Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation (UNILIF): morbidity, clinical and radiological 2-year outcomes of a 66-patient prospective series.

PURPOSE: To assess clinical and radiological outcomes at 2-year follow-up of one-level minimally invasive transforaminal interbody fusion with unilateral pedicle screw fixation (UNILIF) in the treatment of stable lumbar degenerative diseases. METHODS: From January 1, 2012 to January 31, 2013, we prospectively collected clinical and radiological data on patients with stable degenerative lumbar disease managed by UNILIF in a single institution. Preoperatively and at 2 years, we recorded ODI, SF-12, Quebec and VAS. Interbody fusion was analyzed on radiography and on a CT scan, and sagittal balance was tested on full spine radiography. RESULTS: Mean operation time was 74.5 min ± 16.8, mean blood loss was 130.8 ml ± 210.9. At 2 years, ODI, SF-12, Quebec and VAS were significantly improved (p > 0.005).The fusion rate was 96.8% on radiographic analysis and was 87.9% on CT scan analysis. CONCLUSIONS: One-level UNILIF constitutes an effective alternative for management of stable lumbar degenerative diseases. These slides can be retrieved under Electronic Supplementary Material.

[Biometric and biomechanic analysis of lumbar posterior facets based on a CT-scan database]. / Analyse biométrique et biomécanique des articulaires lombaires postérieures au sein d'une base de données scanographique.

AIM OF THE STUDY: Our knowledge on anatomy of lumbar spine is based on few cadaver's study with old and few subjects. CT-scan is very precise for lumbar facet's morphology. We have analysed 400 subjects. The aim of this study is to measure different distances, angles and circles to better understand the mechanical function of the lumbar facets. PATIENTS AND METHODS: We have analysed 720 CT-scan. We had 217 men and 183 women with 59 years of mean age. We used native slices of 1.25 mm thick from L1 to S1. We created transversal plan and we put different mark point. We took their coordinates and we have calculated different distances, angles and mechanical circles. We have compared different axis of rotation of the facets. RESULTS: From L1 to S1, the facets goes near to the posterior wall and far from themselves. Moreover, the posterior angle between both facets increase down to the sacrum. The radius of the left side circle and the right one are very closed in 50% of the cases but the three radius are close only in 10% of cases. CONCLUSION: This study based on 400 subjects shows that there is not a unique axis of rotation for both lumbar posterior facets. We have had only 50% of symmetry between both sides whatever the level studied.

Optimal Correction of Adult Spinal Deformities Requires Restoration of Distal Lumbar Lordosis.

PURPOSE: The aim of this study is to analyze results according to postoperative pelvic incidence-lumbar lordosis (PI-LL) mismatch in the management of adult spine deformity (ASD) patients. Recently, it has been reported that in addition to lumbar lordosis amount, lordosis repartition between its proximal and distal parts was crucial. METHODS: We enrolled 77 consecutive ASD patients who underwent posterior spinal fusion and deformity correction between 2015 and 2018. On preoperative and 1-year follow-up radiographs, we analyzed different parameters such as L1-S1 lumbar lordosis, L1-L4 proximal lordosis (PLL), L4-S1 distal lordosis (DLL), pelvic tilt (PT), sagittal vertical axis (SVA), and PI-LL mismatch. Comparisons were performed according to postoperative PI-LL mismatch (defined as "aligned" when PI-LL was <10°). The relationship between lordosis distribution and postoperative alignment status was investigated. RESULTS: On the whole series, average lumbar lordosis, SVA, and PI-LL improved (28.2° vs.43.5°, 82 vs. 51 mm, and 26°vs. 14°, all p < 0.001, respectively). On the other hand, PT remained unchanged (30° vs. 28°, p > 0.05). 35 patients were classified as "aligned" and 42 as "not aligned." Patients from the "aligned" group had a significantly lower PI than patients from the "not aligned" group (52° vs. 61°, p=0.009). Postoperative PLL was not different between groups (18° vs. 16° p > 0.05), whereas DLL was significantly higher in the "aligned" group (31° vs. 22°, p=0.003). PI-LL was significantly correlated to DLL (rho = 0.407, p < 0.001) but not with PLL (rho = 0.110, p=0.342). CONCLUSIONS: Our results revealed that in ASD patients, postoperative malalignment was associated with a lack of DLL restoration. "Not aligned" patients had also a significantly higher pelvic incidence. Specific attention must be paid to restore optimal distal lumbar lordosis in order to set the amount and the distribution of optimal postoperative lumbar lordosis.

Adult Spinal Deformities: Can Patient-Specific Rods Change the Preoperative Planning into Clinical Reality? Feasibility Study and Preliminary Results about 77 Cases.

Surgical management of adult spinal deformities remains challenging, and one of the major goals is to restore sagittal alignment. Spinal rods used for posterior fixation are usually delivered straight and bended manually during surgery. This manual bending can be responsible for undercorrection of the deformity. In the last years, prebended patient-specific rods have been developed and might be a valuable tool in order to optimize surgical results. The objective is therefore to use the time between surgical decision and operative room in order to realize a precise surgical planning and obtain patient-specific rods. We describe here the planning process and our preliminary experience with patient-specific rods in the management of adult deformity about 77 cases. On the 77 cases, PSR were used without further modifications of the shape. Based on 3-month postoperative evaluation, a significant decrease of sagittal vertical axis (-41%, p < 0.0001) and pelvic incidence-lumbar lordosis (-62%, p < 0.0001) was reported. Pelvic tilt was not significantly corrected, except in patients with Parkinson's disease. In this subgroup of patients, measurements revealed a significant correction of SVA and PI-LL (-53%, p=0.005, and -81%, p < 0.0001, respectively) but also of PT (-23%, p < 0.001). The use of PSR, in our experience, was feasible and provided satisfactory short-term results. It can be a valuable tool in the management of adult spinal deformities. Further studies will be needed in order to confirm these preliminary results.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury.

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

[Pelvic incidence reliability in spine sagittal balance]. / Etude de la fiabilité des mesures de l'incidence pelvienne dans l'analyse de l'équilibre sagittal du bassin.

PURPOSE OF THE STUDY: The pelvic incidence (PI) is an anatomic parameter independent of the spatial orientation of the pelvis. However, measuring the PI remains a technically difficult task. PI is determined from radiographic construction which has several consequences. Imperfect radiographic incidence may compromise optimal conditions for measurement. Anatomic remodeling of the sacral plate can also have an impact on rigorous measurement of the PI. Several solutions have been proposed in the literature in order to obtain equivalent measurements. The proposed methods (Duval-Beaupere, Vialle) appear logical, but remain to be validated. The purpose of this study was to determine whether the angle measured on the plain x-ray is affected by the radiographic quality of the image and to determine whether the "variant pelvic incidence" (VPI) using a reference constituted by the posterior aspect of the sacrum, can be accepted as a valid equivalent to PI in the event of anatomic remodeling. MATERIAL AND METHODS: This was a prospective study conducted in 50 patients. The PI and the VPI were measured on 3D computed tomography reconstructions which allowed three series of measurements: in a strictly lateral view, in a view with the position of the femoral heads shifted in the horizontal plane, and a view with the position of the femoral heads shifted in the vertical plane. Statistical analysis was applied to compare the three series of measures in order to search for a significant difference for the two angles under consideration (PI and VPI) dependent on the position of the pelvis. RESULTS: There was no significant difference in PI as a function of the position of the femoral heads: the coefficients of variation were all greater than 0.98 (p<0.01). For VPI, there was a significant difference between the theoretical ideal position and the horizontal shift of the femoral heads (p<0.05). Average measurements of PI and VPI were statistically different for each individual (p<0.05), with no identifiable relationship between the two values (PI and VPI). DISCUSSION: Pelvic incidence is a reliable measure, even if the quality of the x-ray is not perfect. Conversely, the variant, using the posterior aspect of the sacrum, is highly dependent on pelvic orientation, with significant differences with position. We were unable to establish a relation between PI and VPI. In practice, it would be licit to consider that the straight line between the two femoral heads indicates the center of the femoral heads. On the contrary, it would not be wise to consider the posterior aspect of the sacrum as a reliable reference.

[Long-term outcome of large bone and osteochondral allografts]. / Devenir à long terme des allogreffes osseuses et ostéo-cartilagineuses massives cryopréservées.

Since 1978 the Marseille Bone Tissue Bank has stored 7466 specimens. Of these, 578 were large allografts, of which 529 have so far been used. The grafts are stored in liquid nitrogen with a cryopreserver, and are not sterilized by irradiation. They have been used to replace lost tissue after tumor excision, trauma, and repeated reconstructive surgery. Three hundred and thirteen patients were operated on between 1983 and 1998, and good integration was achieved in 82 % of cases. Immunological complications occurred in 14 % of cases. They were often confused with non microbial sepsis and responded well to immunosuppressive treatment, even though the fluid surrounding the graft sometimes fistulised to the skin. In 4.2 % of cases the graft had to be replaced, and in 6.4 % of cases a joint prosthesis had to be used.

Is anatomic acetabular orientation related to pelvic morphology? CT analysis of 150 healthy pelvises.

BACKGROUND: Links between sagittal spinal alignment and acetabular orientation attract considerable research attention with the goal of optimising prosthetic cup position. However, whether pelvic incidence (PI) is related to anatomic acetabular orientation remains unknown. We therefore conducted a radiological study with the following objectives: to look for correlations between PI and anatomic acetabular parameters; to describe the sacro-pubic angle (SPA), defined by fixed bony pelvic landmarks, and its relations with acetabular anteversion; and to determine whether anatomical parameters (PI and SPA) correlate with demographic characteristics. HYPOTHESIS: PI correlates with anatomical acetabular parameters. MATERIALS AND METHODS: We conducted a computed tomography (CT) study of the pelvises of 150 patients free of degenerative disease. Three parameters were measured: anatomic acetabular orientation in the Lewinnek reference plane, PI, and the SPA subtended by the line connecting the midpoint of the sacral endplate to the pubic symphysis and the anterior pelvic plane. Statistical tests were performed to look for correlations among these parameters. RESULTS: Intra-observer and inter-observer reproducibility was considered highly satisfactory (inter-class correlation coefficient, >86% and >82%, respectively). Mean PI was 58.6°±10.2° (range, 32.8°-97.6°), with no significant differences between genders or across age groups. Mean SPA was 34.7°±5.5° (range, 18.3°-49.8°). Mean anatomic acetabular anteversion (AAA) was greater in females (23.4°; range, 11.5°-34.5°) than in males (20°; range, 7.5°-34.5°) (P<0.001). PI did not correlate with any of the acetabular parameters (PI/AAA, r=0.8 and P=0.33; PI/acetabular inclination on the horizontal, r=-0.96 and P=0.24). SPA correlated significantly with both PI (r=0.33 and P<0.001) and AAA (r=0.33 and P<0.001). DISCUSSION: This CT study of normal pelvises showed that AAA was significantly greater in females and that SPA correlated significantly with both PI and acetabular anteversion. SPA could serve to define the "theoretical" AAA of each individual patient and could thus be incorporated into surgical planning protocols or intra-operative guidance methods for hip replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

Surgical techniques for lumbo-sacral fusion.

Lumbo-sacral (L5-S1) fusion is a widely performed procedure that has become the reference standard treatment for refractory low back pain. L5-S1 is a complex transition zone between the mobile lordotic distal lumbar spine and the fixed sacral region. The goal is to immobilise the lumbo-sacral junction in order to relieve pain originating from this site. Apart from achieving inter-vertebral fusion, the main challenge lies in the preoperative determination of the fixed L5-S1 position that will be optimal for the patient. Many lumbo-sacral fusion techniques are available. Stabilisation can be achieved using various methods. An anterior, posterior, or combined approach may be used. Recently developed minimally invasive techniques are gaining in popularity based on their good clinical outcomes and high fusion rates. The objective of this conference is to resolve the main issues faced by spinal surgeons in their everyday practice.

Surgical management of post-traumatic atlantoaxial rotatory fixation due to C2 facet fracture: 5 clinical cases.

PURPOSE: Report the results of surgical treatment of post-traumatic atlantoaxial rotatory fixation (AARF) due to C2 articular facet fracture in adults. MATERIAL AND METHODS: The records of five patients treated since 2009 for AARF due to a C2 articular facet fracture were analyzed retrospectively. Three women and two men with an average age of 60 years (27-82) were included, one of whom initially had neurological deficits. In all cases, the surgical strategy consisted of posterior fixation: Harms-type in four cases and trans-articular with hooks in one case. RESULTS: Dislocations due to fracture of the C2 articular facet are rare in adults; various treatment strategies have been described. In our experience, posterior screw fixation leads to satisfactory clinical and radiological outcomes. Fusion is not necessary in these cases because the dislocation is related to an asymmetric fracture without ligament damage. CONCLUSION: Posterior fixation provides satisfactory reduction of these injuries and leads to satisfactory bone union. This surgical treatment can be performed early on after the trauma and is an interesting alternative to conservative treatment.

Trends in the surgical management of odontoid fractures in patients above 75 years of age: Retrospective study of 70 cases.

BACKGROUND: Odontoid fractures are the most common upper cervical spine fracture in adults over 70 years of age. Hence, treatment of these fractures has public health implications. OBJECTIVES: Evaluate the early complications, bone healing and mortality in patients above 75 years of age who undergo surgical treatment of an odontoid fracture. Compare the results between patients operated with the Harms technique or anterior screw fixation. METHODS: This was a retrospective study of 70 patients with an odontoid fracture who were treated surgically between 2000 and 2015 at the Hôpital de la Timone in France. The age at the time of diagnosis, comorbidities, ASA score and autonomy were evaluated. Bone healing was determined using computed tomography. RESULTS: In the cohort, 22 patients underwent anterior screw fixation, 38 were treated using the Harms technique and 10 with other procedures. The average age was 85.1 years. Fifty-four percent of patients had an ASA score above 3. The average follow-up was 23.4 months. An Anderson type II fracture was present in 80.6% of patients. In the anterior screw fixation group, the operative time was significantly shorter than in the Harms group and no blood transfusions were needed. However, 13.6% of these patients had to be re-operated because the initial construct was unstable; no patients in the Harms group underwent revision surgery. There were more complications in the anterior screw fixation group than in the Harms group: 41% versus 13.2% (P<0.02). The fractures had healed in all patients reviewed after 1 year. The 3-month survival in the anterior screw fixation group was 64.7% and it was 81.3% in the Harms group. These rates were stable at 1 year with no statistical differences between groups. CONCLUSION: Surgical treatment of odontoid fractures in the elderly results in an excellent union rate. The mortality rate is stable after 3 months. In our experience, the Harms technique has a lower risk of complications and better mechanical stability than anterior screw fixation. Despite the steep learning curve, we believe the Harms technique is probably the best choice for treating odontoid fractures in the elderly. LEVEL OF EVIDENCE: 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.

Quantitative MRI water content mapping of porcine intervertebral disc during uniaxial compression.

BACKGROUND: Intervertebral disc (IVD) diseases are major public health problem in industrialized countries where they affect a large proportion of the population. In particular, IVD degeneration is considered to be one of the leading causes of pain consultation and sick leave. The aim of this study was to develop a new method for assessing the functionality of IVD in order to diagnose IVD degeneration. METHODS: For this purpose, we have designed a specific device that enables to mechanically load porcine IVD ex vivo in the 4.7-Tesla horizontal superconducting magnet of a magnetic resonance (MR) scanner. Proton density weighted imaging (ρH-MRI) of the samples was acquired. FINDINGS: The post-processing on MR images allowed (1) to reconstruct the 3D deformation under a known mechanical load and (2) to infer the IVD porosity assuming an incompressible poroelastic model. INTERPRETATION: This study demonstrates the ability to follow the change in morphology and hydration of an IVD using MR measurements, thereby providing valued information for a better understanding of IVD function.

[Use of pedicle percutaneous cemented screws in the management of patients with poor bone stock]. / Utilisation de vis cimentées percutanées dans la prise en charge rachidienne des patients à faible capacité osseuse.

INTRODUCTION: Management of patients with poor bone stock remains difficult due to the risks of mechanical complications such as screws pullouts. At the same time, development of minimal invasive spinal techniques using a percutaneous approach is greatly adapted to these fragile patients with a reduction in operative time and complications. The aim of this study was to report our experience with cemented percutaneous screws in the management of patients with a poor bone stock. METHODS: Thirty-five patients were included in this retrospective study. In each case, a percutaneous osteosynthesis using cemented screws was performed. Indications were osteoporotic fractures, metastasis or fractures on ankylosing spine. Depending on radiologic findings, short or long constructs (2 levels above and below) were performed and an anterior column support (kyphoplasty or anterior approach) was added. Evaluation of patients was based on pre and postoperative CT-scans associated with clinical follow-up with a minimum of 6 months. RESULTS: Eleven men and 24 women with a mean age of 73 years [60-87] were included in the study. Surgical indication was related to an osteoporotic fracture in 20 cases, a metastasis in 13 cases and a fracture on ankylosing spine in the last 2 cases. Most of the fractures were located between T10 and L2 and a long construct was performed in 22 cases. Percutaneous kyphoplasty was added in 24 cases and a complementary anterior approach in 3 cases. Average operative time was 86minutes [61-110] and blood loss was estimated as minor in all the cases. In the entire series, average volume of cement injected was 1.8 cc/screw. One patient underwent a major complication with a vascular leakage responsible for a cement pulmonary embolism. With a 9 months average follow-up [6-20], no cases of infection or mechanical complication was reported. CONCLUSION: Minimal invasive spinal techniques are greatly adapted to the management of fragile patients. The use of percutaneous cemented screws is, in our experience, a valuable alternative for spinal fixation in patients with poor bone stock. This technique allows a good bony fixation with a low rate of complications. However, rigorous preoperative planning is necessary in order to avoid complications.

Delayed hypersensitivity reaction after cervical disc replacement: a case report.

We report a case of allergic reaction after total cervical disc arthroplasty. A 52-year old woman was operated on for right C6 cervicobrachial neuralgia secondary to C5-C6 disc disease with foraminal stenosis. A cobalt-chromium-molybdenum total disc prosthesis had been implanted two years earlier. The patient was referred to our institution for recurrence of axial neck pain associated with abdominal patches of erythematous itching rash and swallowing disorder. Allergy tests confirmed type-4 allergic reaction to chromium. Symptoms decreased after removal of the prosthesis with secondary fusion. Delayed allergic reaction is uncommon in spine surgery, but should be considered in case of recurrence of initial symptomatology associated with non-spinal signs.

Minimally invasive posterior transforaminal lumbar interbody fusion: One-year postoperative morbidity, clinical and radiological results of a prospective multicenter study of 182 cases.

INTRODUCTION: Interbody fusion is the gold standard treatment for the management of numerous diseases of the spine. Minimally invasive techniques may be more beneficial than conventional techniques. The main goal of this study was to report the one-year postoperative results of a series of posterior lumbar interbody fusions by a minimally invasive technique in relation to improvement in functional outcome, interbody fusion and morbidity. MATERIALS AND METHODS: Between January 2012 and May 2013, 182 patients treated by minimally invasive posterior transforaminal lumbar interbody fusion (TLIF) were included in this prospective multicenter study. Clinical assessment was based on a comparison of the preoperative and one-year postoperative Oswestry (ODI), SF-12 and Quebec Scores and the Visual Analog Scale (VAS). Surgical and postoperative follow-up data were evaluated. Radiological assessment was based preoperative and one-year postoperative full spine teleradiographs. Interbody fusion at one-year was systematically evaluated by CT scan. RESULTS: One hundred and eighty-two patients were included, mean age 58.9 years old. Surgery lasted a mean 101 minutes, mean preoperative bleeding was 143 mL, and mean radiation exposure was 247.4 cGy/cm(2). The rate of postoperative complications was 7.7%. The ODI, the Quebec Score, the SF-12 and the VAS were all significantly improved at one-year (P<0.0001). The rate of fusion was 72.6% at the final follow-up. There was no significant difference in functional outcome between patients with and without fusion. DISCUSSION: The one-year postoperative radiological results and functional outcome of minimally invasive posterior lumbar fusion are satisfactory. The benefits of this minimally invasive approach are mainly found in the first 6 postoperative months. Successful radiological interbody fusion was not correlated to functional outcome at the final follow-up.

Organization of services and nursing care: hospice and palliative medicine.

The health care industry is changing and nursing case management is an integral part of restructured care in many institutions. Health care organizations must evaluate services and outcomes. The terminally ill comprise a large portion of patients in any health care delivery system. Hospitals that provide formal cancer care services need to evaluate where palliative care and hospice fit. Shifts in patient care will be evident due to changes in demographics, payor initiatives, and technological advances. Providing care for patients with advanced disease and the role of nursing have evolved over the past 10 years. One important area that has not changed is the passion and caring evident in the nurse's everyday practice.

Nebulized hydromorphone for dyspnea in hospice care of advanced cancer.

This case report describes the use of nebulized hydromorphone for management of dyspnea in advanced cancer in home hospice care. The patient was intolerant of morphine; nebulized hydromorphone was used as an alternative to nebulized morphine for dyspnea and found to be both safe and effective.

Dying at home: emergency medications for terminal symptoms.

This article discusses the use of a medication kit at home for terminal symptoms. This innovation has been in place for more than two years at the Hospice of the Cleveland Clinic. There is no previously published information on this innovation in the literature.

[Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature]. / Fractures diaphysaires de l'humérus : ostéosynthèse systématique par plaque. Résultats anatomiques et fonctionnels d'une série de 156 cas et revue de la littérature]

PURPOSE OF THE STUDY: Based on our experience with plate fixation of humeral shaft fractures and an analysis of the international literature, we attempted to answer the following questions. What functional outcome and what complications can be expected after surgery? Are the classical complications of open fracture surgery (screw fixation, wiring, plate fixation without compression.) as frequent after plate fixation using the Müller technique? MATERIAL AND METHODS: We reviewed our series of 156 humeral shaft fractures (61 p. 100 men, mean age 45 years) including 21 cases of multiple trauma and 24 multiple fractures. A floating elbow was present in 8 cases and skin opening in 16. Initial radial deficiency was observed in 28 cases. Plate fixation was the only method used for the humeral shaft fractures. We used the modified Stewart and Hundley classification. RESULTS: Postoperative paralysis occurred in 8 cases (5.1 p. 100, 5 complete paralysis); only one patient suffered persistent severe sequelae. There were also 8 malunions and 3 late consolidations. Consolidation rate was 94.2 p. 100, sepsis rate was 1.5 p. 100. Good or very good outcome was achieved in 86.6 p. 100 of the cases. DISCUSSION: In the literature, (71 series, 5 000 patients), plate fixation of humeral shaft fractures has given very good functional results with few initial failures, malunions or cases of sepsis. Radial paralysis is cited as a complication in 6.5 p. 100 of all plate fixations but is reversible in 90 p. 100 of cases. Classical orthopedic methods and centromedullar techniques produce more stiffness. The Sarmiento cuff can give good results after rigorous patient selection. CONCLUSION: Plate fixation according to the Müller technique is a reliable osteosynthesis method with few initial failures or malunions as evidenced by data in the literature. Infection is also rare. Although the radial nerve risk makes this technique rather difficult, excellent functional results can be achieved.