C1-C2 Injury: Factors influencing mortality, outcome, and fracture healing.

BACKGROUND: C1-C2 injury represents 25-40% of cervical injuries and predominantly occurs in the geriatric population. METHODS: A prospective multicentre study was conducted under the aegis of the french spine surgery society (SFCR) investigating the impact of age, comorbidities, lesion type, and treatment option on mortality, complications, and fusion rates. RESULTS: A total of 417 patients were recruited from 11 participating centres. The mean ± SD age was 66.6 ± 22 years, and there were 228 men (55%); 5.4% presented a neurological deficit at initial presentation. The most frequent traumatic lesion was C2 fracture (n = 308). Overall mortality was 8.4%; it was 2.3% among those aged ≤ 60 years, 5.0% 61-80 years, and 16.0% > 80 years (p < 0.001). Regarding complications, 17.8% of patients ≤ 70 years of age presented with ≥ 1 complication versus 32.3% > 70 years (p = 0.0009). The type of fracture did not condition the onset of complications and/or mortality (p > 0.05). The presence of a comorbidity was associated with a risk factor for both death (p = 0.0001) and general complication (p = 0.008). Age and comorbidities were found to be independently associated with death (p < 0.005). The frequency of pseudoarthrosis ranged from 0 to 12.5% up to 70 years of age and then constantly and progressively increased to reach 58.6% after 90 years of age. CONCLUSIONS: C1-C2 injury represents a serious concern, possibly life-threatening, especially in the elderly. We found a major impact of age and comorbidities on mortality, complications, and pseudarthrosis; injury pattern or treatment option seem to have a minimal effect.

Outcomes of surgical treatments of spinal metastases: a prospective study.

BACKGROUND: Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases. OBJECTIVE: To analyse the outcomes of surgical treatments of spinal metastases. METHODS: Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status. RESULTS: A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function. CONCLUSION: Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.

Correction to: Outcomes of surgical treatments of spinal metastases: a prospective study.

The correct name of F. Saihlan should be F. Sailhan.

[Dynamic instrumentation of the lumbar spine. Clinical and biomechanical analysis of success factors]. / Dynamische Versorgung der Lendenwirbelsäule : Klinische und biomechanische Analyse der Erfolgsfaktoren.

Total disc replacement and posterior dynamic stabilization represent alternatives to lumbar spinal fusion which should reduce the risk of adjacent segment degeneration. Disc replacement is indicated for pure discopathy without facet joint degeneration. Spinopelvic balance influences the implant's biomechanics. Therefore pelvic incidence, sacral slope, segmental lordosis and the mean axis of rotation need to be considered. Dynamic stabilization is indicated in moderate discopathy and facet joint degeneration, in degenerative spondylolisthesis grade I with a hypermobile segment and in dynamic lumbar stenosis. The combination of caudal fusion and cranial dynamic stabilization allows a better maintenance of lordosis with multiple level instrumentation and prevents adjacent segment degeneration. If pelvic incidence and sacral slope are high, L5-S1 should be fused because of elevated shear forces.

[Congenital pseudarthrosis of the forearm. Report of two cases and review of the literature]. / Pseudarthrose congénitale de l'avant-bras. A propos de deux cas et revue de la littérature.

Congenital pseudarthrosis of the forearm represents a rare entity which is often associated with neurofibromatosis type I. Isolated pseudarthrosis of the ulna is the most frequent deformity, followed by pseudarthrosis of the radius and both forearm bones. The treatment of these deformities remains difficult: conventional bone grafts rarely lead to complete fusion. The reconstruction by a vascularized fibular graft represents the treatment of choice if the radial head is not dislocated. This procedure allows restoration of a balance between radius and ulna during growth. The presence of a vascularized graft enhances the potential for bony fusion in a fibrous environment. In cases of isolated ulna pseudarthrosis, a luxation of the proximal radial epiphysis may occur when the ulnar deformity increases with time. The single-bone forearm represents a salvage procedure that creates a stable upper limb with a satisfactory wrist and elbow function. The two clinical cases of a pseudarthrosis of both forearm bones and of an ulna pseudarthrosis are presented.

Sagittal alignment correction of the thoracolumbar junction in idiopathic scoliosis by in situ bending technique.

A long thoracolumbar sagittal rectitude is sometimes present in adolescent idiopathic scoliosis. The purpose of this study was to identify typical patterns, by comparing frontal plane deformities and vertebral rotation leading to this rectitude. Surgical thoracolumbar alignment correction by three-dimensional in situ bending of rods was then analyzed. Pre- and postoperative radiographs of 24 patients with scoliosis (36-104 degrees) were reviewed using Spineview software. Frontal curves and levels of sagittal rectitude were determined. Thoracic kyphosis, lumbar lordosis, sacral slope, pelvic incidence, pelvic tilt, T9 and T1 tilt were measured. Vertebral rotation was measured by computed tomography, Perdriolle's, Nash and Moe's methods. The intervertebral mobility of the rectitude was analyzed on side bending radiographs. Three patterns leading to sagittal rectitude were identified: 11 main thoracic curves (Lenke 1, King 3) with cranial prolongation of the physiological thoracolumbar junction (T7T12) and maximal vertebral rotation above this zone, 13 double major or thoracolumbar curves (Lenke 3 or 5, King 1 or 2) with cranial and caudal prolongation (T9L3) and maximal rotation above and below, 1 lumbar curve (Lenke 5) with caudal rectitude (T12L4) and maximal rotation at L1. There was no relationship between intervertebral mobility and rectitude. Postoperatively, this zone of rectitude disappeared in 17 out of 24 patients after anterior release followed by posterior instrumentation using the in situ bending technique. In situ bending realizes a stepwise correction of the three-dimensional deformity at different levels. An accurate preoperative analysis is mandatory to achieve an adequate sagittal balance, frontal curve correction and vertebral derotation simultaneously. The determined patterns of thoracolumbar rectitude are helpful to plan surgical correction accurately.

Volumetric thoracic growth in children with moderate and severe scoliosis compared to subjects without spinal deformity.

Idiopathic scoliosis leads to a three-dimensional thoracic deformity. The purpose of this study is to measure thoracic dimensions and volume related to growth and to verify the influence of moderate and severe scoliosis. 176 children (36 boys, 140 girls; 4-16 years) with scoliosis <45 degrees and 17 patients (2 boys, 15 girls) with scoliosis >65 degrees were compared to 239 children without spinal deformity (97 boys, 142 girls) using an optical system. Thoracic volume, perimeter, anterior-posterior and transversal diameters, T1-T12 and sternal lengths were calculated. These measurements were related to age and sitting height. Thoracic volume (3-16 dm(3)) did not differ significantly over growth between reference and moderate scoliosis groups. At 4 years, it represents 33%, at 10 years it represents 55% of its volume compared with age 16. It triples from 4-16 years and doubles during puberty. In severe scoliosis, the age related thoracic volume was always lower than volumes in reference and moderate scoliosis groups. During growth, the transversal diameter corresponds to 30%, the anterior-posterior diameter represents 20% and the thoracic perimeter 100% of sitting height. In severe lordoscoliosis the anterior-posterior diameter represents less than 20%. Scoliosis <45 degrees does not influence thoracic volume significantly. Severe deformities seem to inhibit volumetric growth. Thoracic parameters should be related to growth parameters such as sitting height rather than age because of possible height variations in one age section. The established relationships offer a reliable orientation of thoracic proportions. They help to understand the global deformity and represent a baseline for surgical treatment using vertical expandable prosthetic titanium ribs.

Limiting interpedicular screw displacement increases shear forces in screws: A finite element study.

BACKGROUND CONTEXT: Screw loosening has been reported for non-fusion devices. Forces on pedicle screws could be related to kinematic parameters as the interpedicular displacement (ID), which consists of the displacement between superior and inferior screw heads from full extension to full flexion. PURPOSE: To investigate the relationship between ID and screw loosening for different designs of posterior implants using a finite element model. METHODS: An L3-sacrum previously validated spine FE model was used. Three-rod designs were considered in L4-L5 segment: a rigid screw-rod implant, a flexible one and a specific design with a sliding rod providing limited restrain in ID. In order to simulate intermediate configurations, the friction coefficient between the sliding rods and connectors were varied. The sacrum was rigidly fixed. Rotations (flexion-extension, lateral bending and axial rotation) were applied to L3, for each modeled configuration: intact, injured, injured with different implants. Model consistency was checked with existing experimental in vitro data on intact and instrumented segments. Screw loads were computed as well as ID. RESULTS: In flexion-extension, the ID was less than 2mm for rigid (R) and flexible (F) constructs and 5.5mm for intact spine and the sliding implant (S3). Screw's shear forces were 272N, 153N, 43N respectively for R, F and S3 constructs. CONCLUSIONS: Implants that allow ID presented lower screws loads. A compromise between the ability of the implant to withstand compressive forces, which requires longitudinal stiffness, and its ability to allow ID could be important for future implant designs in order to prevent screw loosening.

Cervical sagittal alignment in adult hyperkyphosis treated by posterior instrumentation and in situ bending.

BACKGROUND: In the normal adult spine, a link between thoracolumbar and cervical sagittal alignment exists, suggesting adaptive cervical positional changes allowing horizontal gaze. In patients with thoracic hyperkyphosis, cervical adaptation to sagittal global alignment might be different from healthy individuals. However, this relationship has not clearly been reported in hyperkyphotic deformity. PURPOSE: The purpose of this study was to identify cervical sagittal alignment types observed on radiographs in young adults with thoracic hyperkyphosis. The relationship between cervical and thoracolumbar alignment as well as the effect of posterior instrumentation and adaptive positional changes of the mobile cervical segment were retrospectively analyzed. PATIENTS AND METHODS: Twenty-three patients (32.7 years; 5-year follow-up) were included. Full spine radiographic measurements were: T1 slope, T1-T4 kyphosis, T4-T12 kyphosis, L1-S1 lordosis, pelvic incidence, pelvic tilt, sacral slope, SVA C7, SVA C2, lordosis between C0-C2, C2-C7, C2-C4 and C4-C7. A Bayesian model and Spearman correlation were used. RESULTS: Two alignment types existed: cervical lordosis (group A) and cervical kyphosis (group B). Preoperatively, T4-T12 kyphosis and L1-S1 lordosis were significantly higher in group A: 76.6° versus 59.4° and -72.8° versus -65.8° (probability of>5° difference P (ß>5)>0.95). Pelvic incidence was higher in group A (49.8° versus 44.2°) and C0-C2 lordosis in group B (-29.4° versus -21.6°). A significant correlation existed between: T4-T12 kyphosis and C2-C7 lordosis, L1-S1 lordosis and pelvic incidence, C2-C7 lordosis and T1 slope, C2-C7 lordosis and T1-T4 kyphosis. Postoperatively, T4-T12 kyphosis decreased by 33.1° P (ß>5)=0.9995), L1-S1 lordosis decreased by 17.7° (P (ß>5)=0.961), T1-T4 kyphosis increased by 14.1° (P (ß>5)=0.973). SVA C2 (translation) increased by 13.8mm. C0-C2 lordosis (head rotation) remained unchanged. Six patients changed cervical alignment. PJK occurred in 15 patients, unrelated to cervical alignment or proximal instrumentation level. DISCUSSION: Two cervical alignment types, lordotic or kyphotic, were observed thoracic hyperkyphosis patients. This alignment was mainly triggered by the amount of thoracic kyphosis and lumbar lordosis, linked to pelvic incidence. Moreover, the inclination of the C7-T1 junctional area plays a key role in the amount of cervical lordosis. The correction of T4-T12 kyphosis induced compensatory modifications at adjacent segments: T1-T4 kyphosis increase (PJK) and L1-S1 lordosis decrease. Global spino-pelvic alignment and head position did not change in the sagittal plane. The cervical spine tented to keep in its preoperative position in most patients. LEVEL OF EVIDENCE: Level IV.

Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients.

BACKGROUND: The risk of vertebral fracture is increased 4-fold in patients with ankylosing spondylitis (AS). Diagnostic challenges and the vulnerability associated with AS combine to generate high morbidity and mortality rates. The objective of this study was to assess the outcome of percutaneous thoraco-lumbar fracture surgery in patients with AS, in terms of quality of life, fracture healing, and complications. HYPOTHESIS: Percutaneous surgery used to treat thoraco-lumbar fractures in patients with AS reliably provides fracture healing, preserves self-sufficiency, and minimises post-operative complications. METHODS: Two centres included 31 patients with AS who were managed by percutaneous surgery for thoraco-lumbar fractures in 2013-2015. The data were reviewed retrospectively, although admission data were collected prospectively. Clinical outcomes were assessed by comparing the values at baseline and last follow-up of three variables: the Parker score, the visual analogue scale (VAS) pain score, and the EuroQol five dimensions (EQ-5D) quality-of-life score. Computed tomography was performed 1 year after surgery to evaluate bone healing, screw position, and implant loosening. Intra- and post-operative complications were recorded. RESULTS: The 31 patients had a mean age at surgery of 75.1 years, a mean follow-up of 35.6 months, and a minimum follow-up of 12 months. Three patients died during follow-up. Mean hospital stay duration was 6 days. Cemented screw fixation was used in 18 patients. At last follow-up, all patients had recovered their self-sufficiency; the mean Parker score was 7.14, compared to 6.73 at baseline, the mean VAS pain score was 1.8, and the mean EQ-5D score decrease versus baseline was 0.07 (P=0.02). Bone healing was consistently achieved. Loosening of an uncemented pedicle screw was noted in 1 patient. Of the 228 screws implanted, 6 (2.6%) were improperly positioned, including 1 within the spinal canal in a patient free of neurological manifestations. Asymptomatic cement leakage was noted in 2 patients. DISCUSSION: Percutaneous fixation of thoraco-lumbar fractures in patients with AS is a reliable method that produces a high healing rate and allows prompt patient mobilisation with preservation of self-sufficiency. The post-operative complication rate is low. LEVEL OF EVIDENCE: IV, retrospective observational study.

Management of thoracolumbar spine fractures with neurologic disorder.

Thoracic and lumbar fractures represent approximately 50% of neurologic spinal trauma. They lead to paraplegia or cauda equina syndrome depending on the level injured. In the acute phase, the extension of spinal cord lesions should be limited by immediately treating secondary systemic injury factors. Quick recovery of hemodynamic stability, with mean arterial blood pressure>85 mm Hg, appears essential. There is no clinical evidence in favor of high-dose corticosteroid protocols. Their effect on neurologic recovery is unproven, whereas they lead to a higher rate of secondary septic and pulmonary complications. Incomplete deficits (ASIA B-D) require urgent surgery. There is no consensus with regard to complete paraplegia (ASIA A), but early surgery can enable neurologic recovery in some cases. The principle of surgical treatment is based on spinal cord decompression, instrumentation and fracture reduction. Early stabilization of the spine improves respiratory function and shortens the duration of mechanical ventilation and thus intensive care unit stay. Depending on the severity of associated lesions, early surgery within 48 hours is beneficial in polytrauma patients. Percutaneous instrumentation combined with mini-open posterior decompression stabilizes the spine, limiting approach-related morbidity.

Pullout characteristics of percutaneous pedicle screws with different cement augmentation methods in elderly spines: An in vitro biomechanical study.

BACKGROUND: Vertebroplasty prefilling or fenestrated pedicle screw augmentation can be used to enhance pullout resistance in elderly patients. It is not clear which method offers the most reliable fixation strength if axial pullout and a bending moment is applied. The purpose of this study is to validate a new in vitro model aimed to reproduce a cut out mechanism of lumbar pedicle screws, to compare fixation strength in elderly spines with different cement augmentation techniques and to analyze factors that might influence the failure pattern. MATERIALS AND METHODS: Six human specimens (82-100 years) were instrumented percutaneously at L2, L3 and L4 by non-augmented screws, vertebroplasty augmentation and fenestrated screws. Cement distribution (2 ml PMMA) was analyzed on CT. Vertebral endplates and the rod were oriented at 45° to the horizontal plane. The vertebral body was held by resin in a cylinder, linked to an unconstrained pivot, on which traction (10 N/s) was applied until rupture. Load-displacement curves were compared to simultaneous video recordings. RESULTS: Median pullout forces were 488.5 N (195-500) for non-augmented screws, 643.5 N (270-1050) for vertebroplasty augmentation and 943.5 N (750-1084) for fenestrated screws. Cement augmentation through fenestrated screws led to significantly higher rupture forces compared to non-augmented screws (P=0.0039). The pullout force after vertebroplasty was variable and linked to cement distribution. A cement bolus around the distal screw tip led to pullout forces similar to non-augmented screws. A proximal cement bolus, as it was observed in fenestrated screws, led to higher pullout resistance. This cement distribution led to vertebral body fractures prior to screw pullout. CONCLUSION: The experimental setup tended to reproduce a pullout mechanism observed on radiographs, combining axial pullout and a bending moment. Cement augmentation with fenestrated screws increased pullout resistance significantly, whereas the fixation strength with the vertebroplasty prefilling method was linked to the cement distribution.

[Dynamic pedobarography in postoperative evaluation of pes cavovarus]. / Evaluation postopératoire du pied creux à l'aide du podobarographe dynamique.

PURPOSE OF THE STUDY: Pes cavovarus is a complex deformity of the forefoot, the midfoot and the hindfoot, frequently of neuropathologic etiology. The goals of surgical interventions consist of anatomical and functional correction of the foot deformity by soft tissue and bony procedures. Preoperative planning and postoperative assessment are based on clinical and radiographic examination. The present study was undertaken to find out if pedobarographic outcomes correlate with those postoperative results and if the dynamic pedobarography provides useful information in the functional evaluation of cavovarus feet. MATERIAL AND METHODS: Sixteen patients with cavovarus foot deformity (mean age 32.8 years, range 17-56) with a total of 21 feet were examined before and after surgery. The average follow-up time was 24 months (range 6-50). The study protocol included physical examination, angle measurements on weightbearing radiographs and dynamic pedobarography. The patients performed five trials at self-selected speed for each foot. The amount of correlation was established between: plantar peak pressure pattern and patient's subjective functional result, the evidence of callosities and increased peak pressures in forefoot and midfoot regions of interest, the change of calcaneal pitch or Hibbs' angle (first metatarsal - calcaneal axis) and the midfoot contact area. RESULTS: The patient's functional opinion and pedobarographic improvement of peak pressures correlated in 7 feet, the patients estimated the result better in 13 feet and worse in 1 foot. In 4 regions of interest callosities and increased peak pressures occurred together in 69% of the cases, in 15.5% callosities were observed without augmented peak pressures and in 15.5% increased peak pressures were measured without evidence of callosities. No correlation was found between radiographic and pedobarographic parameters which describe a reduction of the cavus deformity: calcaneal pitch angle and midfoot contact area (Pearson correlation coefficient r=- 0.36), Hibbs' angle and midfoot contact area (r=0.55), although all parameters changed significantly (p=0.001). DISCUSSION AND CONCLUSION: Pre- and postoperative assessment of the cavovarus foot is mainly based on static methods such as clinical and radiographic evaluation. The results of this study demonstrate that the dynamic measurement of plantar peak pressures and contact area offers limited information about functional and anatomical improvement after surgery. Patients with severe deformities and muscular discoordination have difficulties walking consistently on the platform at each trial and severe decrease of plantar contact area makes the exact positioning of the masks difficult, which leads to problems with standardised measurements. In this context, the dynamic pedobarography cannot be used as a profitable diagnostic tool which provides an objective measurement that can add a dynamic component to a clinical or radiographic examination.

Update on the surgical management of Pott's disease.

One-third of the world's population is infected with Mycobacterium tuberculosis. Data reported in 2011 indicate, for the first time, a decline in cases of tuberculosis, despite persistent inequalities across geographic areas and increasing rates of drug resistance. Osteo-articular tuberculosis affects the spine in half the cases. Pharmacotherapy must be combined with surgery in patients with spinal cord or nerve root compression, large abscesses, or marked anterior column osteolysis with kyphosis and instability. The quality of debridement and bony fusion is optimal when the anterior approach is used. Posterior fixation is the best means of achieving reduction followed by stable sagittal alignment over time. New treatment strategies combine conventional surgical methods, closed interventional radiology procedures for drainage and spinal cord decompression, and percutaneous fixation.

The effect of posterior non-fusion instrumentation on segmental shear loading of the lumbar spine.

BACKGROUND: Lumbar stenosis and facet osteoarthritis represent indications for decompression and instrumentation. It is unclear if degenerative spondylolisthesis grade I with a remaining disc height could be an indication for non-fusion instrumentation. The purpose of this study was to determine the influence of a mobile pedicle screw based device on lumbar segmental shear loading, thus simulating the condition of spondylolisthesis. MATERIALS AND METHODS: Six human cadaver specimens were tested in 3 configurations: intact L4-L5 segment, then facetectomy plus undercutting laminectomy, then instrumentation with lesion. A static axial compression of 400 N was applied to the lumbar segment and anterior displacements of L4 on L5 were measured for posterior-anterior shear forces from 0 to 200 N. The slope of the loading curve was assessed to determine shear stiffness. RESULTS: Homogenous load-displacement curves were obtained for all specimens. The average intact anterior displacement was 1.2 mm. After lesion, the displacement increased by 0.6mm compared to intact (P=0.032). The instrumentation decreased the displacement by 0.5 mm compared to lesion (P=0.046). The stiffness's were: 162 N/mm for intact, 106 N/mm for lesion, 148 N/mm for instrumentation. The difference was not significant between instrumented and intact segments (P=0.591). CONCLUSIONS: Facetectomy plus undercutting laminectomy decreases segmental shear stiffness and increases anterior translational L4-L5 displacement. Shear stiffness of the instrumented segment is higher with the device and anterior displacements under shear loading are similar to the intact spine. This condition could theoretically be interesting for the simulation of non-fusion instrumentation in degenerative spondylolisthesis.

Posterior surgery in high-grade spondylolisthesis.

INTRODUCTION: High-grade L5-S1 spondylolisthesis alters sagittal spinopelvic balance, which can cause low back pain and progressive neurologic disorder. The present study assessed spondylolisthesis reduction and maintenance over time with L4-S1 versus L5-S1 fusion using a lever-arm system and posterior fusion combined with lumbosacral graft. MATERIALS AND METHODS: Forty patients were operated on for symptomatic high-grade spondylolisthesis, 34 of whom had full pre- and post-operative radiological analysis, with a mean follow-up of 5.4years. There were 9 L5-S1 and 25 L4-S1 instrumentations. Analysis of spinopelvic and slipping parameters and the evolution of segmental lordosis compared results between L5-S1 and L4-S1 instrumentation. RESULTS: Mean Taillard spondylolisthesis index decreased from 64% to 37% (P=0.0001). Overall sagittal spinopelvic balance was not significantly changed. Overall L1-S1 and segmental L4-L5 lordosis were not affected by instrumentation. Mean L5-S1 segmental lordosis increased from 11° to 18°. There was loss of reduction from 19° to 14° with L5-S1 instrumentation, in contrast to maintained reduction with L4-S1 instrumentation (P=0.006). CONCLUSION: The lever-arm system provided anterior-posterior reduction of spondylolisthesis and corrected slippage. Postoperative change in overall sagittal spinopelvic balance was slight and constant. Posterior L4-S1 fusion provided better long-term control of L5-S1 lordosis reduction than the shorter L5-S1 fusion. Retrospective study of level IV.

A comparison of the simplified olecranon and digital methods of assessment of skeletal maturity during the pubertal growth spurt.

Assessment of skeletal age is important in children's orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods. Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods. The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience. The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified.

Fracture in ankylosing spondylitis after minor trauma: radiological pitfalls and treatment by percutaneous instrumentation. A case report.

Patients with ankylosing spondylitis may experience spinal fractures even after minor injuries. The diagnosis of non-dislocated spinal fracture is based on clinical symptoms and radiological findings. Difficulties in interpreting the imaging studies can result in considerable diagnostic delays. We describe the steps of the radiological diagnosis in a patient with a fracture of L2 that was not visible on standard lumbar spine radiographs. Magnetic resonance imaging (MRI) T2 STIR sequences allowed determining the location and showed signs of a recent fracture. Then, MRI T1 images and computed tomography provided a detailed evaluation of the fracture line. In patients with ankylosing spondylitis, fracture instability is common, making surgical treatment mandatory. Open surgery is associated with substantial rates of infection and implant loosening. Percutaneous instrumentation has not yet been evaluated for the treatment of spinal fractures in patients with ankylosing spondylitis. This minimally invasive surgical technique enables multilevel internal fixation and may constitute an interesting alternative to open surgery.

Should post-traumatic thoracolumbar Frankel A paraplegia be operated as an emergency? Report of three cases and review of the literature.

Spinal cord injury is an important contributing factor to morbidity. The thoracolumbar junction is a highly vulnerable axial region due to the biomechanical stresses and the risk of conus medullaris injuries in some cases. In the event of an incomplete neurological injury and if the patient's condition is stable, emergency surgical treatment should be considered. Yet, no clear consensus has emerged regarding the treatment modalities of complete injuries but surgical management is advocated to maximize neurological recovery and reduce the risk of decubitus ulcer formation. We report on the cases of three patients with L1 Frankel A paraplegia resulting from injury to the conus medullaris, treated within the first 6 hours from injury and demonstrating a very satisfactory neurological recovery since independent walking could be resumed at 2.5 years follow-up. Persistent urinary sphincter dysfunctions were observed in two of these patients. Early surgical management appears as an important predictive factor for neurological recovery in conus medullaris injuries. We believe that delayed surgical management in patients with complete paraplegia could be an inappropriate treatment option, which should be further studied.