Isthmic spondylolisthesis treated with circumferential arthrodesis (ALIF and posterior fixation): correction, fusion and indirect decompression.

There is no consensus regarding the choice of the surgical technique for isthmic spondylolisthesis treatment, although they all aim to a common goal, achieving fusion at the index level while restoring an appropriate lordosis and remove potential radicular compression. Analyze outcome of circumferential arthrodesis (CA) with ALIF (Anterior Lumbar Interbody Fusion) and pedicle screw fixation for the treatment of all-grade isthmic spondylolisthesis, with indirect neurological decompression. Retrospective study of isthmic spondylolisthesis treated with CA, with one-year follow-up. Clinical scores were collected at one year: VAS-L, VAS-R and ODI. Pelvic parameters, L4-S1 lordosis and at index and adjacent levels, and lumbo-sacral angle (LSA) were measured pre- and post-operatively and at last follow-up. Foraminal surface and diameters were measured pre- operatively and at follow-up on CT-Scan. Level of evidence: IV. 87 patients were included. Mean VAS-L was 2.3, mean VAS-R was 1, and mean ODI was 13.8%. 10% of the patients presented a high-grade spondylolisthesis and 50% a grade II. Mean lordosis at index level shifted from 6° to 18°, L4-S1 lordosis increased from 37 to 45° and LSA shifted from 116 to 125° (p<0.001). The foraminal surface increased from 50mm 2 to 70mm 2 at last follow-up mostly through the supero-inferior diameter, shifting from 7.4mm to 9.5mm (p<0.001). In LSA<90° group, mean correction was 20° at index level, 13° at L4-S1 and 21° for LSA versus 11°, 8° and 8° respectively in LSA>90° group (p<0.001). Fusion rate was estimated at 96.5%. One infection, 5 sympathetic dysfunctions, one retrograde ejaculation, one iliac vein injury, one incisional hernia, one lateral femoral cutaneous nerve injury and two adjacent syndromes have been noted. CA is an efficient technique for the treatment of isthmic spondylolisthesis of all grades, with an acceptable rate of complications. It allows a restoration of the regional lordosis as well as a foraminal widening, avoiding additional decompression.

[Digestive obstruction: an unusual complication of hereditary multiple exostoses]. / Obstruction digestive : une complication exceptionnelle d'une maladie exostosante.

Hereditary multiple exostoses is an autosomal dominant bone disorder characterized by multiple cartilaginous tumors growing outward from metaphyses of long bones. These tumors are usually located in long bones of the limbs. Exostosis also called osteochondroma can cause many complications, the most serious being malignant transformation as chondrosarcoma. We report a rare phenotype of this disease in a young male patient who presents digestive symptoms caused by a voluminous degenerated lumbar exostosis with anterior abdominal development.

[Long-term survival analysis after surgical management for degenerative lumbar stenosis]. / Etude à long terme du risque de réintervention après traitement chirurgical d'une sténose canalaire lombaire.

PURPOSE OF THE STUDY: The short- and mid-term symptom-relief of surgical treatment for lumbar stenosis is generally acknowledged, but the probability of a long-term reoperation remains to be studied. The purpose of this work was to determine the long-term risk of reoperation after surgical treatment of degenerative lumbar stenosis and to search for factors influencing this probability. MATERIAL AND METHODS: All patients who underwent from 1989 to 1992 surgical treatment for degenerative lumbar spine stenosis were included in this work. At last follow-up, we noted functional outcome using a specific self-administered questionnaire, patient satisfaction, lumbalgia and radiculalgia using a visual analog scale, SF36 quality-of-life, reoperation or not with time since first operation if performed and the reasons and modalities of the reoperation. The probability of reoperation was determined with the acturarial method. A Cox model was used to search for factors linked with the probability of reoperation; variables studied were: age, comorbid factors, extent of the release, posterolateral arthrodesis or not, extent of the potential fusion, use or not of instrumentation for arthrodesis. RESULTS AND DISCUSSION: The study included 262 patients. At last follow-up, 61 patients had died a mean 3.7+/-3 years after the operation; only one of these patients had a second operation 22 months after the first. Forty-four patients were lost to follow-up at mean 6.6+/-3 years. Among these 44 patients, four had a second operation during their initial follow-up at mean 47 months. One hundred fifty-seven patients were retained for this analysis at mean 15+/-1 years follow-up. Among these 157 patients, 29 had a second operation a mean 75 months after the first. There were four reasons for reoperating: insufficient release, destabilization within or above the zone of release, development or renewed zone of stenosis, development or renewed discal herniation. The risk of a second operation was 7.4% [95% CI 4.8-11.6], 15.4% [95% CI 10.7-21.1] and 16.5% [95% CI 11.7-219] at five, 10 and 15 years respectively after the first operation. Among the risk factors studied, only one had a significant impact on reoperation: extent of the zone of release (p=0.003). Compared with a release limited to one level, the risk of reoperation after release of three levels or more was five times greater [95% CI 1.8-12.7].

[Paraplegia after interlaminar epidural steroid injection: a case report]. / Paraplégie secondaire à une infiltration épidurale interlamaire lombaire, à propos d'un cas.

We report the first case of paraplegia observed after epidural steroid injection in the upper spine. The patient was a 42-year-old male who underwent surgery two years earlier for stenosis of the lumbar spine from L2 to the sacrum leading to early manifestations of an equina cauda syndrome. This first operation provided satisfactory function with complete resolution of the objective neurological symptoms. The patient later developed bilateral radiculalgia involving the L3 and L4 territories and was treated by radio-guided epidural steroid injection (125 mg hydrocortancyl) delivered in the L1-L2 interlaminar space. The injection was achieved with no technical difficulty and there was no injury to the dural sac. Immediately after the injection, the patient developed complete motor and sensorial paraplegia from T12. CT and MRI performed 30 min and 4h, respectively, after the accident revealed a medium-sized discal herniation behind the L2 body. No other lesion was observed. Emergency surgery was performed for radicular release but to no avail. The patient's neurological status remained unchanged and four days later the T2 MRI sequence revealed a high-intensity intramedullar signal in the cone. The diagnosis of ischemia of the medullary cone was retained, hypothetically by injury to the dominant radiculomedullary artery via an undetermined mechanism. This complication has been previously described after upper foraminal steroid injections but not after intralaminar epidural steroid injection.

[Influence of disc height on outcome of posterolateral fusion]. / Influence de la hauteur discale sur le devenir d'une arthrodèse postérolaterale.

PURPOSE OF THE STUDY: Experimentally, posterolateral fusion only provides incomplete control of flexion-extension, rotation and lateral inclination forces. The stability deficit increases with increasing height of the anterior intervertebral space, which for some warrants the adjunction of an intersomatic arthrodesis in addition to the posterolateral graft. Few studies have been devoted to the impact of disc height on the outcome of posterolateral fusion. The purpose of this work was to investigate the spinal segment immobilized by the posterolateral fusion: height of the anterior intervertebral space, the clinical and radiographic impact of changes in disc height, and the short- and long-term impact of disc height measured preoperatively on clinical and radiographic outcome. MATERIALS AND METHODS: In order to obtain a homogeneous group of patients, the series was limited to patients undergoing posterolateral arthrodesis for degenerative spondylolisthesis, in combination with radicular release. This was a retrospective analysis of a consecutive series of 66 patients with mean 52 months follow-up (range 3-63 months). A dedicated self-administered questionnaire was used to collect data on pre- and postoperative function, the SF-36 quality of life score, and patient satisfaction. Pre- and postoperative (early, one year, last follow-up) radiographic data were recorded: olisthesic level, disc height, intervertebral angle, intervertebral mobility (angular, anteroposterior), and global measures of sagittal balance (thoracic kyphosis, lumbar lordosis, T9 sagittal tilt, pelvic version, pelvic incidence, sacral slope). SpineView was used for all measures. Univariate analysis searched for correlations between variation in disc height and early postoperative function and quality of fusion at last follow-up. Multivariate analysis was applied to the following preoperative parameters: intervertebral angle, disc height, intervertebral mobility, sagittal balance parameters, use of osteosynthesis or not. RESULTS: At the olisthesic level, there was a 30% mean decrease in disc height and intervertebral angle. These variations were not correlated with functional outcome or quality of fusion observed at last follow-up. Disc height preoperatively did not affect these variations. The only factor correlated with decreased disc height was T9 sagittal tilt: disc height decreased more when T9 sagittal tilt approached 0 degrees . DISCUSSION: In this very restricted context (retrospective study, short arthrodesis for degenerative spondylolisthesis), we were unable to find any evidence supporting the notion that high disc height is an argument which should favor complementary intersomatic arthrodesis in combination with posterolateral fusion. Analysis of the spinal balance in the sagittal plane would probably allow a more pertinent assessment of the specific needs of individual patients.

[Superior mesenteric artery syndrome following correction of spinal deformity: case report and review of the literature]. / Syndrome de la pince aorto-mésentérique après correction d'une déformation rachidienne.

Superior mesenteric artery syndrome is a rare complication which can develop after surgical correction of a spinal deformity. The syndrome is caused by an extrinsic compression on the third portion of the duodenum by the aorta posteriorly and the mesenteric artery anteriorly. We report here a case of aortomesenteric compression of the duodenum secondary to surgical correction of lower thoracic scoliosis in a 19-year-old female. The patient presented vomiting and intestinal obstruction ten days after spinal surgery. Treatment consisted in exclusive parenteral nutrition followed by careful surveillance and progressive reintroduction of oral food intake to avoid unnecessary surgery. Young thin subjects are predominantly exposed to this type of complication. The body mass index is a good indication to identify subjects at risk. Symptoms of upper gastrointestinal obstruction develop seven to ten days after surgery. Diagnosis is based on transit studies using a hydroluble contrast agent which reveals major gastric dilation and a clear interruption of the transit at the level of the third duodenum as well as retrograde peristaltism. Medical treatment should be undertaken first and is effective in the large majority of cases. Surgery may be proposed only in the event of failure. Recurrence is exceptional. Early diagnosis, delivery of clear information for the patient and family and multidisciplinary management are important points to consider for proper care for this complication which if neglected can become life-threatening.

Survey of French spine surgeons reveals significant variability in spine trauma practices in 2013.

BACKGROUND: In France, attempts to define common ground during spine surgery meetings have revealed significant variability in clinical practices across different schools of surgery and the two specialities involved in spine surgery, namely, neurosurgery and orthopaedic surgery. OBJECTIVES: To objectively characterise this variability by performing a survey based on a fictitious spine trauma case. Our working hypothesis was that significant variability existed in trauma practices and that this variability was related to a lack of strong scientific evidence in spine trauma care. METHODS: We performed a cross-sectional survey based on a clinical vignette describing a 31-year-old male with an L1 burst fracture and neurologic symptoms (numbness). Surgeons received the vignette and a 14-item questionnaire on the management of this patient. For each question, surgeons had to choose among five possible answers. Differences in answers across surgeons were assessed using the Index of Qualitative Variability (IQV), in which 0 indicates no variability and 1 maximal variability. Surgeons also received a questionnaire about their demographics and surgical experience. RESULTS: Of 405 invited spine surgeons, 200 responded to the survey. Five questions had an IQV greater than 0.9, seven an IQV between 0.5 and 0.9, and two an IQV lower than 0.5. Variability was greatest about the need for MRI (IQV=0.93), degree of urgency (IQV=0.93), need for fusion (IQV=0.92), need for post-operative bracing (IQV=0.91), and routine removal of instrumentation (IQV=0.94). Variability was lowest for questions about the need for surgery (IQV=0.42) and use of the posterior approach (IQV=0.36). Answers were influenced by surgeon specialty, age, experience level, and type of centre. CONCLUSION: Clinical practice regarding spine trauma varies widely in France. Little published evidence is available on which to base recommendations that would diminish this variability.

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.

Early surgical site infections in adult spinal trauma: a prospective, multicentre study of infection rates and risk factors.

INTRODUCTION: Spine surgery is known to have a high risk of surgical site infection (SSI). Multiple studies have looked into the risk factors and incidence of SSI during elective surgery, but only two retrospective studies have specifically evaluated SSI during surgery following spine trauma. MATERIALS AND METHODS: This work was based on a prospective cohort study that included all the patients operated on for spinal trauma at 13 French hospitals over a three-month period. The main endpoint was the occurrence of a SSI during the three-month period. Patients with multiple trauma or open fractures were excluded from the study. RESULTS: Of the 169 patients re-examined after a minimum of three months, six had had an acute SSI (3.55%). The following factors were significantly related to a SSI: age, ASA score, diabetes, procedure duration, delay elapsed between accident and procedure, number of levels fused, bleeding and prolonged presence of urinary catheter. DISCUSSION: Our results were consistent with the published infection rates of 2 to 10%. The risk factors identified have all been described in previous studies on elective spine surgery. LEVEL OF EVIDENCE: Level IV, prospective cohort study.

Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan.

BACKGROUND: Whole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan. METHODS: 177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient's initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis. RESULTS: 157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p=0.003) and ISS over 14 (OR: 4.17, p<0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p<0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI. CONCLUSION: Trauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading.

Hydatid disease drug therapy primarily to reconstruction of a multilevel thoracolumbar vertebral lesion.

We report, a very unusual case of multilevel vertebral hydatidosis adjacent to the thoracolumbar junction, without concomitant chord compression. Two months after initiating oral antiparasite treatment, the patient underwent resection of the lesion using a posterior approach, medullary decompression, and a T11-L3 instrumented arthrodesis. Arthrodesis via the anterior approach was performed at a later stage. In addition to its diagnostic value, this case raises renewed discussion about single-level lesions given their rarity: their indication for preoperative medullary angiography, their indication for circumferential surgery, the timing of medical treatment, and the strategy to implement for the residual lesions.

CT evaluation of torsional malalignment after intertrochanteric fracture fixation.

INTRODUCTION: Trochanteric fractures are commonly stabilized either by intramedullary nailing or plate and screw fixation after reduction on the orthopaedic surgical table under radiological guidance. HYPOTHESIS: Closed trochanteric fracture anatomic reduction is difficult in the transversal plane. OBJECTIVES: The objective of this prospective study was to assess the rotational malalignment induced after reduction and osteosynthesis of trochanteric fractures. PATIENTS AND METHODS: Prospective study including 40 patients (mean age, 78 years; range, 51-90 years) operated for a trochanteric fracture between January 2007 and September 2008. Fourteen fractures were treated using DHS™ (Synthes™) plate and screw fixation and 26 with intramedullary nailing (trochanteric nail™, Stryker™). All these patients underwent postoperative CT of the pelvis during their hospitalization with measurement of anteversion of the operated and healthy femoral necks at the posterior condyles. The evaluation criterion was whether or not there was malalignment greater than 15° on the operated side compared to the healthy side. RESULTS: The mean anteversion was 14.2° for the healthy side and 23° for the operated side. The mean rotational malalignment was 15.3°. Forty percent of the rotational malalignments were greater than 15°, with a majority of cases showing excess internal rotation (35%) of the distal fragment. CONCLUSION AND DISCUSSION: The rate of internal rotational malalignment of the distal fragment greater than 15° was high (40% of this series). This should encourage surgeons to reduce the excess internal rotation that tends to be attributed to the distal fragment during preoperative reduction of these fractures. LEVEL OF EVIDENCE: Level III. Prospective diagnostic study with no control group.

Thoracolumbar junction lateral spine dislocation.

The authors describe a case of traumatic lateral spine dislocation at the thoracolumbar junction level, without fracture, in a healthy young adult, complicated by a complete neurological deficit. The main aspects of surgical management are discussed based on a review of the literature. Control of the spinal cord is a mandatory first step, before reduction, independently of neurological deficits considerations. Instrumented stabilization and fusion are achieved thereafter; levels selection for instrumentation and fusion depends on the injury location.

Odontoid process pathologic fracture in spinal tuberculosis.

Craniovertebral junction tuberculosis is a rare lesion in which treatment remains controversial. Options range from conservative treatment to surgery, independently of any associated neurological threat. We here report the first case of pathologic odontoid fracture in a context of spinal tuberculosis, complicated by unusual neurological evolution. The patient presented with non-contiguous multifocal tuberculosis, of which there have previously been only 6 reported cases.

Effects of the knee-chest position on cardiac index and propofol requirements during bispectral index (BIS)-guided spine surgery.

INTRODUCTION: The knee-chest (KC) position is often used for spine surgery. It is considered to promote significant changes in venous return and cardiac output. However, the magnitude of these changes and their consequences on intraoperative haemodynamics and anaesthetic requirements remain to be determined. The goal of the present study was to determine the changes in cardiac index and propofol requirements of patients undergoing spine surgery in the KC position. METHODS: Twenty ASA 1-3 patients scheduled for elective spine surgery were included in the study. A radial artery catheter and an oesophageal Doppler probe were properly positioned after induction of anaesthesia. Anaesthesia consisted of bispectral index (BIS)-guided, plasma target-controlled, propofol-remifentanil anaesthesia. After positioning the patient KC, remifentanil target concentration was maintained throughout the case as in the supine position whilst propofol target concentration was adjusted to maintain BIS values between 40 and 50. Cardiac index, stroke volume, heart rate, end-tidal CO(2) (ETCO(2)), mean arterial pressure, peak and plateau airway pressures, BIS values and plasma target concentrations of propofol and remifentanil were compared 15 min after induction of anaesthesia (in the supine position) and 15 min after placing the patients KC. Data are expressed as mean+/-S.D. except for DeltaPP expressed as a number of patients with DeltaPP greater than 13%. RESULTS: Cardiac index, stroke volume, mean arterial pressure and propofol target concentration were significantly decreased from supine to KC position: 2.6+/-0.03 to 1.7+/-0.04 l/min/m(2), p<0.0001; 68+/-1.2 to 45+/-1 ml, p<0.0001; 83+/-1.2 to 76+/-1.4 mmHg, p<0.0001 and 3+/-0.06 to 2+/-0.05 microg/ml, p<0.0001, respectively. The number of patients with DeltaPP greater than 13% was zero in the supine position and 18 (90%) in the KC position (p<0.0001). CONCLUSION: Placing surgical patients in the KC position during BIS guided anaesthesia was associated with marked decrease in cardiac index and propofol requirements. These results suggest that monitoring intraoperative cardiac index via an oesophageal Doppler and depth of anaesthesia with the BIS may be useful in patients undergoing spine surgery in the KC position.