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.

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.

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.

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.

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.

Anterior Cervical Idiopathic Hyperostosis and Dysphagia: The Impact of Surgical Management-Study of a Series of 11 Cases.

OBJECTIVE: To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. METHODS: This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. RESULTS: Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9 patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. CONCLUSIONS: Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

Burden of fractures in France: incidence and severity by age, gender, and site in 2016.

PURPOSE: Fractures are common events, but the exact incidence and severity of fractures have not been clearly determined for most anatomical sites. We estimated the incidence and severity of fractures in France regardless of the anatomical site. METHODS: Observational cross-sectional study in France in 2016 based on the national health data system. All incident fractures in patients 20 years and older were included. We determined the anatomical fracture site (12 sites) and the severity using a 4-point scale (outpatient care, hospitalization, surgery, and in-hospital death). RESULTS: We identified 562,094 incident fractures, predominantly occurring in women (319,858: 56.9%); with a mean age of 63.6 years, and an exponential increase after the age of 70 years. Distal upper limb (172,591: 30.7%), distal lower limb (84,602: 15.1%), and femoral neck (78,766: 14.0%) accounted for more than one-half of all fractures. Sex and age of onset distributions varied widely according to fracture sites, with earlier onset for distal lower limb fractures (mean age: 54.2 years) and distal upper limb fractures (mean age: 55.2 years) with a men predominance for skull fractures. Only 105,165 (18.7%) fractures were treated on an outpatient basis; 11,913 (2.1%) in-hospital deaths occurred in patients with a mean age of 79.5 years. High mortality was observed for skull (12.9%), rib (4.9%), and femoral fractures (femoral neck 4.3% and proximal lower limb 4.2%). CONCLUSION: We estimated the incidence of fractures in France by sex and anatomical site. We also showed that fractures remain common and serious life events, especially in older people.

Successful 6-Week Antibiotic Treatment for Early Surgical-site Infections in Spinal Surgery.

BACKGROUND: The incidence of spinal surgical site infections (SSIs) remains stable at less than 10%. Surgical reinterventions may be hampered by decubitus, treatment-related adverse events, and cost. In the context of emergence of bacterial resistance, a short duration of antimicrobial treatment is of critical importance. If the duration of treatment for SSI is currently 12 weeks, the aim of our study was to assess the efficacy of an antimicrobial treatment shortened to 6 weeks. METHODS: This prospective study was carried out from November 2014 to July 2016 in an 827-bed teaching hospital. After surgical management of SSIs, patients received broad-spectrum antibiotics intravenously for 10 days and orally for the remainder, for a total of 6 weeks. Success was defined as absence of relapse, superinfection, or surgical failure at the end of treatment and at 1-year follow-up. RESULTS: Eighty-five patients were included in this study. The median delay between initial surgery and diagnosis of SSI was 16 days. In 65 cases (76.4%), SSIs were monomicrobial; among these, Staphylococcus aureus was found in 30 cases (46%). Failure was observed in 7 cases (8.2%), with more than half caused by anaerobic bacteria. CONCLUSIONS: Surgical management of SSI followed by a 6-week antibiotic treatment is associated with favorable outcome. Anaerobic bacteria seem to play a role in the occurrence of relapses. A 6-week reduction in antibiotic treatment leads to reduction in cost and, likely, also to reduction in the emergence and spread of resistant microorganisms.

Influence of comorbidities on patients reported outcomes in degenerative lumbar spinal stenosis.

INTRODUCTION: In degenerative lumbar spinal stenosis (DLSS) variability of symptoms according to the severity of stenosis is not well understood. Therefore, another factor that impacts functional outcomes of DLSS patients has been evoked: patient's comorbidities. The aim of this study was to investigate influence of comorbidities on clinical symptoms and functional outcomes in DLSS patients. METHODS: In this prospective study, patients treated for DLSS were included during 12 consecutive months. Both clinical and radiographic exams were required to confirm DLSS diagnosis. Epidemiologic, clinical and radiographic data were collected. Two questionnaires were used to assess functional outcomes: a specific score dedicated to lumbar stenosis consequences assessment (self-administered Beaujon questionnaire, SABQ) and a non-specific score (Short Form 36, SF-36). Four comorbidity scores were calculated: Cumulative Illness Rating Scale, Charlson index, Functional Comorbidity Index and Index of Co-Existent Diseases Correlations between functional and comorbidity scores were calculated. RESULTS: 250 patients were included (65.6±12 years). The four comorbidities scores were significantly correlated to total SABQ, as well as lumbar and radicular ischemia components. Best correlations were observed for cumulative illness rating scale and SABQ. Two factors were observed that significantly influenced the relationship between SABQ and cumulative illness rating scale: herniated disc and SF-36 general health perception. DISCUSSION: This study highlighted that preoperative function is influenced by comorbidities in DLSS patients. Relationships existed between comorbidities and symptoms related to low back pain and neurogenic claudication, contrary to radicular pain. Therefore, comorbidities might impact the variability of patients' outcomes. This finding should be part of the patient's preoperative information. Moreover, role of comorbidities on postoperative outcomes need to be investigated.

Successful treatment of Pseudomonas aeruginosa osteomyelitis with antibiotic monotherapy of limited duration.

OBJECTIVES: The aim of this study was to present a 15-year experience and provide a comprehensive analysis of a large cohort of patients with Pseudomonas aeruginosa osteomyelitis. METHODS: We reviewed the medical records of patients admitted to a large French university hospital for P. aeruginosa osteomyelitis over a 15-year period. Patient outcome was assessed at follow-up after at least six months. RESULTS: Sixty-seven patients were included, comprising 57% with chronic osteomyelitis. Polymicrobial infection was predominant (63%), and an infected device was involved in 39% patients. The overall treatment success rate was 79.1%. All but one patient were treated with a combination of surgery and antibiotic therapy. The antibiotic treatment had a mean duration of 45 days (range, 21-90 days). Single-antibiotic therapy was preferred in nearly all cases. Treatment failure was reported for 14 (21%) patients and was due to the persistence of P. aeruginosa in four cases. No significant risk factor for treatment failure was identified, especially when treatment strategies were compared. CONCLUSIONS: We advocate optimal surgical debridement combined with initial parenteral antibiotics for a maximum of 15 days, followed by an oral fluoroquinolone. Total treatment duration should not exceed six weeks, and antibiotic treatment with two-drug combinations does not seem necessary.

Terrorist attacks in Paris: Surgical trauma experience in a referral center.

BACKGROUND: On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS: This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS: Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION: Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.

Spondylodiscitis Due to Aspergillus terreus in an Immunocompetent Host: Case Report and Literature Review.

Aspergillus terreus, a saprophytic fungus, is recognized as an emerging pathogen responsible for various infections in human beings. However, bone and joint involvement is uncommon. We report a rare case of A. terreus spondylodiscitis in a 20-year-old male with a past history of recurrent, incompletely treated pulmonary tuberculosis. Clinical signs at the time of admission included cough, low-grade fever, general weakness and left-sided back pain. Histological examination of spinal biopsy samples revealed lesions of necrosis, granulomatous inflammation and septate hyphae with acute-angle branching. A. terreus was recovered from culture. The patient received antifungal therapy with voriconazole plus caspofungin and underwent surgical debridement. Further investigations revealed no cause of primary immunodeficiency such as chronic granulomatous disease, severe combined immunodeficiency syndrome or disorders of the IL-12/IFNγ signaling pathway. Moreover, HIV serological tests resulted negative and the patient was not under immunosuppressive therapy. Unfortunately, owing to precarity and medication non-adherence, vertebral sequelae occurred. This new report emphasizes the need to consider a fungal infection in patients with spondylodiscitis, regardless of the immune status.

Risk of revision surgery for adult idiopathic scoliosis: a survival analysis of 517 cases over 25 years.

PURPOSE: Little is known about the long-term status of patients operated for spine deformities. The aim of this study was to determine the survival of primary fusion in adult idiopathic scoliosis and identify the risk factors of revision surgery. METHODS: Adult patients who underwent primary fusion for idiopathic scoliosis between 1983 and 2011 were included in a continuous monocentric retrospective series. Any additional surgery was registered for survival analysis. Survival and follow-up were estimated by the Kaplan-Meier method and an analysis was performed to identify the risk factors of revision surgery. RESULTS: This series included 447 women (86.5 %) and 70 men (13.5 %) reviewed after a mean follow-up of 7 years (range 0-26.4). Mean age was 44.4 years. Fusion was performed on a median 11 levels (range 3-15); revision rate was 13 % (CI 10-17), 18 % (CI 14-23) and 20 % (CI 16-26) at 5, 10 and 15 years, respectively. Revision surgery was associated with age, anterior release, length of fusion, the inferior limit of fusion, post-operative sagittal balance and junctional kyphosis. The length of fusion (HR 1.13 per vertebrae fused, p = 0.007) and the lower limit of fusion (HR 5.9, p < 0.001) remained independent predictors of revision surgery on multivariate analysis. CONCLUSION: This series evaluated the risk of revision surgery following spinal fusion for idiopathic scoliosis. Our results show that the risk seemed to increase linearly with a rate of nearly 20 % after 10 years. The length and lower limit of fusion are the main risk factors for revision surgery. Level IV (e.g. case series).

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.