Distal Junctional Failure: A Feared Complication of Multilevel Posterior Spinal Fusions.

Objectives: Distal junctional failure (DJF) is less commonly described than proximal junctional failure following posterior spinal fusion, and particularly adult spinal deformity (ASD) surgery. We describe a case series of patients with DJF, taking into account sagittal spinopelvic alignment, and suggest potential risk factors in light of the current literature. Methods: We performed a single-center, retrospective review of posterior spinal fusion patients with DJF who underwent subsequent revision surgery between June 2009 and January 2019. Demographics and surgical details were collected. Radiographical measurements included the following: preoperative and postoperative sagittal and coronal alignment for each index or revision surgery. The upper-instrumented vertebra (UIV), lower instrumented vertebra (LIV), and fusion length were recorded. Results: Nineteen cases (64.7 ± 13.5 years, 12 women, seven men) were included. The mean follow-up was 4.7 ± 2.4 years. The number of instrumented levels was 6.79 ± 2.97. Among the patients, 84.2% (n = 16) presented at least one known DJF risk factor. LIV was frequently L5 (n = 10) or S1 (n = 2). Six patients had an initial circumferential fusion at the distal end. Initial DJFs were vertebral fracture distal to the fusion (n = 5), screw pull-out (n = 9), spinal stenosis (n = 4), instability (n = 4), and one early DJK. The distal mechanical complications after a first revision included screw pull-out (n = 4), screw fracture (n = 3), non-union (n = 2), and an iatrogenic spondylolisthesis. Conclusions: In this case series, insufficient sagittal balance restoration, female gender, osteoporosis, L5 or S1 LIV in long constructs were associated with DJF. Restoring spinal balance and circumferentially fusing the base of constructs represent key steps to maintain correction and prevent revisions.

Variation of Global Sagittal Alignment Parameters According to Gender, Pelvic Incidence, and Age.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: The aim was to describe existing global sagittal alignment parameters across ages and to analyze differences according to gender and pelvic incidence (PI). SUMMARY OF BACKGROUND DATA: Variability with age has been reported. It remains unclear how gender and spinopelvic morphology could additionally influence global alignment parameters. MATERIALS AND METHODS: Radiographs of 2599 individuals (5-93 y) were analyzed. Translation parameters were: Sagittal Vertical Axis (SVA)-C7, SVA-C2, SVA-Center Acoustic Meatus (CAM), C7/Sacrofemoral Distance (SFD) ratio. Inclination parameters were: C7-Vertical Tilt (VT), T1-VT and T9-VT, Odontoid-Hip Axis (OD-HA), OD-CAM. Pelvic compensation parameters were: T1-Pelvic Angle (TPA), Global Tilt (GT), Spino-Sacral Angle (SSA). Global sagittal alignment (GSA) was considered among formulae. The distribution of parameters was analyzed using a Bayesian inference. Correlations with spinopelvic parameters were investigated. RESULTS: SVA-C7, SVA-C2, SVA-CAM were larger in males and high PI, and increased significantly after 50 years (Pr>0.9999). C7/SFD decreased during growth and was larger in low PI (Pr=0.951). There was no correlation with spinopelvic parameters. Age-related variations of inclination parameters were nonsignificant. T1-VT and T9-VT increased with PI and were significantly larger in high PI (Pr>0.95). C7-VT was significantly larger in low PI (Pr>0.9999). OD-HA and OD-CAM were constant and increased after 80 years. TPA and GT increased with PI (Pr>0.9999) and age after 35 years (Pr>0.9999). SSA decreased nonsignificantly after 50 years. TPA correlated with PI (ρ=0.6130) and pelvic tilt (PT) (ρ=0.8375). GT correlated with PI (ρ=0.5961) and PT (ρ=0.8996). SSA correlated with sacral slope (ρ=0.9026). GSA was larger in high PI (Pr>0.9999) and increased after 35 years (Pr>0.9999). GSA correlated with PT (ρ=0.7732). CONCLUSION: Translation parameters increase with age, more prominently in males and high PI. Variations of inclination parameters are smaller. Pelvic compensation parameters and GSA increase with age and are closely related to PT and spinopelvic morphology. LEVEL OF EVIDENCE: Level III.

S2-Alar-iliac screw fixation for paediatric neuromuscular scoliosis: Preliminary results after two years.

BACKGROUND: Correcting pelvic obliquity is among the main goals of surgery for neuromuscular scoliosis. Spino-pelvic fixation must be stable and capable of withstanding the considerable mechanical forces applied at the lumbo-sacral junction. Selection of the best anchoring option is therefore crucial. S2-alar-iliac (S2AI) screws, which are used in adults, are less often chosen in the French paediatric spinal-surgery community. The objective of this study was to report our preliminary experience with S2AI screws used in the treatment of paediatric patients with neuromuscular scoliosis. HYPOTHESIS: Pelvic anchoring by means of S2AI screws is reliable and technically feasible in non-ambulatory children with neuromuscular scoliosis. MATERIALS AND METHODS: Consecutive non-ambulatory patients who underwent scoliosis surgery with S2AI screw fixation to the pelvis between 2016 and 2018 were retrospectively included. The surgical procedure consisted in either posterior spinal fusion (PSF) or magnetic growing rod (MGR) implantation. In all patients, radiographs were obtained before surgery, within 3 months after surgery, and at last follow-up; and low-dose computed tomography (CT) was performed before and after surgery. RESULTS: We included 25 patients with a mean age of 13.8±4.0 years, 18 managed by PSF and 7 by MGRs. Screw diameters ranged from 7.5 to 9.5mm and all screws were at least 60mm in length. The diameters and lengths were the same on both sides in 16 (89%) patients in the PSF group and in all patients in the MGR group. At last follow-up after a mean of 35.5±3.0 months, pelvic obliquity was corrected in all 23 patients with this abnormality before surgery. Complications consisted of lateral cortical screw breakthrough in 8 (32% of screws) patients and screw malposition in 2 (8% of screws) patients. No clinically significant complications related to the fixation material were recorded. DISCUSSION: The results of our study demonstrate the feasibility of S2AI screw fixation in paediatric patients with neuromuscular scoliosis. Pelvic asymmetry and dysmorphism do not contra-indicate the procedure but must be evaluated before surgery. Further work is needed to assess the potential long-term consequences on pain and growth of screw passage through the sacro-iliac joints. LEVEL OF EVIDENCE: IV, retrospective study.

The functional method: experience from the Robert Debré Hospital.

BACKGROUND: In the 1970s a conservative treatment for clubfoot (CF) deformity based on daily physiotherapy combining specific sequences was developed: the French functional method (FFM). Over time, the FFM technique has improved and additional measures have been introduced. The aim of this study was to report mid-term and long-term results of clubfeet treated conservatively by the FFM at birth. METHODS: All patients consecutively treated for clubfoot by the FFM between 1993 and 2010 were prospectively included. Initial severity was assessed by the Dimeglio classification. All patients were followed up by the same treating surgeon until skeletal maturity. Final assessment was performed using the International Clubfoot Study Group evaluation system (ICFSG). RESULTS: A total of 779 feet were included. Surgery was required in 41% of cases (mean age 2.0±0.1 years). The incidence of surgery significantly decreased after the introduction of percutaneous Achilles tenotomy (PAT) in 2000 (63.4% vs. 29.6%). At latest evaluation (mean follow-up 12±0.2 years), 86% of patients had excellent or good outcomes (mean ICFSG was 1.83±0.1). Mean ankle dorsiflexion was 10° in non-idiopathic CF and 12.1° in idiopathic CF. Eleven percent of the idiopathic clubfeet exhibited decreased ankle function (0-10°). There were no cases of overcorrection into excess ankle dorsiflexion or rocker bottom foot deformities. CONCLUSIONS: Current team was the funding institution of the FFM and several modifications were proposed over times to improve outcomes. Eighty-six percent of feet had excellent to good outcomes according to the ICFSG score, with minimal residual deformities (ankle dorsiflexion between 0° and 10°, calcaneal-thigh angle between 10° and 20°) or insufficient radiological correction (defined by talo-calcaneal angle between 10° and 20°) at latest follow-up.

Sagittal Correction and Reciprocal Changes After Thoracic Pedicle Subtraction Osteotomy.

STUDY DESIGN: A retrospective clinical review. OBJECTIVE: To evaluate the sagittal correction efficacy of a thoracic pedicle subtraction osteotomy (PSO), to determine and predict changes at both the cervical and lumbar mobile unfused segments after whether an upper or lower level thoracic PSO. SUMMARY OF BACKGROUND DATA: Thoracic PSO is a technically challenging but increasingly valid procedure in the treatment of fixed thoracic deformities.Anatomical characteristics differentiate upper and lower segment thoracic PSOs and define its corrective ability. There is yet paucity in the literature concerning the causality between the osteotomy level and the reciprocal changes observed postoperatively at the adjacent unfused curves. METHODS: Data collection from a single institutional database was carried out retrospectively by reviewing medical records and imaging of fixed thoracic kyphotic deformity patients submitted to a single level thoracic PSO. RESULTS: Seventeen patients (11M:6F), with a mean age of 44 years (range, 17-76). Fifty-nine percent had a previous spine surgery. The mean follow-up was of 55 months (range, 27-122). In six patients PSO was performed in the upper thoracic segment (T1-T6) and in 11 patients between T7 and T12 (lower thoracic segment), allowing a mean local kyphosis correction of 31° and 41° respectively. The mean cervical and lumbar lordosis globally improved. The upper thoracic PSO group had a significant improvement of the cervical lordosis with a mean C7 slope correction of 28° (P = 0.004), whereas in the lower thoracic PSO group a more pronounced correction of the maximal lumbar lordosis was observed (22°, P = 0.033). CONCLUSION: After a fixed sagittal thoracic deformity, the predominant lordotic compensation seems to occur at the nearest mobile curve from the deformity apex. The PSO-induced restoration of the thoracic kyphosis relieved the compensatory cervical and/or lumbar excessive lordosis, which were present preoperatively and are now no longer needed to achieve balance and maintain horizontal gaze. LEVEL OF EVIDENCE: 4.

[Surgery for chronic low back pain: good option? Better than conservative treatment?]

The goal of this article is to assess, using the literature and our own experience, whether surgery is a reasonable option in the management of non-specific or degenerative chronic low back pain. The usual starting points for low back pain are without doubt the intervertebral disc and the facet joints, but the actual etiology is often difficult to determine. Moreover, psychogenic factors may amplify clinical symptoms. In our experience, thorough clinical, psychological, and socioprofessional assessment along with relevant imaging studies, parti- cularly MRI to look for inflammatory disc disease and EOS system to evaluate sagittal balance, leads to surgical indication in only 5 % of the patients with chronic low back pain. In these cases, surgery is aimed at short-circuiting ideally one, but sometimes two, interver- tebral segment by a conventional rigid fixation (arthrodesis), or by more recent non-rigid fixation techniques (disc replacement or interspinous dynamic stabilization). Their preven- tive effect on accelerated degeneration of adjacent segment appears to be moderate at best. The problem is to compare the results of surgical and conservative treatment: The analysis of publications concerning comparative randomized studies and personal studies shows that surgery is useful in only a small proportion of well selected patients with chronic low back pain, compared with physical and cognitive-behavioral management techniques.