Plate-only open-door laminoplasty is associated with durable, significantly improved clinical outcomes and a very low reoperation rate for progressive spondylosis or adjacent segment disease: average 8-year follow-up.

BACKGROUND CONTEXT: Multilevel cervical myelopathy is a common cause of spinal cord dysfunction in adults. Surgical intervention via laminoplasty can provide satisfactory clinical outcomes by expansive decompression of the spinal cord. Traditional suture or bone graft techniques have been associated with insufficient fixation, leading to premature closure and subsequent neurological deterioration. In contrast, plated laminoplasty has been shown to provide stable fixation to maintain canal enlargement, but longer-term outcomes are lacking. PURPOSE: To evaluate longer-term clinical outcomes and reoperations associated with plate-only open-door laminoplasty. STUDY DESIGN: Retrospective review of prospectively collected data. PATIENT SAMPLE: Postoperative patients who underwent plate-only open door laminoplasty with minimum 5-year follow up. OUTCOME MEASURES: modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), and 12-item Short Form Health Survey (SF-12). METHODS: All patients at a single academic institution who underwent plate-only open-door cervical laminoplasty from 9/1/2006 to 9/1/2016 were identified to ensure minimum 5 year follow up. Clinical outcomes included the modified Japanese Orthopaedic Association (mJOA) score, the Neck Disability Index (NDI), and the 12-item Short Form Health Survey (SF-12). The occurrence of any repeat operations on the cervical spine was evaluated, as well as its cause. The study team attempted to contact all eligible patients to achieve at least 5 years postoperative follow-up. Pairwise t tests were performed to compare clinical outcomes at preoperative, 6 months, 1-year, and final postoperative follow-up with an α level of 0.05. RESULTS: A total of 774 met the initial inclusion criteria, of which 157 were included in the study (20.3%). Most common reasons for exclusion included inability to reach after 3 attempts (49.48%), inactive phone numbers (20.28%), and patient declining (3.49%). Included patients had an average age of 60.66±10.63 and an average follow-up time of 8.37±2.57 years (minimum 5 years). mJOA scores (preoperative 11.59±2.16) improved significantly at 6-months (14.57±2.07, p<.001), 1-year (15.19±1.95, p<.001), and final follow-up (14.59±2.63, p<.001). NDI (preoperative 33.89±18.54) improved significantly at 6 months (27.89±19.72, p=.03), 1-year (25.96±19.79, p=.01) and final follow-up (17.88±17.17, p<.001). SF-12 MCS (preoperative 44.73) improved significantly at 6 months (52.01, p=.001), 1-year (51.62, p=.008), and final follow-up (52.32, p<.001). No patient underwent reoperations for plate failure or canal closure with recurrent stenosis. Reoperations for progressive spondylosis during the follow up period were rare and occurred in only three patients for new onset radiculopathy (1.9%) and two patients for myelopathy (1.3%) at an average of 3.2 years postoperative. There were no reoperations performed for adjacent segment disease. CONCLUSIONS: At a minimum of 5 years and an average of more than 8 years postoperative, laminoplasty was associated with significant and sustained improvements in mJOA, NDI, and SF-12 MCS. Importantly, no patients underwent revision surgery for plate failure or recurrent canal closure. Reoperations for new onset radiculopathy and myelopathy were also very rare over the 8-year average follow-up period, with no reoperations for adjacent segment disease. Plate-only laminoplasty is a durable means of treating multilevel myelopathy with excellent longer-term outcomes and a very low risk of reoperation, either for premature closure or the inevitable spondylotic changes that occur over time in patients with similar baseline characteristics to the study population.

Prospective comparison of dysphagia following anterior cervical discectomy and fusion (ACDF) with and without rhBMP-2.

BACKGROUND CONTEXT: Previous studies have called into question the safety of using rhBMP-2 in anterior cervical fusion due to the possibility of airway compromise and dysphagia. A retrospective chart review identified a significant increase in the severity of dysphagia after II-level ACDF with rhBMP-2 compared to patients who did not receive rhBMP-2. To date, this topic has not been studied prospectively. PURPOSE: Compare the incidence of dysphagia following anterior cervical discectomy and fusion (ACDF) when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used with allograft compared to allograft alone. STUDY DESIGN: Prospective cohort study. PATIENT SAMPLE: A total of 114 patients completed a baseline SWAL-QOL survey and met the inclusion criteria. Thirty-nine patients underwent I- or II-level ACDF with allograft plus 0.5mg rhBMP-2/level. 44 patients underwent ACDF with allograft alone. Thirty-one patients undergoing a lumbar decompression were enrolled in a third cohort to control for dysphagia secondary to intubation. OUTCOME MEASURES: The primary outcome measure was the 14-point SWAL-QOL dysphagia questionnaire. Other patient factors obtained from anesthesia and operative records were examined to evaluate their potential relationship to postoperative dysphagia. METHODS: The 14-point SWAL-QOL questionnaire was administered at multiple time points (pre-op, post-op 7 days, 6 weeks, 6 months, and at least 1 year). Multivariable repeated-measures analysis was applied to data. RESULTS: Baseline adjusted SWAL-QOL means 7 days after surgery were significantly different between the three study groups. These differences resolved by 6 weeks postoperative, beyond which point there were no differences. At final follow-up, baseline adjusted SWAL-QOL means at 1 year were similar for the three study groups. CONCLUSIONS: This single-center study of anterior cervical surgery demonstrated that the addition of rhBMP-2 to an ACDF increased postoperative dysphagia at 7 days after surgery, but these patients recover to levels comparable to those who underwent ACDF without rhBMP-2 or lumbar surgery within 6 weeks.

Evaluation of pediatric distal femoral physeal fractures and the factors impacting poor outcome requiring further corrective surgery.

Fractures of the distal femur carry a significant risk of physeal arrest and resulting growth complications which often require additional surgeries to correct the deformity. This study examines the risk of needing corrective procedures as a child approaches skeletal maturity. A retrospective analysis of patients treated at a single institution for distal femoral physeal fractures from 2000 to 2015 was performed. Association between sex, age, Salter-Harris (SH) class, and fracture displacement with the risk of physeal arrest were examined. Association between years of growth remaining to skeletal maturity and the risk of needing additional corrective surgery (defined by leg length difference >2 cm or angular deformity (>5°) was examined using a logistic regression model. One hundred one patients were available for review with an average age of 12.6 ± 3.2 years. Twenty-six patients (25.7%) developed a physeal arrest. Seventy-six percent of these required subsequent surgical intervention to address length and angular deformities Sex, age, and SH class were not significantly associated with physeal arrest (P > 0.05). Percent fracture displacement was significantly associated with physeal arrest (P = 0.02). Years of growth remaining to skeletal maturity were significantly associated with an increased risk of requiring corrective surgery for growth complications (odds ratio: 0.758; 95% confidence interval 0.587-0.979; P = 0.03), however, this association failed to persist when accounting for age. Years of growth remaining to skeletal maturity may predict the need for future interventions and should be accounted for when planning treatment of these challenging injuries.

Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results.

BACKGROUND: Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present. PURPOSE: Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction. RESULTS: Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release. CONCLUSION: The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.

A reproducible and reliable localization technique for lumbar spine surgery that minimizes unintended-level exposure and wrong-level surgery.

BACKGROUND CONTEXT: Exposure of unintended levels (defined as a spinal segment outside the intended surgical levels) is unnecessary and potentially adds to operative time and patient morbidity. Wrong-level surgery (defined as decompression, instrumentation, or fusion of a spinal segment not part of the intended surgical procedure) clearly adds to morbidity as well as putting the surgeon at medicolegal risk. PURPOSE: To describe a localization technique for posterior lumbar spine surgery to minimize both unintended-level exposure and wrong-level surgery. STUDY DESIGN: Consecutive case series. PATIENT SAMPLE: One thousand nine hundred and eighty-six consecutive posterior lumbar operations performed from January 2010 to January 2017 using this technique were reviewed. OUTCOME MEASURES: The primary outcome measure was the incidence of unintended-level exposure and wrong-level surgery. METHODS: This localization technique was consistently used for determination of skin incision, soft tissue dissection, and identification of spinal levels for all patients undergoing posterior lumbar surgery during the time interval noted. Two spinal needles are inserted under sterile technique 3cm lateral to the midline before incision at the approximate cranial and caudal aspects of the anticipated incision based on external landmarks. A cross-table lateral X-ray before incision is obtained and the actual incision is adjusted based on the location of the spinal needles. Once dissection is carried down to the facet capsules, spinal needles are then placed in adjacent facets, and a second cross-table lateral film is obtained to confirm appropriate levels. A retrospective review of all posterior lumbar cases was performed to determine the incidence of unintended-level exposure and wrong-level surgery using this technique. RESULTS: There were no wrong-level surgeries during this time period. There were six (0.30%) cases of unintended-level exposure. CONCLUSIONS: The technique described provides surgeons with a reliable, accurate, and easily reproducible method for localizing surgical levels during posterior lumbar spine surgery while minimizing exposure of uninvolved areas. This technique offers distinct advantages over previously proposed protocols and may lead to a widely accepted system for intraoperative spinal level identification.

Roflumilast inhibits the release of chemokines and TNF-α from human lung macrophages stimulated with lipopolysaccharide.

BACKGROUND AND PURPOSE: Lung macrophages are critically involved in respiratory diseases. This study assessed the effects of the PDE4 inhibitor roflumilast and its active metabolite, roflumilast N-oxide on the release of a range of chemokines (CCL2, 3, 4, CXCL1, 8, 10) and of TNF-α, from human lung macrophages, stimulated with bacterial lipopolysaccharide LPS. EXPERIMENTAL APPROACH: Lung macrophages isolated from resected human lungs were incubated with roflumilast, roflumilast N-oxide, PGE(2), the COX inhibitor indomethacin, the COX-2 inhibitor NS-398 or vehicle and stimulated with LPS (24 h). Chemokines, TNF-α, PGE(2) and 6-keto PGF(1α) were measured in culture supernatants by immunoassay. COX-2 mRNA expression was assessed with RT-qPCR. PDE activities were determined in macrophage homogenates. KEY RESULTS: Expression of PDE4 in lung macrophages was increased after incubation with LPS. Roflumilast and roflumilast N-oxide concentration-dependently reduced the LPS-stimulated release of CCL2, CCL3, CCL4, CXCL10 and TNF-α from human lung macrophages, whereas that of CXCL1 or CXCL8 was not altered. This reduction by the PDE4 inhibitors was further accentuated by exogenous PGE(2) (10 nM) but abolished in the presence of indomethacin or NS-398. Conversely, addition of PGE(2) (10 nM), in the presence of indomethacin restored inhibition by roflumilast. LPS also increased PGE(2) and 6-keto PGF(1α) release from lung macrophages which was associated with an up-regulation of COX-2 mRNA. CONCLUSIONS AND IMPLICATIONS: Roflumilast and roflumilast N-oxide reduced LPS-induced release of CCL2, 3, 4, CXCL10 and TNF-α in human lung macrophages.

[Pulmonary hamartoma with lipomatous form]. / Hamartome pulmonaire à forme lipomateuse.

We report of the case of a 41-year-old patient, who had previously undergone thoracic surgery at the age of 16 for a single giant emphysematous bulla. The CT scan showed an abnormal middle mediastinal lesion containing an aerated cystic areas and areas of fat density. The patient underwent surgery and a well-defined mass was found between the mediastinum and the pulmonary hilum, which was able to be completely resected. Microscopic examination disclosed a composite tumour containing a bronchogenic cyst, a benign lipoma and two hamartochondromas. As no similar case had been reported previously, it was difficult to assert the nature of the lesion, which has been labelled as a "hamartoma". The main diagnoses which should be considered when an intra pulmonary fat density mass is disclosed, are discussed.

[Conservative management of the phrenic nerve and surgical treatment of lung cancer]. / La préservation du nerf phrénique dans la chirurgie du cancer bronchique.

Bronchial carcinoma may involve the phrenic nerve, confronting the surgeon with a difficult choice. In 10 patients undergoing surgery for bronchial carcinoma without previous diaphragmatic palsy, extension to the nerve was discovered during the thoracotomy, leading to a choice between radical surgery involving resection of the nerve, with subsequent diaphragmatic palsy, or incomplete conservative resection preserving the lung function. Conservative surgery was chosen. The subsequent evolution validated this choice. However, the paucity of papers on such cases, although they are not outstandingly unusual, should be noted.

The role of adenosine receptors in regulating production of tumour necrosis factor-alpha and chemokines by human lung macrophages.

BACKGROUND AND PURPOSE: Adenosine is a major endogenous regulator of macrophage function, and activates four specific adenosine receptors (A(1), A(2A), A(2B) and A(3)). Here, we have assessed in human lung macrophages the modulation of the expression of adenosine receptor mRNA by lipopolysaccharide (LPS), and the relative contributions of the different adenosine receptors to LPS-induced production of tumour necrosis factor (TNF)-alpha and chemokines. EXPERIMENTAL APPROACH: Lung macrophages isolated from resected lungs were stimulated with LPS and treated with adenosine receptor agonists or/and antagonists. Adenosine receptor expression was assessed with qRT-PCR. Cytokines were measured in lung macrophage supernatants with elisa. KEY RESULTS: LPS increased (about 400-fold) mRNA for A(2A) adenosine receptors, decreased mRNA for A(1) and A(2B), but had no effect on A(3) adenosine receptor mRNA. The adenosine receptor agonist NECA inhibited TNF-alpha production concentration dependently, whereas the A(1) receptor agonist, CCPA, and the A(3) receptor agonist, AB-MECA, inhibited TNF-alpha production only at concentrations affecting A(2A) receptors. NECA also inhibited the production of CCL chemokines (CCL2, CCL3, CCL4, CCL5) and CXCL chemokines (CXCL9 and CXCL10), but not that of CXCL1, CXCL8 and CXCL5. Reversal of NECA-induced inhibition of TNF-alpha and chemokine production by the selective A(2A) adenosine receptor antagonist ZM 241385, but not the A(2B) receptor antagonist, MRS 1754, or the A(3) receptor antagonist, MRS 1220, indicated involvement of A(2A) receptors. CONCLUSIONS AND IMPLICATIONS: LPS up-regulated A(2A) adenosine receptor gene transcription, and this receptor subtype mediated inhibition of the LPS-induced production of TNF-alpha and of a subset of chemokines in human lung macrophages.

[Inflammatory pseudotumor: a rare cause of proximal bronchial obstruction]. / Une cause rare d'obstruction bronchique proximale récidivante: la pseudo-tumeur inflammatoire.

Inflammatory pseudotumor of the lung is a rare disease with usual benign course. Relapse after incomplete resection and aggressive forms have already been described. We report the case of a 67-year-old woman with atelectasis of the left lung related to an endobronchial inflammatory pseudotumor. After laser resection, relapse occurred 3 months later, requiring surgical treatment.

[Lung cancer and peritoneal mesothelioma: two complications of asbestos exposure in the same patient]. / Cancer broncho-pulmonaire et mésothéliome péritonéal: association de deux complications de l'exposition à l'amiante chez le même patient.

INTRODUCTION: Association of a lung cancer and a malignant peritoneal mesothelioma is reported in a 78-year-old patient with significant asbestos exposure. OBSERVATION: After exploration of an intra-pulmonary opacity, with inspissated pleura, the diagnosis of primary pulmonary adenocarcinoma was obtained by thoracotomy in April 1999. In February 2002, the diagnosis of peritoneal mesothelioma was made by laparoscopy. The course was marked by irreducible ascites and was fatal 7 months after the diagnosis of peritoneal mesothelioma. CONCLUSION: Malignant mesothelioma is a rare disease and even rare in association with lung cancer.

[Hyperplasia of the thymus in Graves' disease. A case report]. / Hyperplasie du thymus au cours de la maladie de Basedow. A propos d'un cas.

Graves' disease is rarely associated with hypertrophy of the thymus which takes on a pseudotumor aspect. We observed a case in a 40-year-old woman who presented clinical and biological hyperthyroidism with anti-TSH receptor antibodies, favoring the diagnosis of Graves' disease which was confirmed by scintigraphy. The chest x-ray performed because of chest pain revealed enlargement of the mediastinum. The thoracic CT-scan without contrast injected showed a pseudotumor aspect of the thymus. Medical treatment with anti-thyroid drugs and beta blockers led to regression of the thymus mass. Knowledge of this type of association can avoid unnecessary thymus surgery. The clinical course is favorable irrespective of the type of anti-thyroid drug given.

[Thymoma and autoimmune thyroiditis. A case report]. / Association d'un thymome et d'une thyroïdite auto-immune.

We report an association between a thymus tumor and autoimmune thyroiditis. This association is probably related to loss of immune control secondary to loss of thymus integrity. A 48-year-old woman was hospitalized for thoracic pain. Her past history included thyroiditis treated by L-thyroxin for two years. The chest x-ray demonstrated a mediastinal opacity which was confirmed by computed tomography. Surgical resection was performed and histological analysis of the surgical specimen confirmed the diagnosis of lympho-epithelial thymoma. Thyroid immunity tests demonstrated the presence of anti-peroxidase antibodies confirming the diagnosis of Hashimoto's thyroiditis. Chest x-ray and CT-scan are indicated in patients with autoimmune thyroiditis to search for a thymic mass. Conversely, search for autoimmune thyroiditis is warranted in patients with an identified thymic mass.

[Chronic hematic cyst of the orbit (orbital subperiosteal hematoma)]. / Kyste hémorragique chronique de l'orbite (hématome sous-périosté orbitaire).

A case of chronic hematic cyst of the orbit which caused unilateral globe displacement with painful diplopia is described in a 72-year-old man. CT scans showed an extraconal soft tissue mass located between the orbital roof and the superior rectus muscle with a bone lysis. Characteristic appearance on MRI (benign signs, subperiosteal localization of the hematoma) has been confirmed by removal surgery. Chronic hematic cyst of the orbit is uncommon and MRI is helpful to establish this diagnostic.

[Secondary intraocular lens implantation: methods and complications]. / Implantation secondaire. Techniques et complications.

PURPOSE: We report a review of the literature on complications of secondary lens implantation without capsular support. METHODS: We assessed results and complications after trans-sulcus sclera l fixation (SSIOL), open-loop anterior chamber intraocular lens (ACIOL) and iris-claw lens (ICIOL). RESULTS: Series published in the literature showed variable results. The rate of increased visual acuity ranged from 71% to 92% for SSIOL, 77% to 92% for ACIOL, 83% to 100% for ICIOL. Complications included: decentration and tilt of th IOL in 0-15.3% for SSIOL, 0-8.6% for ACIOL, 1.8-4.8 % for ICIOL; retinal detachment in 1.1-6% for SSIOL, 0-3.3% for ACIOL; cystoid macular edema in 5.8-23% for ACIOL, 4.8%-5.2% for ICIOL; bullous keratopathy in 0-26.3% for SSIOL, 0-14.2% for ACIOL, 4.8% for ICIOL. Vitreous hemorrhage and suture erosion were specific complications report ed for SSIOL in 1.1-25% and 15-20% of cases respectively. CONCLUSION: Secondary IOL implication is a good alternative for correction of aphakia eyes without a posterior capsule. This analysis shows no one procedures offers more safety than the others. The decisive facto r for choosing among the different types of IOL appears to be surgical experience.

[A further case of tracheal paraganglioma]. / Un nouveau cas de paragangliome trachéal.

Paragangliomas, or chemodectomas, are neuro-endocrine tumors of the neural type, derived from extra-adrenal paraganglia. Tracheal localizations are rare. We report the case of a patient with a paraganglioma of the upper part of the trachea. The tumor was totally removed by means of the resection of the subglottic trachea and anastomosis. Surgery is the treatment of such lesions, but can be difficult in cases of subglottic or juxta-carinal localizations.

[Two new cases of autonomous ectopic goiter]. / Deux nouveaux cas de goitre ectopique autonome.

We observed two cases of autonomous intrathoracic goiter in patients with no past history of thyroidectomy. After resection, the surgical specimens confirmed the non-malignant nature of the goiter. We discuss the literature on management of autonomous intrathoracic goiter.