuits. LEVEL OF PROOF: IV, retrospective observational database study.

Onyx injection by direct puncture for presurgical embolization of a C2 hypervascular metastasis from a thyroid cancer.

Surgery for spinal hypervascular lesions, such as hemangioma or metastases from thyroid or renal cancer, may be challenging because of the risk of massive blood loss.1 To overcome this limitation, presurgical embolization has gained acceptance to reduce this risk.2 However, some configurations, such as the origin of a radiculomedullary artery close to the vessels feeding the lesion or when the lesion is supplied by vessels feeding an eloquent territory, may limit the possibility of presurgical embolization, especially with microparticles.3 Direct percutaneous puncture of the spinal lesion and subsequent embolization with liquid embolic agent may be a valuable option in such challenging cases.4 We present a case of presurgical embolization of a C2 metastasis from a thyroid cancer using Onyx-18 injected by direct puncture (video 1). In this technical video, we stress the technical aspects of the direct puncture technique and the safety rules to avoid neurological complications. neurintsurg;14/1/neurintsurg-2020-017180/V1F1V1Video 1.

Screw Loosening in Posterior Spine Fusion: Prevalence and Risk Factors.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Screw loosening in spinal fusion is poorly defined. Accordingly, its prevalence rates range from 1% to 60%, and its risk factors remain undefined. The goal of this study was to assess the prevalence of screw loosening, according to precise definitions, and to identify factors associated with it. METHODS: We retrospectively reviewed records for 166 patients who underwent a posterior spinal fusion in our institution between 2011 and 2016. We recorded demographic data, osteoporosis, pelvic balance, surgery-related information, and postoperative radiographic data at a minimum follow-up of 6 months. Univariable and multivariable logistic regression models were used. Significance was defined by P < .05. RESULTS: When loosening was defined by partial pull-out, its prevalence was 9.6% (95% CI 5.6-15); thoracic localization, the use of CrCo (chromium-cobalt) rods, osteoporosis, PI/LL (pelvic incidence/lumbar lordosis) mismatch (preoperative), and frontal imbalance (preoperative) were significant risk factors. When loosening was defined by osteolysis (radiolucent rim) >1 mm around at least 1 screw, its prevalence was 40.4% (95% CI 33-48) and age, scoliosis as indication for fusion, ASA (American Society of Anesthesiologists) 2 or 3, the use of CrCo rods, more than 5 levels fused, no circumferential arthrodesis, postoperative bracing, and sacrum or ilium as the inferior level of instrumentation were also significant risk factors. CONCLUSIONS: A clear definition of screw loosening seems essential for a useful analysis of the literature. Osteoporosis, sagittal imbalance, and rigid material appear to be risk factors, regardless of the definition.

Transoral vertebroplasty for the C1 lateral mass.

BACKGROUND: Osteolytic lesions of the atlas (C1) are challenging to treat by vertebroplasty due to the vicinity of the vertebral artery and the spinal cord. OBJECTIVE: To present our experience with transoral vertebroplasty (TOV) for osteolytic lesions of the lateral mass of the atlas. METHODS: Retrospective case series involving 15 consecutive patients (nine male, six female, mean age 63 years) who underwent TOV for the treatment of an osteolytic lesion of the lateral mass of the atlas. Among the osteolytic lesions, 10/15 (67%) were bone metastases from various cancers; 4/15 (27%) were lesions related to multiple myeloma; and one lesion (7%) was an aggressive hemangioma. All the TOVs were performed under general anesthesia and in most cases (10/15; 67%) in a hybrid angiosuite combining a C-arm flat panel and a CT scan. The remaining five patients were treated under biplane fluoroscopic guidance. RESULTS: Vertebroplasty of the lateral mass of C1 through a transoral route was feasible in all cases. Significant pain relief was obtained in most cases (1 month average decrease in Numeric Rating Scale: 4.9±4.1). No major complication was recorded. In 7/15 cases (47%), cement leakage surrounding the C1 lateral mass was seen; none of these leakages had a significant clinical consequence. No additional spine surgery was required in any of the patients. CONCLUSION: TOV of osteolytic lesions of the lateral mass of the atlas is feasible and seems safe and effective, providing pain relief and bone stabilization.

Survival in breast cancer patients with spine metastases: Prognostic assessment involving molecular markers.

BACKGROUND: To clarify and update the prognostic assessment for heterogeneous population of patients with breast cancer and spine metastases (SpM), using molecular markers. METHODS: The patient data used in this study was obtained from a French national multi-center database of patients treated for breast cancer with SpM between 2014 and 2017. 556 SpM cases were diagnosed. RESULTS: Median overall survival (OS) time for all patients following the SpM event was 43.9 months. First, we confirmed 3 previously known significant prognostic factors for survival of patients with SpM: young age [HR: 2.019, 95% CI 1.343-3.037; p = 0.001], good WHO status [ Status 0 HR: 2.823, 95% CI 1.231-3.345; p < 0.0001] or [ Status 1 HR: 1.956, 95% CI 0.768-2.874; p = 0.001] and no-ambulatory neurological status: Frankel A-C [HR: 0.438, 95% CI 0.248-0.772; p = 0.004]. Secondly, we determined the effect of gene mutations on survival in patients with SpM, and we identified that HER2+ cancer subtype [HR: 1.567, 95% CI 0.946-2.557; p = 0.008] was an independent predictor of longer survival, whereas basal cancer subtype [HR: 0.496, 95% CI 0.353-0.699; p < 0.0001] was associated with a poorer prognosis. Other factors including the number of SpM, surgery, extraspinal metastases, synchrone metastases, metastasis-free survival, and SpM recurrence were not identified as prognostically relevant to survival. CONCLUSION: Survival and our ability to estimate it in breast cancer patients with SpM has improved significantly. Therefore, SpM prognostic scoring algorithms should be updated and incorporate genotypic data on subtypes to make treatment more adaptive.

Spinal metastases from lung cancer: Survival depends only on genotype, neurological and personal status, scarcely of surgical resection.

BACKGROUND: For patients with non-small cell lung cancer (NSCLC), the spinal column is the most common site for bone metastasis. Studies that assess survival prognostic factors associated with specific lung spinal metastases (SpM) are weak and required the incorporation of genotype mutations. METHODS: A prospective French national multicenter database of patients treated for SpM between January 2014 and 2017.818 lung SpM were diagnosed over the course or at the time of diagnosis of 210 consecutive patients with NSCLC. RESULTS: Median overall survival (OS) time for all patients from the lung SpM event was 5.9 months (SD 0.609). For 122 patients (61%), lung tumor and SpM were diagnosed synchronously. In univariate analysis, good World Health Organisation (WHO) status (p < 0.0001), ambulatory status (Frankel score) (p < 0.0001), the absence of spine epiduritis (p < 0.0001), immunotherapy after SpM diagnosis (p < 0.0001), ALK gene rearrangement (p < 0.0001) and EGFR mutation (p < 0.0001) were associated with longer survival, whereas spine surgery showed no association (0.141). Cox multivariate proportional hazard model identified that EGFR + status (HR: 0.339, 95% CI 0.166-0.693; p = 0.003), good WHO status (p < 0.0001) and good neurological status (Frankel E; p < 0.001 and D; p = 0.018) were associated with higher median OS. Whereas the other factors, including ALK + status, epiduritis and immunotherapy were not independent prognostic factors of survival. CONCLUSION: Survival in SpM must be prognosticated from general health performance status: clinical (WHO) and neurological (Frankel) as well as the EGFR mutation status. Immunotherapy, surgery and epiduritis have not demonstrated prognostic value. Therefore, surgical prognostic scoring algorithms should incorporate genotype subtypes in NSCLC cancers to adapt surgical treatment.

Immediate and late discal lesions on MRI in Magerl A thoracolumbar fracture: Analysis of 76 cases.

INTRODUCTION: Magerl type A thoracolumbar fracture is frequent, but consensus is lacking on management, which ranges from non-operative treatment to corpectomy. It is, however, essential to spare adjacent discs in young patients. Historically, Magerl defined type A fracture in terms of isolated bone involvement. Subsequently, several authors suggested that discal lesions are associated, but results were inconsistent. The present study assessed the presence of immediate post-trauma discal lesions and late degeneration. HYPOTHESIS: Type A fracture does not entail discal lesion. MATERIAL AND METHOD: Fifty-four patients with type A fracture and immediate post-trauma MRI (76 fractures, 138 discs) were retrospectively reviewed. Twenty-seven also had follow-up MRI at a mean 32 months. Two observers analyzed adjacent discs on Oner's classification, on the immediate post-trauma MRI, and on follow-up MRI to assess disc degeneration. RESULTS: Immediate post-trauma analysis of the cranial discs of the fractured vertebrae found 81% normal (type 1), none type 2, 7% type 3, 4% type 4, 7% type 5 and 1% type 6. Caudal discs were 97% type 1. Analysis at follow-up found degeneration in only 15% of cranial and 9% of caudal discs. DISCUSSION: A large majority of type A fractures lead to no immediate discal lesions, and only 15% of cranial discs subsequently degenerate. MRI analyzing disc signal and morphology is essential before removing material. LEVEL OF EVIDENCE: IV, retrospective study.