Evolution and complications after surgery for spine deformation in patients with Parkinson's disease.

INTRODUCTION: Surgical treatment of spinal deformity is high risk in patients suffering from Parkinson's disease (PD). Several series have already reported a high rate of complications. However, none of these studies included more than 40 patients and none of the risk factors of complications were described. The aim of this study was to describe the rate and risk factors of revision surgery as well as the clinical outcome at the last visit in a large multicenter study of PD patients operated for spinal deformities. METHODS: A multicenter retrospective study included arthrodesis for spinal deformity in patients with PD. Clinical and surgical data including revision surgeries were collected. Assessment of functional outcomes at last follow-up was classified in 3 grades and spinal balance was assessed on anteroposterior and lateral plain X-rays of the entire spine. RESULTS: Forty-eight patients were included. Median age was 67 years old (range 41-80). Median follow-up was 27 months. The rate of surgical revision was 42%. Eighty per cent of revisions were performed for chronic mechanical complication. Global results were considered to be good in 17 patients (35%), doubtful in 17 patients (35%) and a failure in 14 patients (30%), for the whole series. CONCLUSIONS: The results of surgery for spinal deformities in patients with Parkinson disease vary with a high rate of complications and revisions. Nevertheless, these results should be seen in relation to the natural progression of these spinal deformities once spinal imbalance has developed. The association between preoperative clinical balance and final outcome suggests that early surgery can probably play a role in treatment. LEVEL OF EVIDENCE: Level IV (e.g. case series).

Surgical treatment of degenerative spondylolisthesis.

Degenerative spondylolisthesis is a common pathology, often causing lumbar canal stenosis. There is, however, no strong consensus regarding the various medical and surgical treatments available. Surgery is indicated mainly for perceived functional impairment; when the indication is accepted, several questions determine the choice of surgical strategy. Improvement in neurological symptoms is one of the main treatment objectives. For this, it is useful to perform radicular decompression. Some authors recommend indirect decompression by interbody fusion (ALIF, TLIF, XLIF), others by means of an interspinous spacer but the most frequent technique is direct posterior decompression. In degenerative spondylolisthesis, functional results seem to be improved by associating stabilization to decompression, to prevent secondary destabilization. The following risk factors for destabilization are recognized: anteroposterior hypermobility, angular hypermobility and large disc height. Two stabilization techniques have been described: "dynamic" stabilization and (more frequently) fusion. Spinal instrumentation is frequently associated to fusion, in which case, it is essential for fusion position and length to take account of pelvic incidence and the patient's overall pattern of balance. Posterolateral fusion may be completed by interbody fusion (PLIF or TLIF). This has the theoretic advantage of increasing graft area and stability, restoring local lordosis and opening the foramina. Surgical treatment of degenerative spondylolisthesis usually consists in posterior release associated to instrumented fusion, but some cases can be more complex. It is essential for treatment planning to take account of the patient's general health status as well as symptomatology and global and segmental alignment.

Neurological deficit secondary to a pre-sacral abscess with epidural extension up to L3: A case report and literature review.

Isolated epidural abscesses are uncommon lesions. Surgical treatment may be difficult due to the extension of these lesions. We present a case of a pelvic abscess spreading along the path of the sciatic nerve to the gluteus muscles and the lumbar canal, causing neurological compression; requiring surgical treatment with three simultaneous approaches.

Radiologic adjacent segment degeneration 2 years after lumbar fusion for degenerative spondylolisthesis.

INTRODUCTION: Lumbar fusion is now a currently accepted treatment for degenerative lumbar spondylolisthesis (DLSP), but may induce adjacent segment degeneration (ASD). The present study hypothesis was that there are radiological parameters associated with ASD. The study objective was to determine predictive factors of ASD. MATERIAL AND METHODS: A single-center retrospective study included patients operated on between 2006 and 2013 for DLSP. Radiological parameters were analyzed on preoperative, immediate postoperative and final follow-up lateral X-ray. ASD was defined by the following adjacent segment criteria:>3mm anteroposterior translation,>10° segmental kyphosis, or>50% loss of disc height. RESULTS: One hundred and seven patients were included: 79% female; mean age, 67±10.2 years. Fusion involved 1 level in 67% of cases and 2 or more in 33%, with transforaminal lumbar interbody fusion (TLIF) in 27% of cases. There was overall significant gain in lumbar lordosis (mean, 3.1°; P=0.04). At a mean 27.8 months' follow-up, 29% of cases showed ASD and 10% required surgical reintervention. Preoperative anterior imbalance and long fusion (>2 levels) were significantly associated with ASD (OR=2.81, 95% CI [1.17-6.74] versus OR=2.76, 95% CI [1.15-6.63]). There were no significant differences according to postoperative radiological parameters, or to TLIF (OR=1.8, 95% CI [0.7-4.4]). CONCLUSION: Twenty-nine percent of patients developed ASD, with a surgical revision rate of 10%. ASD risk factors comprised high number of instrumented levels and preoperative sagittal imbalance. LEVEL OF EVIDENCE: IV, retrospective cohort.

Reduction and fusion in high-grade L5-S1 spondylolisthesis by a single posterior approach. Results in 50 patients.

INTRODUCTION: Treatment strategies in high-grade L5-S1 spondylolisthesis are controversial. Reduction of slippage, correction of lumbosacral kyphosis and the necessity of a complementary anterior approach are debated in the literature. The present study reports clinical and radiological outcome for reduction and instrumented fusion on a single posterior approach. MATERIAL AND METHOD: A retrospective study included all consecutive adolescent and young adult patients operated on by a single surgeon (D.C.) for high-grade (Meyerding 3-4-5) L5-S1 spondylolisthesis. The technique consisted in reduction of lumbosacral kyphosis and posterolateral fusion on a single posterior approach without resection of the sacral dome or complementary anterior approach. Only cases of adult ptosis required impacted tibial interbody graft. Clinical complications, radiologic lumbopelvic results and sagittal balance were analyzed at last follow-up. RESULTS: Fifty patients, with a mean age at surgery of 21±11 years, were followed up for a mean 5.5±4.6 years. Mean lumbosacral angle was reduced by 25° (from 76° to 101°; P<0.05), and mean listhesis grade by >50% (from 75% to 23%; P<0.0001), without correction loss at last follow-up. C7 sagittal offset was corrected (from 8° to 4°; P<0.05), with harmonization of lumbar (from 57° to 64°; P<0.001) and thoracic curvature (from 37° to 44°; P=0.1). Seventeen patients (34%) showed postoperative radicular deficit, without sequelae at last follow-up. There were no cauda equina lesions. Bone fusion was achieved in 42 patients (84%), in the same surgical step. After revision by complementary interbody graft, there was no residual non-union. CONCLUSION: Surgery on a single posterior approach gave reliable results in high-grade spondylolisthesis in adolescents and young adults. The technique is not however, free of risk (transient neurologic deficit and non-union), and patients should be forewarned. Complementary interbody graft can be reserved to adult ptosis with incomplete reduction of lumbosacral kyphosis and to revision surgery for non-union. LEVEL OF EVIDENCE: IV, retrospective study.

Sacral stress fracture after lumbar and lumbosacral fusion. How to manage it? A proposition based on three cases and literature review.

Sacral fracture after lumbosacral instrumentation could be a source of prolonged pain and a late autonomy recovery in old patients. Diagnosis remains difficult and usually delayed. No clear consensus for efficient treatment of this complication has been defined. Aim of this study was to determine how to manage them. Three patients who sustained sacral fracture after instrumented lumbosacral fusion performed for degenerative disease of the spine are discussed. History, physical examinations' findings and radiographic features are presented. Pertinent literature was analyzed. All patients complained of unspecific low back and buttock pain a few weeks after index surgery. Diagnosis was done on CT-scan. We always choose revision surgery with good functional results. Sacral stress fracture has to be reminded behind unspecific buttock or low back pain. CT-scan seems to be the best radiological test to do the diagnosis. Surgical treatment is recommended when lumbar lordosis and pelvic incidence mismatched.

Clinical and stereoradiographic analysis of adult spinal deformity with and without rotatory subluxation.

INTRODUCTION: In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory subluxation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis. Stereoradiography, recently developed for medical applications, provides full-body standing radiographs and 3D reconstruction of the spine, with low radiation dose. HYPOTHESIS: 3D stereoradiography improves analysis of RS and of its relations with transverse plane and spinopelvic parameters and clinical impact. MATERIAL AND METHODS: One hundred and thirty adults with lumbar ASD and full-spine EOS® radiographs (EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in the coronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation (apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS (lateral listhesis>5mm) and without RS (without lateral listhesis exceeding 5mm: non-RS). Correlations between radiologic and clinical data were assessed. RESULTS: RS patients were significantly older, with larger Cobb angle (37.4° vs. 26.6°, P=0.0001), more severe sagittal deformity, and greater apex AVR and TI (respectively: 22.9° vs. 11.3°, P<0.001; and 41.0° vs. 19.9°, P<0.001). Ten percent of patients had AIR>10° without visible RS on 2D radiographs. RS patients reported significantly more frequent low back pain and radiculalgia. DISCUSSION: In this EOS® study, ASD patients with RS had greater coronal curvature and sagittal and transverse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosis and prognosis to guide management. LEVEL OF EVIDENCE: 4, retrospective study.

Sacro-iliac joint arthroscopy for arthrodesis after traumatic dislocation. Cadaver and clinical feasibility study.

BACKGROUND: Sacro-iliac arthrodesis usually requires an extended posterior approach, which is associated with a number of dreaded complications. Here, we assessed the feasibility of arthroscopic exploration of the dislocated sacro-iliac joint. MATERIALS AND METHODS: In the first step of our study, we used ligament section to induce loss of sacro-iliac joint coaptation in a cadaver. We then studied 5 patients with Tile C pelvic ring injuries. Arthroscopy was used to clear the joint of fibrous tissue and to roughen the bone to subchondral level in order to induce sacro-iliac arthrodesis. In addition, posterior fixation was performed using a hinge system or an ilio-sacral screw. RESULTS: The cadaver study confirmed the feasibility of sacro-iliac arthroscopy after disruption of the strong posterior inter-osseous ligament. In the clinical part of the study in 5 patients with Tile C pelvic ring injuries, arthroscopy allowed direct visualisation extending to the anterior part of the joint space. A power burr and synovial knife were introduced to remove the interposed fibrous tissue and to roughen the bone to subchondral level in order to induce joint fusion. In addition, percutaneous or open posterior fixation was performed in all 5 patients. No infectious complications were recorded. DISCUSSION: An arthroscope cannot be introduced into the normal sacro-iliac joint. In contrast, after traumatic sacro-iliac dislocation, arthroscopy can be used to evaluate the intra-articular injuries and to roughen the bone to subchondral level.

Recurrent solitary fibrous tumour of the thoracic spine. A case-report and literature review.

Solitary fibrous tumours (SFTs) are rare tumours originating in the soft tissues. SFT development in the spine is an exceedingly rare event about which little is known. We describe a case of SFT of the thoracic spine in a 56-year-old woman. She presented with neurological deficits that required emergency resection, which was incomplete. Two subsequent local recurrences prompted further surgical procedures. At last follow-up, 12 months after the last procedure, function was satisfactory and there was no evidence of tumour recurrence. The management of SFTs is not well standardised, and no proven adjuvant treatments are available to date. Complete excision is effective in controlling disease progression. Prolonged follow-up is mandatory.

Early surgical site infections in adult spinal trauma: a prospective, multicentre study of infection rates and risk factors.

INTRODUCTION: Spine surgery is known to have a high risk of surgical site infection (SSI). Multiple studies have looked into the risk factors and incidence of SSI during elective surgery, but only two retrospective studies have specifically evaluated SSI during surgery following spine trauma. MATERIALS AND METHODS: This work was based on a prospective cohort study that included all the patients operated on for spinal trauma at 13 French hospitals over a three-month period. The main endpoint was the occurrence of a SSI during the three-month period. Patients with multiple trauma or open fractures were excluded from the study. RESULTS: Of the 169 patients re-examined after a minimum of three months, six had had an acute SSI (3.55%). The following factors were significantly related to a SSI: age, ASA score, diabetes, procedure duration, delay elapsed between accident and procedure, number of levels fused, bleeding and prolonged presence of urinary catheter. DISCUSSION: Our results were consistent with the published infection rates of 2 to 10%. The risk factors identified have all been described in previous studies on elective spine surgery. LEVEL OF EVIDENCE: Level IV, prospective cohort study.

Surgery of lumbar and thoracolumbar scolioses in adults over 50. Morbidity and survival in a multicenter retrospective cohort of 180 patients with a mean follow-up of 4.5 years.

INTRODUCTION: The increasing life expectancy of the population and the improvement in surgical and medical management of elderly patients mean that the indication for surgical treatment of adult lumbar and thoracolumbar scolioses has been extended. However the benefit/risk ratio of these procedures is still under debate. MATERIALS AND METHODS: We reviewed 180 patients, mean age 63years old with a minimum follow-up of 1year in a retrospective, continuous, multicenter study. The incidence rate of complications from surgery and the factors influencing their frequency were evaluated by uni- and multivariate analysis. The risk of a second operation was studied by actuarial survival analysis. RESULTS: After a mean follow-up of 4.5years, 79 patients (44%) presented with at least one complication, including 32% with a serious complication. The most frequent complications were mechanical. The risk factors were medical co-morbidities, the extent of fusion and the extent of the preoperative sagittal imbalance. A second operation was necessary in 25% of patients at 1year and 50% of patients at 6years of follow-up. DISCUSSION: Studies in the literature show that functional results are better with surgical treatment than with medical treatment in the management of thoracic spine and thoracolumbar deformities in patients over 50years old. An objective assessment of this deformity and associated co-morbidity should make it possible to reduce the rate of complications for this type of surgery. LEVEL OF EVIDENCE: Level IV.

Hydatid disease drug therapy primarily to reconstruction of a multilevel thoracolumbar vertebral lesion.

We report, a very unusual case of multilevel vertebral hydatidosis adjacent to the thoracolumbar junction, without concomitant chord compression. Two months after initiating oral antiparasite treatment, the patient underwent resection of the lesion using a posterior approach, medullary decompression, and a T11-L3 instrumented arthrodesis. Arthrodesis via the anterior approach was performed at a later stage. In addition to its diagnostic value, this case raises renewed discussion about single-level lesions given their rarity: their indication for preoperative medullary angiography, their indication for circumferential surgery, the timing of medical treatment, and the strategy to implement for the residual lesions.

Benign febrile cervicalgia due to calcific retropharyngeal tendinitis: case study.

Periarticular calcific tendinopathy has been well described, but no retropharyngeal locations have been reported in the surgical orthopedic literature. This pathology is a diagnostic pitfall, leading to fruitless invasive examinations and treatment. The clinical aspect is misleading, but pathognomic imaging can establish diagnosis. We report a case of febrile postoperative cervicalgia, initially suggestive of a septic complication, but in which imaging indicated retropharyngeal calcific tendinitis.

Thoracolumbar junction lateral spine dislocation.

The authors describe a case of traumatic lateral spine dislocation at the thoracolumbar junction level, without fracture, in a healthy young adult, complicated by a complete neurological deficit. The main aspects of surgical management are discussed based on a review of the literature. Control of the spinal cord is a mandatory first step, before reduction, independently of neurological deficits considerations. Instrumented stabilization and fusion are achieved thereafter; levels selection for instrumentation and fusion depends on the injury location.

Odontoid process pathologic fracture in spinal tuberculosis.

Craniovertebral junction tuberculosis is a rare lesion in which treatment remains controversial. Options range from conservative treatment to surgery, independently of any associated neurological threat. We here report the first case of pathologic odontoid fracture in a context of spinal tuberculosis, complicated by unusual neurological evolution. The patient presented with non-contiguous multifocal tuberculosis, of which there have previously been only 6 reported cases.

Pelvic ring fractures internal fixation: iliosacral screws versus sacroiliac hinge fixation.

INTRODUCTION: Pelvic ring fractures are severe injuries whose functional results depend on the quality of reduction. Numerous internal fixation alternatives have been described, but the biomechanical studies comparing them remain rare. HYPOTHESIS: This study compared the biomechanical behavior of iliosacral screws (ISS) with sacroiliac hinge type fixation (SIF) following unstable pelvic ring fractures fixation. MATERIALS AND METHODS: A lesion simulating sacroiliac disruption and pubic disruption was created on 14 cadaver pelves. After randomization, the fractures were internally fixed using an anterior plate associated with either an ISS or an SIF. The specimens were then submitted to forces applied vertically at the coxofemoral joints. Relative movements in vertical translation and in rotation between the iliac wing and the sacrum, as well as the stiffness and the forces at failure of the assemblies were measured and compared. RESULTS: The mean age of the bodies was 66 years (+/-8). No significant difference was demonstrated between the groups in terms of residual motion and stiffness in both vertical and rotational displacement. The results showed a slight residual mobility in rotation of the hemipelvis. The SIFs presented greater, although non significant resistance to failure. No fixation, however, restituted stiffness comparable to a healthy pelvis. DISCUSSION: The results of this study show that a Tile C.1.2-type injury to the pelvic ring can be treated as effectively with ISS or SIF when combined anterior and posterior fixations are performed. SIF therefore seems reliable and its continued use is justified. The long-term clinical outcomes should nevertheless be evaluated, notably on the younger population, more often affected by this type of injury.

[Spinal migration of a Kirschner wire after surgery for clavicular nonunion. A case report and review of the literature]. / Migration intrarachidienne d'une broche de Kirschner après une cure de pseudarthrose de la clavicule. Cas clinique et revue de la littérature.

Kirschner wires (K-wires) are often used for osteosynthesis particularly in the upper limb. Postoperative K-wire migration through the tissues is a well-recognised and significant complication of surgery of the clavicle, the wire ending up in the lungs, the oesophagus, the aorta, or the subclavian artery. Localisation of a K-wire migration into the spinal cord is very rare. We report the case of a 34-year-old man with K-wire migration into the spinal cord through the intervertebral foramen of T2, two months after surgery for nonunion of a fracture of the lateral clavicle. Apart from acute respiratory failure related to a pneumothorax, the patient initially had no neurological deficit. It was decided to operate on him immediately. Two therapeutic options are possible: simple K-wire removal via a supraclavicular approach, or the same but with direct visual control in the spinal cord after laminectomy. A postoperative check with an MRI scan is desirable after two days. Even if mechanism of K-wire migration is not known, the means of prevention are, namely strict postoperative immobilization, K-wire removal as soon as bone healing is achieved, and bending the external tip of each implanted wire.

An unusual Hangman's fracture: description and surgical management.

C2 pedicles, or "Hangman's" fracture and "Tear-Drop" fracture, have until now been described as two distinct entities, the former caused by extension-distraction and the latter by compression-flexion mechanisms. The present clinical case combined these two fracture types of the second cervical vertebra (C2), without neurologic complication. Surgical management reduced and stabilized the lesions of the bone and of the mobile segment between C2 and C3. A right-side subhyoid presternocleidomastoid approach was selected, the main deformity lying between the body of the second and third cervical vertebrae.

[Paraplegia after interlaminar epidural steroid injection: a case report]. / Paraplégie secondaire à une infiltration épidurale interlamaire lombaire, à propos d'un cas.

We report the first case of paraplegia observed after epidural steroid injection in the upper spine. The patient was a 42-year-old male who underwent surgery two years earlier for stenosis of the lumbar spine from L2 to the sacrum leading to early manifestations of an equina cauda syndrome. This first operation provided satisfactory function with complete resolution of the objective neurological symptoms. The patient later developed bilateral radiculalgia involving the L3 and L4 territories and was treated by radio-guided epidural steroid injection (125 mg hydrocortancyl) delivered in the L1-L2 interlaminar space. The injection was achieved with no technical difficulty and there was no injury to the dural sac. Immediately after the injection, the patient developed complete motor and sensorial paraplegia from T12. CT and MRI performed 30 min and 4h, respectively, after the accident revealed a medium-sized discal herniation behind the L2 body. No other lesion was observed. Emergency surgery was performed for radicular release but to no avail. The patient's neurological status remained unchanged and four days later the T2 MRI sequence revealed a high-intensity intramedullar signal in the cone. The diagnosis of ischemia of the medullary cone was retained, hypothetically by injury to the dominant radiculomedullary artery via an undetermined mechanism. This complication has been previously described after upper foraminal steroid injections but not after intralaminar epidural steroid injection.

[Long-term survival analysis after surgical management for degenerative lumbar stenosis]. / Etude à long terme du risque de réintervention après traitement chirurgical d'une sténose canalaire lombaire.

PURPOSE OF THE STUDY: The short- and mid-term symptom-relief of surgical treatment for lumbar stenosis is generally acknowledged, but the probability of a long-term reoperation remains to be studied. The purpose of this work was to determine the long-term risk of reoperation after surgical treatment of degenerative lumbar stenosis and to search for factors influencing this probability. MATERIAL AND METHODS: All patients who underwent from 1989 to 1992 surgical treatment for degenerative lumbar spine stenosis were included in this work. At last follow-up, we noted functional outcome using a specific self-administered questionnaire, patient satisfaction, lumbalgia and radiculalgia using a visual analog scale, SF36 quality-of-life, reoperation or not with time since first operation if performed and the reasons and modalities of the reoperation. The probability of reoperation was determined with the acturarial method. A Cox model was used to search for factors linked with the probability of reoperation; variables studied were: age, comorbid factors, extent of the release, posterolateral arthrodesis or not, extent of the potential fusion, use or not of instrumentation for arthrodesis. RESULTS AND DISCUSSION: The study included 262 patients. At last follow-up, 61 patients had died a mean 3.7+/-3 years after the operation; only one of these patients had a second operation 22 months after the first. Forty-four patients were lost to follow-up at mean 6.6+/-3 years. Among these 44 patients, four had a second operation during their initial follow-up at mean 47 months. One hundred fifty-seven patients were retained for this analysis at mean 15+/-1 years follow-up. Among these 157 patients, 29 had a second operation a mean 75 months after the first. There were four reasons for reoperating: insufficient release, destabilization within or above the zone of release, development or renewed zone of stenosis, development or renewed discal herniation. The risk of a second operation was 7.4% [95% CI 4.8-11.6], 15.4% [95% CI 10.7-21.1] and 16.5% [95% CI 11.7-219] at five, 10 and 15 years respectively after the first operation. Among the risk factors studied, only one had a significant impact on reoperation: extent of the zone of release (p=0.003). Compared with a release limited to one level, the risk of reoperation after release of three levels or more was five times greater [95% CI 1.8-12.7].