Three-dimensional cardiac magnetic resonance allows the identification of slow-conducting anatomical isthmuses in tetralogy of Fallot.

BACKGROUND AND AIMS: Patients with repaired tetralogy of Fallot remain at risk of life-threatening ventricular tachycardia related to slow-conducting anatomical isthmuses (SCAIs). Preventive ablation of SCAI identified by invasive electroanatomical mapping is increasingly performed. This study aimed to non-invasively identify SCAI using 3D late gadolinium enhancement cardiac magnetic resonance (3D-LGE-CMR). METHODS: Consecutive tetralogy of Fallot patients who underwent right ventricular electroanatomical mapping (RV-EAM) and 3D-LGE-CMR were included. High signal intensity threshold for abnormal myocardium was determined based on direct comparison of bipolar voltages and signal intensity by co-registration of RV-EAM with 3D-LGE-CMR. The diagnostic performance of 3D-LGE-CMR to non-invasively identify SCAI was determined, validated in a second cohort, and compared with the discriminative ability of proposed risk scores. RESULTS: The derivation cohort consisted of 48 (34 ± 16 years) and the validation cohort of 53 patients (36 ± 18 years). In the derivation cohort, 78 of 107 anatomical isthmuses (AIs) identified by EAM were normal-conducting AI, 22 were SCAI, and 7 blocked AI. High signal intensity threshold was 42% of the maximal signal intensity. The sensitivity and specificity of 3D-LGE-CMR for identifying SCAI or blocked AI were 100% and 90%, respectively. In the validation cohort, 85 of 124 AIs were normal-conducting AI, 36 were SCAI, and 3 blocked AI. The sensitivity and specificity of 3D-LGE-CMR were 95% and 91%, respectively. All risk scores showed an at best modest performance to identify SCAI (area under the curve ≤ .68). CONCLUSIONS: 3D late gadolinium enhancement cardiac magnetic resonance can identify SCAI with excellent accuracy and may refine non-invasive risk stratification and patient selection for invasive EAM in tetralogy of Fallot.

Contribution of MRI and imaging exams in the diagnosis of lumbar pseudarthrosis.

INTRODUCTION: The diagnosis of pseudoarthrosis is based on imaging and clinical exam findings. The standard for pseudarthrosis diagnosis remains postoperative observation through computer tomography (CT) and patient's symptoms. This can be further augmented by dynamic X-ray imaging or nuclear positron emission tomography (PET) CT to demonstrate an absence of fusion by showing a persistence of mobility. However, there is not a uniform diagnostic approach that is a standard of care amongst spine practioners. The aim of this study is to describe the timeline and diagnostic analysis for pseudoarthrosis between the initial surgery and follow-up procedure. METHODS: This is a single-center retrospective observational study. The aim was to enroll patients reoperated for pseudarthrosis after 1 or 2 level lumbar fusions, between August 1st, 2008 and August 1st, 2018. The exams were reviewed by one surgeon and one radiologist, defining a status either in favor of pseudarthrosis, or against it, or inconclusive, based on the radiological criteria mentioned below. We then investigated different combinations of exams and their specific chronology before a diagnosis was established. RESULTS: Forty-four patients were included, 70.5% male and with a mean age of 47.3 years. The median time between the 2 surgeries was 23.7 months. Plain X-rays supported the diagnosis in 38.7% of cases, dynamic X-rays showed hypermobility in 50% of cases. The CT-scan demonstrated pseudarthrosis in 94,4% of cases. A MODIC 1 signal was observed in 87,2% of cases on MRI. SPECT-CT showed a tracer uptake in 70% of cases. CONCLUSION: Reducing the time to reintervention is a key objective for improving the management and clinical outcomes of these patients. We suggest that MRI is an additional tool in combination with CT in the assessment of suspected mechanical pseudarthrosis, in order to optimize the diagnosis and shorten the time to revision surgery. LEVEL OF EVIDENCE: IV.

Local VA index for the differential diagnosis of supraventricular tachycardia.

BACKGROUND: Differentiating between atypical atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic reciprocating tachycardia utilizing a septal accessory pathway is a complex challenge. OBJECTIVE: The purpose of this study was to describe the "local VA index," a straightforward method based on signals from the coronary sinus catheter, to distinguish between these arrhythmias during tachycardia and entrainment. The ventriculoatrial (VA) interval on the coronary sinus catheter is measured during tachycardia and entrainment, at the site of earliest atrial activity. The difference between these 2 situations defines the "local VA index." We also propose a mechanism to clarify the limitations of historical pacing maneuvers, such as postpacing interval minus tachycardia cycle length (PPI-TCL) and stimulus-atrial interval minus ventriculoatrial interval (SA-VA), by examining nodal decrement and intraventricular conduction delay. METHODS: In a retrospective study of 75 patients referred for supraventricular tachycardia evaluation, 37 were diagnosed with atrioventricular reentrant tachycardia (AVRT) with orthodromic reciprocating tachycardia, and 38 with AVNRT (27 typical, 11 atypical). RESULTS: In comparison to AVRT patients, AVNRT patients exhibited longer PPI-TCL (176 ± 47 ms vs 113 ± 42 ms; P <.01) and SA-VA (138 ± 47 ms vs 64 ± 28 ms; P <.01). The AVRT group had mean local VA index of -1 ± 13 ms, whereas the AVNRT group had a significantly longer index of 91 ± 46 ms (P <.01). An optimal threshold for differentiation was a local VA index of 40 ms. Importantly, there was no significant correlation between pacing cycle length and nodal decrement as well as intraventricular delay related to pathway location. This interindividual variability might explain misleading interpretations of PPI-TCL and SA-VA. CONCLUSION: This novel approach is advantageous because of its simplicity and effectiveness, requiring only 2 diagnostic catheters. A local VA interval difference <40 ms provides a clear distinction for AVRT.

Clinical Implications of CT-detected Hypoattenuation Thickening on Left Atrial Appendage Occlusion Devices.

Background At follow-up CT after left atrial appendage occlusion (LAAO), hypoattenuation thickening (HAT) on the atrial aspect of the device is a common finding but the clinical implications require further study. Purpose To assess the association of HAT grade at follow-up CT with clinical characteristics and outcomes in patients who underwent LAAO. Materials and Methods This prospective study included consecutive participants with atrial fibrillation and who were at high risk for stroke (CHA2DS2-VASc score ≥4) who underwent LAAO and were administered pacifier or nonpacifier devices at two French medical centers between January 2012 and November 2020. Postprocedure CT images were evaluated by two radiologists in consensus and device-specific interpretation algorithms were applied to classify HAT as low grade (low suspicion of thrombosis) or high grade (high suspicion of thrombosis). The association between HAT grade and clinical characteristics was assessed using multinomial logistic regression, and variables associated with risk of stroke were assessed using a Cox proportional hazard model. Results This study included 412 participants (mean age, 76 years ± 8 [SD]; 284 male participants) who underwent follow-up CT at a mean of 4.2 months ± 1.7 after LAAO. Low-grade and high-grade HAT were depicted in 98 of 412 (23.8%) and 21 of 412 (5.1%) participants, respectively. High-grade HAT was associated with higher odds of antithrombotic drug discontinuation during follow-up (odds ratio, 9.5; 95% CI: 3.1, 29.1; P < .001), whereas low-grade HAT was associated with lower odds of persisting left atrial appendage patency (odds ratio, 0.46; 95% CI: 0.27, 0.79; P = .005). During a median follow-up of 17 months (IQR, 11-41 months), stroke occurred in 24 of 412 (5.8%) participants. High-grade HAT was associated with stroke (hazard ratio, 4.6; 95% CI: 1.5, 14.0; P = .008) and low-grade HAT (P = .62) was not. Conclusion Low-grade HAT was a more common finding at CT performed after LAAO CT (24%) than was high-grade HAT (5%), but it was associated with more favorable outcomes than high-grade HAT, which was associated with higher stroke risk. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Choe in this issue.

Omnipolar versus bipolar mapping to guide ventricular tachycardia ablation.

BACKGROUND: Omnipolar technology (OT) was recently proposed to generate electroanatomic voltage maps with orientation-independent electrograms. We describe the first cohort of patients undergoing ventricular tachycardia (VT) ablation guided by OT. OBJECTIVE: The purpose of this study was to compare omnipolar and bipolar high-density maps with regard to voltage amplitude, late potential (LP) annotation, and isochronal late activation mapping distribution. METHODS: A total of 24 patients (16 [66%] ischemic cardiomyopathy and 12 [50%] redo cases) underwent VT ablation under OT guidance. Twenty-seven sinus rhythm substrate maps and 10 VT activation maps were analyzed. Omnipolar and bipolar (HD Wave Solution algorithm, Abbott, Abbott Park, IL) voltages were compared. Areas of LPs were correlated with the VT isthmus areas, and late electrogram misannotation was evaluated. Deceleration zones based on isochronal late activation maps were analyzed by 2 blinded operators and compared to the VT isthmuses. RESULTS: OT maps had higher point density (13.8 points/cm2 vs 8.0 points/cm2). Omnipolar points had 7.1% higher voltages than bipolar points within areas of dense scar and border zone. The number of misannotated points was significantly lower for OT maps (6.8% vs 21.9%; P = .01), showing comparable sensitivity (53% vs 59%) but higher specificity (79% vs 63%). The sensitivity and specificity of detection of the VT isthmus in the deceleration zones were, respectively, 75% and 65% for OT and 35% and 55% for bipolar mapping. At 8.4 months, 71% freedom from VT recurrence was achieved. CONCLUSION: OT is a valuable tool for guiding VT ablation, providing more accurate identification of LPs and isochronal crowding due to slightly higher voltages.

Left Ventricular Abnormal Substrate in Brugada Syndrome.

BACKGROUND: Slow-conductive structural abnormalities located in the epicardium of the right ventricle (RV) underlie Brugada syndrome (BrS). The extent of such substrate in the left ventricle (LV) has not been investigated. OBJECTIVES: This study sought to characterize the extent of epicardial substrate abnormalities in BrS. METHODS: We evaluated 22 consecutive patients (mean age 46 ± 11 years, 21 male) referred for recurrent ventricular arrhythmias (mean 10 ± 13 episodes) in the setting of BrS. The patients underwent clinical investigations and wide genetic screening to identify SCN5A mutations and common risk variants. High-density biventricular epicardial mapping was performed to detect prolonged (>70 ms) fragmented electrograms, indicating abnormal substrate area. RESULTS: All patients presented with abnormal substrate in the epicardial anterior RV (27 ± 11 cm2). Abnormal substrate was also identified on the LV epicardium in 10 patients (45%), 9 at baseline and 1 after ajmaline infusion, covering 15 ± 11 cm2. Of these, 4 had severe LV fascicular blocks. Patients with LV substrate had a longer history of arrhythmia (11.4 ± 6.7 years vs 4.3 ± 4.3 years; P = 0.003), longer PR (217 ± 24 ms vs 171 ± 14 ms; P < 0.001) and HV (60 ± 12 ms vs 46 ± 5 ms; P = 0.005) intervals, and abnormal substrate also extending into the inferior RV (100% vs 33%; P = 0.001). SCN5A mutation was present in 70% of patients with LV substrate (vs 25%; P = 0.035). SCN5A BrS patients with recurrent ventricular arrhythmias present a higher polygenic risk score compared with a nonselected BrS population (median of differences: -0.86; 95% CI: -1.48 to -0.27; P = 0.02). CONCLUSIONS: A subset of patients with BrS present an abnormal substrate extending onto the LV epicardium and inferior RV that is associated with SCN5A mutations and multigenic variants.

Electrophysiological study prior to planned pulmonary valve replacement in patients with repaired tetralogy of Fallot.

AIM: Ventricular arrhythmias (VAs) are the most common cause of death in patients with repaired Tetralogy of Fallot (rTOF). However, risk stratifying remains challenging. We examined outcomes following programmed ventricular stimulation (PVS) with or without subsequent ablation in patients with rTOF planned for pulmonary valve replacement (PVR). METHODS: We included all consecutive patients with rTOF referred to our institution from 2010 to 2018 aged ≥18 years for PVR. Right ventricular (RV) voltage maps were acquired and PVS was performed from two different sites at baseline, and if non-inducible under isoproterenol. Catheter and/or surgical ablation was performed when patients were inducible or when slow conduction was present in anatomical isthmuses (AIs). Postablation PVS was undertaken to guide implantable cardioverter-defibrillator (ICD) implantation. RESULTS: Seventy-seven patients (36.2 ± 14.3 years old, 71% male) were included. Eighteen were inducible. In 28 patients (17 inducible, 11 non-inducible but with slow conduction) ablation was performed. Five had catheter ablation, surgical cryoablation in 9, both techniques in 14. ICDs were implanted in five patients. During a follow-up of 74 ± 40 months, no sudden cardiac death occurred. Three patients experienced sustained VAs, all were inducible during the initial EP study. Two of them had an ICD (low ejection fraction for one and important risk factor for arrhythmia for the second). No VAs were reported in the non-inducible group (p < .001). CONCLUSION: Preoperative EPS can help identifying patients with rTOF at risk for VAs, providing an opportunity for targeted ablation and may improve decision-making regarding ICD implantation.

Advanced Imaging Integration for Catheter Ablation of Ventricular Tachycardia.

PURPOSE OF REVIEW: Imaging plays a crucial role in the therapy of ventricular tachycardia (VT). We offer an overview of the different methods and provide information on their use in a clinical setting. RECENT FINDINGS: The use of imaging in VT has progressed recently. Intracardiac echography facilitates catheter navigation and the targeting of moving intracardiac structures. Integration of pre-procedural CT or MRI allows for targeting the VT substrate, with major expected impact on VT ablation efficacy and efficiency. Advances in computational modeling may further enhance the performance of imaging, giving access to pre-operative simulation of VT. These advances in non-invasive diagnosis are increasingly being coupled with non-invasive approaches for therapy delivery. This review highlights the latest research on the use of imaging in VT procedures. Image-based strategies are progressively shifting from using images as an adjunct tool to electrophysiological techniques, to an integration of imaging as a central element of the treatment strategy.

Use of specific agar plates for early detection of anaerobic bacteria in surgical site infections after spinal surgery: a prospective single centre study.

To determine if additional agar plates could allow earlier detection of anaerobes in spinal surgical site infections (SSIs), we performed a prospective study (November 2017-January 2019) of patients with early spinal SSIs. In addition to routine 14-day cultures, surgical samples were inoculated onto three additional plates (CDC anaerobe agar with 5% sheep blood [CDC], CDC anaerobe laked sheep blood agar with kanamycin/vancomycin [BBL], and Bacteroides bile esculin [BBE] agar with amikacin (BD, USA)) incubated under anaerobic conditions (72 h, 37°C). The primary endpoint was detection of anaerobes by these methods, as compared to routine culture. Anaerobes were identified in 7/61 patients (11%) using the routine procedure and in one extra case with additional plates (overall detection rate 8/61, 13%). Sensitivity was greater for the CDC plate than for the BBL and BBE plates. When routine culture was positive, the CDC plate was always positive, and in three cases showed at least one additional anaerobe. Using additional agar plates, anaerobes were identified in early spinal SSI in 13% of patients. Within 3 days, CDC agar plate enabled detection of anaerobes in one extra case and at least one additional anaerobe in three other cases, compared to routine 14-day culture.

Gaps after linear ablation of persistent atrial fibrillation (Marshall-PLAN): Clinical implication.

BACKGROUND: Beyond pulmonary vein (PV) isolation, anatomic isthmus transection is an adjunctive strategy for persistent atrial fibrillation. Data on the durability of multiple lines of block remain scarce. OBJECTIVE: The purpose of this study was to evaluate the impact of gaps within such a lesion set. METHODS: We followed 291 consecutive patients who underwent (1) vein of Marshall ethanol infusion, (2) PV isolation, and (3) mitral, cavotricuspid, and dome isthmus transection. Dome transection relied on 2 distinct strategies over time: a single roof line with touch-ups applied in case of gap demonstrated by conventional maneuvers (first leg), and an alternative floor line if the roof line exhibited a gap during high-density mapping with careful electrogram reannotation (second leg). RESULTS: Twelve-month sinus rhythm maintenance was 70% after 1 procedure and 94% after 1 or 2 procedures. Event-free survival after the first procedure was lower in case of residual gaps within the lesion set (log-rank, P = .004). Delayed gaps were found in 94% of a second procedure performed in the 69 patients relapsing despite a complete lesion set with PV gaps increasing the risk of recurrence of atrial fibrillation (67% vs 34%; P = .02) and anatomic isthmus gaps supporting a majority of atrial tachycardias (60%). Between the first leg and the second leg, a significant decrease was found in roof lines considered blocked during the first procedure (99% vs 78%; P < .001) and in delayed dome gaps observed during a second procedure (68% vs 43%; P = .05). CONCLUSION: Gaps are arrhythmogenic and can be reduced by optimized ablation and assessment of lines of block. Closing these gaps improves sinus rhythm maintenance.

Surgical site infection is a major risk factor of pseudarthrosis in adult spinal deformity surgery.

BACKGROUND CONTEXT: Despite the evidence in appendicular skeletal surgery, the effect of infection on spinal fusion remains unclear, particularly after Adult Spinal Deformity (ASD) surgery. PURPOSE: The purpose of this study was to determine the impact of surgical site infection (SSI) in ASD surgery fusion rates and its association with other risks factors of pseudarthrosis. STUDY DESIGN: We conducted an international multicenter retrospective study on a prospective cohort of patients operated for spinal deformity. PATIENT SAMPLE: A total of 956 patients were included (762 females and 194 males). OUTCOME MEASURES: Patient's preoperative characteristics, pre and postoperative spinopelvic parameters, surgical variables, postoperative complications and were recorded. Surgical site infections were asserted in case of clinical signs associated with positive surgical samples. Each case was treated with surgical reintervention for debridement and irrigation. Presence of pseudarthrosis was defined by the association of clinical symptoms and radiological signs of nonfusion (either direct evidence on CT-scan or indirect radiographic clues such as screw loosening, rod breakage, screw pull out or loss of correction). Each iterative surgical intervention was collected. METHODS: Univariate and multivariate analysis with logistic regression models were performed to evaluate the role of risk factors of pseudarthrosis. RESULTS: Nine hundred fifty-six surgical ASD patients with more than two years of follow-up were included in the study. 65 of these patients were treated for SSI (6.8%), 138 for pseudarthrosis (14.4%), and 28 patients for both SSI and pseudarthrosis. On multivariate analysis, SSI was found to be a major risk factor of pseudarthrosis (OR=4.4; 95% CI=2.4,7.9) as well as other known risks factors: BMI (OR=1.1; 95% CI=1.0,1.1), smoking (OR=1.6; 95% CI=1.1,2.9), performance of Smith-Petersen osteotomy (OR = 1.6; 95% CI 1.0,2.6), number of vertebrae instrumented (OR=1.1; 95% CI=1.1,1.2) and the caudal level of fusion, with a distal exponential increment of the risk (OR max for S1=6, 95% CI=1.9,18.6). CONCLUSION: SSI significantly increases the risk of pseudarthrosis with an OR of 4.4.

Sinus node exit, crista terminalis conduction, interatrial connection, and wavefront collision: Key features of human atrial activation in sinus rhythm.

BACKGROUND: An understanding of normal atrial activation during sinus rhythm can inform catheter ablation strategies to avoid deleterious impacts of ablation lesions on atrial conduction and mechanics. OBJECTIVE: The purpose of this study was to describe how the sinus node impulse originates, propagates, and collides in right and left atria with normal voltage. METHODS: Fifty consecutive patients undergoing catheter ablation of atrial fibrillation with endocardial atrial voltage >0.5 mV during high-density 3-dimensional mapping were studied. RESULTS: Sinus node exits varied among patients along a lateral oblique arc extending from the anterior aspect of the superior vena cava (SVC) to the mid-posterior wall of the right atrium (RA). Conduction slowing or block at one of the smooth components that faces the crista terminalis was observed in 54% of cases, including complete block at the SVC musculature and systemic venous sinus in 6% of cases. Depending on these 2 key features of RA activation, interatrial conduction was mediated by the Bachmann bundle (64%) and posterior bundles (54%), with an overlap of the resulting left atrial breakthrough location. Wavefront collision was consistently observed at 3 sites: the septal aspect of the cavotricuspid isthmus, and the lower aspects of the dome and of the mitral isthmus. CONCLUSION: During sinus rhythm, atrial activation occurs via distinct sequences mediated by a complex interaction of anatomic factors.

Doughnut vertebroplasty for circumferential aggressive vertebral hemangiomas.

BACKGROUND: To assess the feasibility, safety and efficacy of a percutaneous doughnut vertebroplasty of circumferential aggressive vertebral hemangiomas (VHs). METHODS: We retrospectively reviewed our prospectively collected database of patients with VHs treated with vertebroplasty between January 2009 and January 2018. Patient demographics, clinical presentations and procedural details were recorded. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI). All vertebroplasties were performed under conscious sedation in the prone position, predominantly using biplane fluoroscopic guidance. A clinical and imaging evaluation (early CT scan and MRI) as well as a final follow-up clinical assessment was performed. RESULTS: Twenty-two patients with aggressive VHs who underwent circumferential vertebroplasty with cementation of the entire vertebral body and at least one posterior hemi-arch were included (six males, mean age 53 years). At 3 months follow-up, nine patients (41%) had complete, 11 (50%) had partial and two (9%) had no resolution of pain. Nine of 14 patients had a decrease in venous swelling on MRI. No complications were observed. Five patients (23%) underwent adjunctive surgery within 1 year for persistence or worsening of neurological symptoms. Clinical and radiographic improvements were maintained to final follow-up. CONCLUSIONS: Doughnut vertebroplasty offers a mini-invasive, safe and effective treatment of aggressive circumferential VHs. This technique improves pain in over 90% of patients as well as a reduction in radicular and neurological symptoms associated with a tendency to regression of the compressive epidural venous component of these lesions.

The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration.

BACKGROUND: Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE. METHODS: A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme. RESULTS: 145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03). CONCLUSIONS: The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.

Evaluation of enhanced recovery after spine surgery: Specificities in an academic public hospital.

INTRODUCTION: Enhanced recovery after surgery (ERAS) has been well described in many surgical specialties, including orthopedics. Application in spine surgery, on the other hand, is more recent and not yet precisely assessed. The present study aimed to assess the implementation of an ERAS program in a European spine surgery department and its impact on length of hospital stay and complications rate. MATERIALS AND METHODS: A comparative observational study was conducted on patient progression with and without ERAS. As of the launch date of the program, all eligible patients were included over a 6-month period. A retrospective control group comprised patients managed over the same 6-month period of the previous year, matched for pathology, comorbidity and individual surgeon. Endpoints comprised mean length of stay and major complications (i.e., requiring readmission or revision surgery within 90days). RESULTS: Eighty-eight patients were included: 44 per group. Demographic characteristics did not significantly differ between groups. Mean length of stay, taking all pathologies together, was 3.3days in ERAS versus 6days in the control group (p<0.001). Complications rates did not significantly differ between groups (p=1). DISCUSSION: The introduction of the ERAS program gave care teams the opportunity to think over good practices and set up a number of concomitant measures generally agreed to be effective in isolation. The present study showed ERAS to be perfectly feasible in a public-sector structure, reducing length of stay without increasing the rate of complications. LEVEL OF EVIDENCE: IV CEBM.

Fear Avoidance Beliefs and Outcome After Surgery for Degenerative Lumbar Spine.

STUDY DESIGN: This was a prospective cohort study. OBJECTIVE: The aim of this study is to question the influence of fear avoidance beliefs on functional outcome following surgery for degenerative lumbar spine. BACKGROUND: Fear avoidance beliefs are well-studied modifiers of low back pain. Nonetheless, the influence of fear avoidance beliefs on the outcome of spinal surgery remains controversial. METHODS: We conducted a prospective cohort study including patients undergoing surgery for degenerative lumbar discopathy, spondylolisthesis, and stenosis. Patients completed a preoperative questionnaire including the Fear Avoidance Beliefs Questionnaire (FABQ) as well as Visual Analog Scales for radicular and lumbar pain (VAS-R/L), Oswestry Disability Index (ODI), and Short-Form 36 health survey (SF36). Functional outcome was measured at least 6 months after surgery using ODI. RESULTS: Sixty-three patients with a mean follow-up of 254 days (8.5 mo, minimum=179 d, maximum=534 d) were included in the study. Women showed stronger work-related fear avoidance beliefs but there was no other difference in baseline characteristics and functional outcome between patients with low or high (>75th percentile) baseline FABQ-P or FABQ-W scores. Individual variables associated with whether patients reached minimal clinically important difference for ODI were: working status [odds ratio (OR)=0.13; 95% confidence interval (95% CI), 0.03-0.62; P =0.01], American Society of Anesthesiologists classification score (OR=0.32; 95% CI, 0.11-0.92; P =0.03), preoperative duration of symptoms (OR=0.94; 95% CI, 0.89-0.99; P =0.03), and preoperative ODI (OR=1.03; 95% CI, 1.00-1.07; P =0.05). Neither physical nor work-related preoperative FABQ scores were predictors of functional results. CONCLUSIONS: In our study, the FABQ was not associated with functional outcome following surgery for degenerative lumbar spine. Other psychological patient-reported measures are needed to refine selection of patients undergoing spine surgery in order to ensure better outcomes.

Diagnosis of reoperated cervical non-union: Multicenter retrospective study about 45 patients.

INTRODUCTION: Non-union is one of the main complications of single- or multi-level cervical spine fusion, considerably impairing functional results. The aim of this study was to evaluate the respective contributions of imaging examinations in the diagnostic process, the challenge being to avoid inappropriate surgery and unnecessary complementary examinations. MATERIAL AND METHOD: A retrospective multicenter study included all patients managed for cervical spine non-union between 2008 and 2018. We evaluated the imaging examinations performed on each patient and determined signs of non-union in each image. RESULTS: The study included 45 patients in 4 centers: 55% female; mean age, of 48±8.0 years; 57% smokers. Systematic static radiography showed signs of non-union in 55% of cases. Dynamic X-ray was performed in 34% of patients, and showed hypermobility of the level in 80% of cases. CT supported diagnosis of non-union in 97% of cases, and MRI in 48%. SPECT-CT was positive in all cases of non-union. DISCUSSION: Dynamic X-ray is rarely prescribed, but frequently provided an objective measure of hypermobility of the level in non-union, justifying first-line use. Millimetric-slice CT was reliable for diagnosis. MRI is relevant only once diagnosis has been made, as part of preoperative work-up. Nuclear imaging can be useful in order to solve doubtful cases. CONCLUSION: In suspected cervical spine non-union, we recommend dynamic X-rays (flexion/extension) and CT-scan as first-line diagnosis examinations. LEVEL OF EVIDENCE: IV.

Influence of Renal Function and Age on the Pharmacokinetics of Levofloxacin in Patients with Bone and Joint Infections.

Despite its efficacy and toxicity being exposure-related, levofloxacin pharmacokinetics in patients with bone and joint infections has been poorly described to date, so the possible need for a dose adjustment is unknown in this population. A prospective population pharmacokinetic study was conducted in 59 patients to answer this question. The final model consisted of a one-compartment model with first-order absorption and elimination. Mean parameter estimates (% interindividual variability) were 0.895 h-1 for the absorption rate constant (Ka), 6.10 L/h (40%) for the apparent clearance (CL/F), 90.6 L (25%) for the apparent distribution volume (V/F). Age and glomerular filtration rate (GFR), estimated by the modification of diet in renal disease formula, were related to CL/F by power models, and CL/F was found to increase for increasing GFR and decreasing age. For a similar GFR, the simulated area under the curve (AUC) was 55% higher in 70 years-old patients compared to 30 year-old patients. Based on this model, a 750 mg dose should provide an optimal exposure (AUC/ minimum inhibitory concentration (MIC) ≥100), with the possible exception of patients older than 60 years and with GFR <70 mL/min/m² who may necessitate a dose reduction, and patients with infections caused by bacteria with MIC close to 1 mg/L who may need an increase in the dose.

Individual decontamination measures reduce by two the incidence of surgical site infections in spinal surgery.

BACKGROUND: In spinal surgery, incidence of surgical site infections (SSI) is estimated between 1 and 10%. It results in increased morbidity, mortality and cost of management. Individual Staphylococcus aureus (SA) decolonization has already proved efficiency to prevent those events in various surgical domains. The aim of this study was to evaluate a strategy of prevention of SSI and in particular the decolonization of the nasal carriage of SA by a protocol with Mupirocin application. METHODS: We conducted a bicentric observational study on 5314 spinal surgery patients over a seven-year period. In both center, we compared periods before and after implementation of two measures: modification of antibioprophylaxis and staphylococcus decolonization. Homogeneity of the different samples of patients was assessed through measure of individual and surgical variables. We measured monthly incidence of SSI and evaluated its evolution in order to assess efficiency of these interventions. RESULTS: The incidence of SSI decreased by half, from 7.3% to 3% at the Beaujon Hospital and from 8.3% to 3.9% at the Georges-Pompidou European Hospital (GPEH). We do not observe any significant decrease of SA rate in these SSI. CONCLUSION: We believe that Staphylococcus aureus decolonization should be recommended in spinal surgery, and should be combined with an overall improvement of the quality of care.