A prospective multicenter randomized study comparing the SpineJack system and nonsurgical management with a brace in acute traumatic vertebral fractures: the SPICO study.

OBJECTIVE: The objective of this study was to evaluate the efffectiveness of a titanium vertebral augmentation device (SpineJack system) in terms of back pain, radiological outcomes, and economic burden compared with nonsurgical management (NSM) (bracing) for the treatment of vertebral compression fractures. Complications were also evaluated for both treatment methods. METHODS: A prospective multicenter randomized study was performed at 9 French sites. Patients (n = 100) with acute traumatic Magerl type A1 and A3.1 vertebral fractures were enrolled and randomized to treatment with the SpineJack system or NSM consisting of bracing and administration of pain medication. Participants were monitored at admission, during the procedure, and at 1, 12, and 24 months after treatment initiation. Primary outcomes included visual analog scale back pain score, and secondary outcomes included disability (Oswestry Disability Index [ODI] score), health-related quality of life (EQ-5D score), radiological measures (vertebral kyphosis angle [VKA] and regional traumatic angulation [RTA]), and economic outcomes (costs, procedures, hours of help, and time to return to work). RESULTS: Ninety-five patients were included in the analysis, with 48 in the SpineJack group and 47 in the NSM group. Back pain improved significantly for all participants with no significant differences between groups. ODI and EQ-5D scores improved significantly between baseline and follow-up (1, 12, and 24 months) for all participants, with the SpineJack group showing a larger improvement than the NSM group between baseline and 1 month. VKA was significantly lower (p < 0.001) (i.e., better) in the SpineJack group than in the NSM group at 1, 12, and 24 months of follow-up. There was no significant change over time in RTA for the SpineJack group, but the NSM group showed a significant worsening in RTA over time. SpineJack treatment was associated with higher costs than NSM but involved a shorter hospital stay, fewer medical visits, and fewer hours of nursing care. Time to return to work was significantly shorter for the SpineJack group than for the NSM group. There were no significant differences in complications between the two treatments. CONCLUSIONS: Overall, there was no statistical difference in the primary outcomes between the SpineJack treatment group and the NSM group. In terms of secondary outcomes, SpineJack treatment was associated with better radiological outcomes, shorter hospital stays, faster return to work, and fewer hours of nursing care.

Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF.

INTRODUCTION: Circumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques-TLIF versus ALIF plus posterior instrumentation-for low-grade isthmic spondylolisthesis in adults. MATERIALS AND METHODS: This was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1-3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion. RESULTS: The cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18-79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=-0.3295; p=.021). CONCLUSION: ALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis. LEVEL OF EVIDENCE: III; multicenter comparative study.

Fusion and clinical outcomes of lumbar interbody fusion for low-grade isthmic spondylolisthesis.

INTRODUCTION: Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique. HYPOTHESIS: The various interbody fusion strategies provide satisfactory fusion rates and clinical results. METHODS: A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF)+posterolateral fusion (ALIF+PLF: n=60), and ALIF+percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R), Oswestry Disability Index (ODI) and Short Form 12 (SF12). RESULTS: Among the 129 patients, 85.3% showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p<0.001) and VAS-R (p<0.0001), ODI (p<0.001) and SF12 physical (PCS) (p<0.01) and mental component sores (MCS) (p<0.001) all showed significant improvement at 12months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p<0.0001) and radicular pain (p<0.05), ODI (p<0.0001) and SF12 PCS (p<0.01). At 12months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p<0.004) and VAS-L ratings (p<0.001) than Lenke 1-2 patients. CONCLUSION: Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results. LEVEL OF EVIDENCE: IV.

Dynamic global sagittal alignment in patients with lumbar spinal stenosis: Analysis of the effects of decompression surgery on gait adaptations.

BACKGROUND: Lumbar spinal stenosis (LSS) leads patients to adapt their posture and walking parameters. Pelvic retroversion might be a compensation mechanism of pain. Pelvic and lower limbs compensations during gait are still not precisely understood, as well as the effect of a surgical decompression on them. These dynamic parameters can be studied through three-dimensional gait analysis. RESEARCH QUESTION: Is the dynamic pelvic tilt modified after decompression surgery in LSS patients compared to asymptomatic subjects? MATERIAL AND METHODS: 50 asymptomatic subjects (C-group) and 37 patients operated on for lumbar decompression underwent a three-dimensional gait analysis one month before (M0) and six months after (M6) the surgery. 3D gait analysis was performed and hip and knee flexion, trunk kinematics, walking speed, stride length and pelvic tilt during gait or dynamic pelvic tilt (dPT) were recorded. Health-related quality of life (HRQL) scores (Oswestry Disability Index (ODI) and Visual Analogic Scales (VAS)) and radiological assessment were performed preoperatively and postoperatively. RESULTS: Mean values of maximum and minimum dPT in the LSS-group preoperatively were significantly higher compared to the C-group (respectively 10.9 (6.2)° versus 7.3 (5.6)°, p = 0.003; 7.7 (6.1)° versus 4.8 (5.8)°, p = 0.011), and were significantly lowered at M6 (respectively 10.9 (6.2)° versus 8.1 (4.8)°, p = 0.0087; and 7.7 (6.1)° versus 5.1 (4.7)°, p = 0.012), and became similar to the C-group. The dPT range of motion at M0 and M6 were similar, and were both significantly higher than control values. Mean values of maximum and minimum hip flexion were significantly higher at M0 compared to the C-group, and were significantly lowered at M6. No difference was found between the pre- and postoperative radiographic pelvic tilt. The VAS for lumbar pain, the VAS for radicular pain and the ODI were significantly decreased at M6. SIGNIFICANCE: Compared to asymptomatic people, LSS patients walked with a pelvic anteversion, a hip flessum and a knee flessum before surgery, which tended to disappear after the surgical decompression. These differences were not noticed on static radiographs.

Transdural Spinal Cord Herniation: An Exceptional Complication of Thoracoscopic Discectomy: 2-Dimensional Operative Video.

Thoracic disc herniation is a rare and severe condition, whose treatment may have complications including dural tears. Although benign in most cases, dural tears may induce iatrogenic transdural herniation of the spinal cord. The video demonstrates the diagnosis and surgical treatment of iatrogenic transdural herniation of the spinal cord. Here, we report a case of spinal cord herniation after thorascopic treatment of a thoracic disc herniation (DH). A 28-yr-old male presented with several years of left lower extremity weakness and was found to have a T6-7 DH. He underwent DH resection through video assisted mini-thoracotomy at another institution. In the immediate postoperative period, he developed a Brown-Sequard syndrome with left leg weakness. The surgeon decided not to reoperate and the patient improved with rehabilitation, allowing him to walk again. At 6 mo postop, he experienced sudden neurologic worsening but did not present to our clinic until 6 mo later. At this time, he had near complete paraplegia with bilateral lower extremity spasticity and central neuropathic pain. MRI showed a pseudo-meningocele and features suggesting a lateral spinal cord herniation. After a multidisciplinary meeting, we elected to perform a posterolateral approach with costo-arthro-pediculectomy and durotomy to repair the SC herniation. Immediately postop, the patient had a slight improvement in right lower extremity function, with decreased pain and spasticity. This case shows a transdural SC herniation, a rare complication after resection of DH. It is possible that an unreported or unrecognized dural tear at the time of the initial surgery, combined with the negative pressure of the thoracic cavity, put the patient at risk for this particular complication. The authors state that the patient gave his informed consent.

Under-contouring of rods: a potential risk factor for proximal junctional kyphosis after posterior correction of Scheuermann kyphosis.

OBJECTIVE: Scheuermann kyphosis (SK) could require surgical treatment in certain situations. A posterior reduction is the most widespread treatment so far, although the development of proximal junctional kyphosis (PJK) is one of the possible complications of this procedure. The contour of the proximal part of the rod could influence the occurrence of PJK in SK patients. The objective of this study was to analyze the impact of the proximal rod contour on the occurrence of a PJK complication in SK patients. METHODS: This retrospective monocentric study was performed in the Nanjing Spine Surgery Department. All eligible patients had undergone posterior correction surgery with pedicle screws only between 2002 and 2017 and had at least 24 months of follow-up. The presence of PJK was quantified on radiographs using the proximal junctional angle (PJA > 10° at the last follow-up). The authors propose a new radiological parameter to measure the angulation of the proximal part of the instrumentation: the proximal contouring rod angle (PCRA) is the angle between the upper endplate of the upper instrumented vertebra (UIV) and the lower endplate of the second vertebra caudal to the UIV. The patients were analyzed according to the presence or absence of PJK. A t-test, receiver operating characteristic (ROC) curve analysis, and logistic regression analysis were performed for statistical analysis. RESULTS: Sixty-two patients treated for SK were included in this study. The mean age was 18.6 ± 8.5 years, and the mean follow-up was 42.5 ± 16.4 months. The mean correction rate of global kyphosis was 46.4% ± 13.7%. At the last follow-up, 17 patients (27.4%) presented with PJK. No significant difference was found between the PJK and non-PJK groups in terms of age and other preoperative variables. A significant difference in the postoperative PCRA was found between the PJK and non-PJK groups (8.2° ± 4.9° vs 15.7° ± 6.6°, respectively; p = 0.001). A postoperative PCRA less than 10.1° predicted a significantly higher risk for PJK (p = 0.002, OR 2.431, 95% CI 1.781-4.133). CONCLUSIONS: Under-contouring of the proximal part of the rods (lower than 10°) is a risk factor for PJK after posterior correction of SK.

An analysis of the interactions between the spine, pelvis, and lower limbs in asymptomatic adults with limited pelvic compensation.

BACKGROUND: The interactions between the spine, pelvis, and lower limbs are dynamic based on the "cone of economy" concept; thus, different global radiographic parameters could be regarded as reflections of different centers of gravity. We conducted this retrospective study to evaluate the offsets of different centers of gravity in asymptomatic populations and to investigate how the global sagittal alignment is supported. METHODS: The following parameters were measured: cervical lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), the ratio between PT and PI (PT/PI), sacral slope, PI minus LL (PI-LL), the sagittal vertical axis (SVA), cranial SVA to ankle center (Cr-A), CrSVA to the femoral head center (Cr-FH), C2SVA to the femoral head center (C2-FH), pelvic translation (P. Shift), and knee angle (KA). Participants were divided into subgroups based on the PT/PI ratio. Mean values were compared using the t-test, and correlations were assessed using Pearson's coefficient. RESULTS: A total of 82 asymptomatic adults were enrolled. The average PT/PI in subgroup 1 was the smallest, showing that individuals in this group may have limited pelvic retroversion. No significant differences in Cr-FH, Cr-A, or C2-FH were found between subgroups (all P>0.1), implying that global alignment was well supported in each group. Specifically, C2-FH showed minor changes between subgroups (P=0.998), showing that C2-FH may be a target for sagittal compensation. There were positive correlations between PT/PI and both P. Shift and SVA (r=0.930 and r=0.606, respectively). However, Cr-FH, Cr-A, and C2-FH were not significantly correlated with P. Shift or PT/PI (all P>0.05). Weak correlations existed between Cr-A, Cr-FH, and age (all P>0.2). CONCLUSIONS: This study revealed that the Cr-FH and C2-FH offsets are stable across the population and could be maintained by regulating only the sagittal spinal curvature when pelvic compensation is limited. Cr-FH is not affected by age in the asymptomatic population. Thus, the stable Cr-FH and C2-FH could provide references for surgeons during the surgical decision-making process in patients with adult spinal deformity with sagittal malalignment.

Patients with Coronavirus 2019 (COVID-19) and Surgery: Guidelines and Checklist Proposal.

The management of patients with novel coronavirus 2019 (COVID-19) represents a new challenge for medical and surgical teams. Each operating room in the world should be prepared thoughtfully, and the development of a protocol and patient route seems mandatory. An adequate degree of protection must be used. We propose recommendations to help different professionals in the establishment of protocols for the management of patients with COVID-19. We also offer a checklist that could be used in the operating room.

Cervical Cord Compression by Exostosis.

A 51-year-old woman presented to physical therapy with complaints of weakness in her left arm, progressive numbness in both hands, and mild progressive neck pain radiating into the left upper arm. She reported that her condition had started after playing in an amateur tennis tournament 4 weeks prior and progressed to inability to play tennis. Following examination by the physical therapist, the patient was referred to her physician, who ordered magnetic resonance imaging of the spine, which showed a bony exostosis at C1-2 with myelopathy. J Orthop Sports Phys Ther 2019;49(2):112. doi:10.2519/jospt.2019.7942.

Cervical Hyperextension Deformity After Sagittal Balance Correction in Patient with Congenital Limb-Girdle Myopathy: Surgical Technique and Review of Literature.

BACKGROUND: There is no gold standard surgical treatment for cervical hyperextension deformity, especially in case of muscular dystrophy. Special considerations and caution should be taken as they carry a high risk of early mortality and spinal cord injury. Only a few case reports are available in the literature. CASE DESCRIPTION: We report a case of surgical correction of an iatrogenic cervical hyperextension deformity following sagittal balance correction in a patient with congenital limb-girdle myopathy. The patient was successfully treated by posterior cervical release and fusion after verification of the range of motion, reducibility of the deformity, and absence of any positional spinal cord compression with dynamic radiographic examination and preoperative magnetic resonance imaging in the desired postoperative position. CONCLUSIONS: We suggest posterior cervical release and fusion in case of a radiologically and clinically reducible cervical hyperextension deformity under both motor and sensory spinal evoked potential monitoring. In cases of longstanding, rigid, nonreducible cervical hyperextension, laminectomy and concomitant duroplasty could be considered.

Rare Complication of Percutaneous Technique: Intradural Cement Leakage and Its Surgical Treatment.

Popularity of percutaneous vertebroplasty and vertebral augmentation to treat vertebral compression fractures is increasing. Cement leakages are relatively common, but intradural cement leakage is rare. Few cases of intradural cement leakage have been reported in the literature, and emergency surgery has been reported to be <1%. A 64-year-old man with osteolytic vertebral compression fracture at L1, caused by a malignant tumor, had undergone a vertebral augmentation by craniocaudal procedure. Neurologic examination after the surgery revealed paralysis in both legs immediately postoperatively. Computed tomographic imaging revealed a large cement leakage into the spinal canal. The patient was referred to our department for emergency management. He was rapidly scheduled for surgical decompression by laminectomy. First, stabilization by a secure posterior short fixation was done. The laminectomy showed that insertion of a needle through the pedicle had breached the dura and had caused intradural cement leakage. As shown in the Supplementary Video, the piece of intradural cement was finally removed after posterior durotomy. This case demonstrates that even if percutaneous vertebroplasty is a relatively safe technique, it should be performed by well-trained physicians and with great care to prevent disabling complications.

Mid-Term Clinical and Radiological Outcomes After Kyphoplasty in the Treatment of Thoracolumbar Traumatic Vertebral Compression Fractures.

BACKGROUND: The management of thoracolumbar posttraumatic compression fractures varies widely among centers, and there is no real consensus as to the optimum approach. The objective of our retrospective study was to detect the progression of vertebral kyphosis in nonosteoporotic patients treated by balloon kyphoplasty (KPB) who presented with recent compression fractures of the thoracolumbar region. METHODS: In this retrospective study, we investigated the evolution of vertebral and regional kyphosis in 77 patients treated by KPB for compression vertebral fractures (Magerl A) between 2007 and 2011. All treated patients, even those lost to follow-up, were included in our statistical analysis. RESULTS: In the 77 patients, a 2.4° deterioration of vertebral kyphosis (P = 0.0004) and a 4.5° worsening of regional kyphosis (P < 0.0001) were observed at the end of the follow-up period. No statistical correlation between the worsened kyphosis and the deterioration of long-term pain was identified. The mean visual analog scale score was 2.5, associated with very low disability on functional scores. A3-2 and A3-3 fractures are characterized by worsening vertebral and regional kyphosis. CONCLUSIONS: The paucity of studies of posttraumatic vertebral compression fractures in the scientific literature explains the lack of consensus regarding the optimum treatment approach. Postoperative results with KPB favor vertebral and regional kyphosis stability. KPB remains indicated in this situation except in cases of for burst fracture.

Improvement in Sagittal Balance After Decompression Surgery without Fusion in Patients with Degenerative Lumbar Stenosis: Clinical and Radiographic Results at 1 Year.

OBJECTIVE: To evaluate modifications in static spinal status after posterior decompression surgery without fusion in patients with symptomatic central canal stenosis. METHODS: From November 2014 to May 2016, 72 patients who underwent isolated decompression for lumbar spinal stenosis were enrolled prospectively in this single-center study. All of the patients had lateral full-body x-ray scans with the EOS system (EOS Imaging, Paris, France) before surgery and after 12 months of follow-up. Patients were classified into 3 groups according to their preoperative sagittal vertical axis (<50 mm, ≥50 mm, and <100 mm, ≥100 mm). RESULTS: SVA decreased significantly (SVA preoperative: 72.3 ± 43.1; SVA postoperative: 48.3 ± 46.8. P < 0.001). Lumbar lordosis increased significantly from 41.9 ± 13.4 in the preoperative period to 46.5 ± 14.8 at the last follow-up (P < 0.001). In the imbalance groups, the mean postoperative SVA decreased significantly compared with preoperative SVA (P = 0.004). Surgery led to a significant increase in lumbar lordosis in the 3 groups (P < 0.05). Nonetheless, a certain degree of residual imbalance persisted in the major imbalance group. In all of the groups, decompression surgery led to a significant improvement in clinical scores (P < 0.05). CONCLUSIONS: Our study showed an improvement in sagittal balance and lumbar lordosis after decompression surgery without fusion, even in patients with a preoperative SVA >100 mm. However, a certain degree of sagittal imbalance may persist after surgery in patients with major initial imbalance (SVA >100 mm). Nonetheless, after surgery, these patients experienced a clinical benefit comparable with that in the other groups.

Assessment of the Radiation Exposure of Surgeons and Patients During a Lumbar Microdiskectomy and a Cervical Microdiskectomy: A French Prospective Multicenter Study.

OBJECTIVE: Cervical and lumbar disk herniations are the most frequently carried out procedures in spinal surgery. Often, a few snapshots during the procedure are necessary to validate the level or to position the implant. The objective of this study is to quantitatively estimate the radiation received by a spine surgeon and patient during a low-dose radiation procedure. METHODS: We conducted a prospective multicenter study in France from November 2014 to April 2015. Four spine centers were monitored for radiation received by surgeons during interventions for lumbar disk herniation and cervical disk herniation. RESULTS: A total of 134 patients were included. For lumbar disk herniation, the average exposure for the surgeon was 0.584 µSv on the chest, 5.291 µSv on the lens, and 9.295 µSv on the hands per procedure. For these procedures, the dose area product (DAP) was 94.2 ± 198.4 cGy·cm(2), and the fluoroscopic time was 10.2 ± 16.9 seconds. For a herniated cervical disk, the average exposure for the surgeon was 0.122 µSv on the chest, 3.106 µSv on the lens, and 7.143 µSv on the hands per procedure. For these procedures, the DAP was 35.7 ± 72.1 cGy·cm(2), and the fluoroscopic time was 19.7 ± 13.7 seconds. CONCLUSIONS: Exposure to x-rays for surgeons and patients during surgery for lumbar disk herniation is higher than during surgery for cervical herniation disk. Our results show that radiation exposure to the spine surgeon is still far below the annual dose limits.

Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients.

PURPOSE: To investigate the incidence of surgical-site infection (SSI) and determinate the risk factors of SSI in the context of spinal injury. METHODS: From February 1, 2011 to July 31, 2011, for a multicentre cohort of patients with acute spinal injury, we prospectively censored those with SSI for at least 12 months. We recorded epidemiologic characteristics and details of surgical procedure and postoperative care for each patient. We calculated the incidence of SSI at 1, 3 and 12 months after surgery. Univariate and multivariate analysis were used to establish the association of risk factors and SSI. We studied clinical outcomes by a visual analog scale for pain and physical and mental component summaries (PCS and MCS) of the Medical Outcomes Survey 36-Item Short Form (SF-36). RESULTS: At 1 year, among 518 patients, we recorded 25 SSI events, with median occurrence at 16 days (25-75 % quartile: 13-44 days). Incidence of SSI was 3.2 % (95 % confidence interval [1.9-5.3 %]) at 1 month, 3.7 % (95 % [2.2-5.8 %]) at 3 months and 4.6 % (95 % CI [3-6.9 %]) at 12 months. On multivariate analysis, age, presence of diabetes and surgical duration were predictors of SSI (p = 0.009, p = 0.047, and p = 0.015 respectively). At 12 months, infected and non-infected patients did not differ in pain (p = 0.58) or SF-36 PCS (p = 0.8) or MCS (p = 0.68). CONCLUSIONS: In this large prospective multicentre study in the context of spinal injury, we obtained an equivalent incidence rate and risk factors of SSI as found in the literature for elective spinal surgery.