Assessing Abnormal Proximal Junctional Angles in Adult Spinal Deformity: A Normative Data Approach to Define Proximal Junctional Kyphosis.

STUDY DESIGN: Multicentric retrospective study of prospectively collected data. OBJECTIVE: Based on normative data from a cohort of asymptomatic volunteers, this study sought to determine the rate of abnormal values of proximal junctional angles (PJA) in adult spinal deformity (ASD) surgery patients, and compare it with PJK rate. SUMMARY OF BACKGROUND DATA: Proximal junctional kyphosis (PJK) definition does not take the vertebral level into account. METHODS: This study included 721 healthy volunteers and 824 ASD surgery patients with 2-year postoperative follow-up. Normative values for each disc and vertebral body between T1 and T12 were analyzed, then normative values for PJA at each thoracic level were defined in the volunteer cohort as the mean±2 standard deviations. PJA abnormal values at the upper instrumented vertebra (UIV) were compared with Glattes' and Lovecchio's definitions for PJK in the ASD population at two years. RESULTS: Mean age was 37.7±16.3 in the volunteer cohort, with 50.5% of females. Mean thoracic kyphosis (TK) was -50.9±10.8°. Corridors of normality included PJA greater than 20° between T3 and T12. Mean age was 60.5±14.0 years in the ASD cohort, with 77.2% of females. Mean baseline TK was -37.4±19.9°, with a significant increase after surgery (-15.6±15.3°, P<0.001). There was 46.2% of PJK according to Glattes' versus 8.7% according to Lovecchio's and 22.9% of kyphotic PJA compared to normative values (P<0.001). CONCLUSION: This study provides normative values for segmental and regional alignment of thoracic spine, used to describe abnormal values of PJA for each level. Using level-adjusted PJA values allows a more precise assessment of abnormal proximal angles and question the definition for PJK. LEVEL OF EVIDENCE: II.

Readmission rate after adult scoliosis surgery on primary cases over 45 years-old with long term follow-up.

PURPOSE: Scoliosis surgery is becoming increasingly frequent. Rate of readmission is little discussed in the literature. It is an interesting data for the patient's information and for public authorities to calculate cost-effectiveness. Aim of the study was to evaluate rate and causes of short and long-term readmissions in patients > 45 years old operated on for a scoliosis primary cases, then to look for predictors of these readmissions. METHODS: In this monocentric retrospective cohort study, over 45 years-old scoliosis primary cases operated on between 2015 and 2018 and with a minimum of 2 years follow-up were included. The number of readmissions and their causes were analyzed. Rehospitalized patients (RH) were then compared to non-rehospitalized patients (NRH). Risk factors were sought using a multivariate analysis by logistic regression. RESULTS: 105 patients were included (90% female; 64 ± 8 years). 56% were readmitted at least once. Main cause of readmission as pseudarthrosis (70%). Among the RH patients, fifty-eight required at least one revision. We found no significant difference between RH and NRH, apart from the rate of immediate post-operative medical complications which was significantly higher in RH (17% (n = 11) vs. 4% (n = 2), p = 0.04). According to multivariate analysis, BMI and age were found as predictors of readmission of mechanical origin, and BMI for readmissions of septic origin. CONCLUSION: The readmission rate after scoliosis surgery was 56%. The main cause was pseudarthrosis. Rehospitalized patients had more immediate post-operative medical complications. The elderly and overweight patients are more likely to be readmitted for mechanical or septic reasons.

Influence of pelvic tilt correction on PJK occurrence after adult spinal deformity surgery.

INTRODUCTION: Many risk factors for proximal junctional kyphosis (PJK) have been reported in the literature, especially sagittal alignment modifications, but studies on pelvic tilt (PT) variations and its influence on PJK are missing. Aim of this study was to analyze the influence of pelvic tilt correction, after long fusion surgery for ASD patients, on PJK occurrence. METHODS: A monocentric retrospective study was conducted on prospectively collected data, including 76 patients, operated with fusion extending from the thoraco-lumbar junction to the ilium. Radiologic parameters were measured on fullspine standing radiographs preoperatively, postoperatively (<6 months) and at latest follow-up (before revision surgery or >2 years). All parameters were analyzed comparing patients with PJK (group "PJK") and without PJK (group "no PJK"). A further analysis compared patients with low (PT/PI<25th percentile, LowPT group) and high (PT/PI>75th percentile, HighPT group) preoperative pelvic tilt. RESULTS: « PJK ¼ patients had a greater lumbar lordosis and thoracic kyphosis correction (p=0,03 et <0,001 respectively) compared to the "no PJK" patients. Pelvic tilt was significantly lower postoperatively in the "PJK" group (p=0,03). Patients from the HighPT PJK group were significantly more corrected than patients from the HighPT noPJK group (p=0,003). CONCLUSION: Through the analysis of 76 patients, we showed that pelvic tilt did not seem to play a role in the setting of PJK after ASD surgery. Decreasing PT after surgery could be an element to watch out for in patients with PJK risk factors.

Pregnancy and childbirth after adolescent idiopathic scoliosis surgery: A study of 80 pregnancies.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a common spinal disease affecting 2% of adolescents, and women in 90% of the cases. When a surgical treatment is opted for, many questions are frequently asked by families and patients about the course of pregnancy and childbirth after the spinal fusion. This subject remains little studied in the literature, especially with modern instrumentation techniques. HYPOTHESIS: The goal was to describe pregnancy and childbirth after AIS surgery in terms of access to epidural analgesia, need for cesarean section (c-section), and low back pain during and after pregnancy. We thus hypothesized that women undergoing spinal surgery for AIS have subsequently uncomplicated pregnancies and childbirths, and have access to epidural analgesia as women without AIS do. PATIENTS AND METHODS: In this retrospective multicenter study, 198 women who underwent surgery between 1984 and 2014 were reviewed from two university hospitals. Among them, 50 women became pregnant, for a total of 80 pregnancies. Surgical data were collected [approach, uppermost and lowermost instrumented vertebra (UIV, LIV)]. Pregnancy characteristics were evaluated: time between surgery and pregnancy, number of births, mode of analgesia, type of delivery, weight gain. Occurrence of low back pain during pregnancy and at follow-up was recorded using ODI. RESULTS: Of the 50 women, 34 had posterior surgery and 16 had anterior surgery. Deliveries took place from 1988 to 2018. Of the 80 pregnancies, 81% were delivered by vaginal route (n=65/80), and an effective epidural anesthesia was performed for 49% of them (n=39/80). Epidural analgesia failed in 9% of pregnancies (n=7/80), and was denied in 35% of cases (n=28/80), half of the time by anesthesiologists (n=15/80). Patients refused epidural in 13 pregnancies (16%, n=13/80). A general anesthesia was used in six pregnancies (8%, n=6/80), for c-sections only. Back pain was reported in 48% of the pregnancies (n=38/80). The level of fusion was correlated with c-section, and conversely with epidural anesthesia. DISCUSSION: A normal pregnancy with vaginal delivery seems to be the rule for women undergoing spinal fusion for AIS. The c-section rate in AIS women was similar to the general population (19%). Yet, access to epidural anesthesia still seems problematic with only 49% of births in this series, compared with 81% in the French population. LEVEL OF EVIDENCE: IV, retrospective cohort.

Social media use among French spine surgeons: an underrated tool?

PURPOSE: The goal of this study was to determine the use of social media (SM) among the French spine surgeons. METHODS: In 2022, an online questionnaire has been sent to the community of French spine surgeons. All surgeons were asked to answer a 21-question survey about their use of SM in their daily practice. RESULTS: Eighty-five surgeons were included, with 80% claiming to use SM. Mean age was 45 ± 10.7. Usage rate significantly differed among experience categories: 85% of younger surgeons and 69% after ten years of experience (p = 0.01). LinkedIn was the most commonly used (78% among SM users), then Facebook (46%). Instagram was less used by most experienced surgeons (p = 0.01). Time spent on SM was more important at home (p < 0.01). About 31% of participants' patients were able to contact their surgeon through SM, mainly through LinkedIn, professional websites and Facebook (respectively 15%, 13% and 12%). Pictural data were shared on SM by 29% of SM users, mainly on LinkedIn (19%), then professional websites (12%). Google reviews were significantly less valued by most experienced surgeons (p = 0.01) but more valued by private practice surgeons (p = 0.009). CONCLUSION: 80% of French spine surgeons use social media for professional purposes. However, SM may not be used to its full potential as only 25% of SM-using broadcast pictures and contact their patients through SM. The most popular network is LinkedIn, followed by Facebook. Most experienced surgeons use less SM, particularly Instagram, and value less Google reviews.

Lumbar scoliosis and stenosis: What outcomes for which treatment? Analysis of three surgical techniques in 154 patients with minimum two-year follow-up.

STUDY DESIGN: Prospective multicentric study. OBJECTIVE: This study goal was to analyze the clinical and radiographic outcomes of lumbar stenosis and scoliosis (LSS) patients, treated with lumbar decompression (LD), short fusion and decompression (SF) or long fusion with deformity correction (LF). HYPOTHESIS: Procedures without correction lead to poorer long-term outcomes. METHODS: Consecutive patients with two-year minimum follow-up, older than 50, with lumbar scoliosis (Cobb angle>15°), and symptomatic lumbar stenosis were included. Age, gender, Lumbar and Radicular Visual Analog Scale, ODI, SF12 and SRS30 were collected. Main and adjacent curves Cobb angles, C7 coronal tilt (C7CT), spinopelvic parameters, and spino-sacral angle (SSA) were measured preoperatively, at one and two years. Patients were sorted into surgery type groups. RESULTS: In total, 154 patients were included, with respectively 18, 58 and 78 patients in LD, SF and LF groups. Mean age was 69, 85% were women. Clinical scores improved in each group at one year, but only LF group exhibited persistent improvement at 2years. A significant fractional Cobb angle increase was noted in the SF group at 2years (from 12±11° to 18±14°). C7CT significantly increased in the LD group at 2years (from 2.5±1.3° to 5.1±3.5°). LF group presented the highest complication rate (45%, 19% for SF and 0% for LD). The overall revision rate was 14% in SF group and 30% in LF group. CONCLUSION: LSS is a complex pathology requiring custom-made surgical treatment. LD, SF and LF allow satisfactory clinical outcome, with a better and more sustained clinical improvement for LF despite higher complication and revision rates. LEVEL OF EVIDENCE: IV.

Surgical treatment of degenerative lumbar spondylolisthesis: Effect of TLIF and slip reduction on sagittal alignment.

INTRODUCTION: The surgical treatment of lumbar degenerative spondylolisthesis (LDS) remains controversial. The aim of this study was to determine the effect of adding transforaminal lumbar interbody fusion (TLIF) to posterolateral fusion (PLF) on the local lordosis, sagittal alignment and potential complications. The second aim was to evaluate the effect of slip reduction on the same parameters. HYPOTHESIS: The initial hypothesis was that TLIF provides better correction of the local lordosis and that reducing the slip improves the global sagittal balance. METHODS: In this retrospective, single-center study, patients who had been operated on for LSD at one or two levels by laminectomy and PLF, with or without a TLIF cage, were included. Data collected consisted of age, sex, number of levels fused and whether or not a TLIF cage was used. Fusion was defined as the absence of indirect nonunion signs on radiographs at 2 years postoperative. The occurrence and time frame of any complications and the need for reoperation were documented. Lateral radiographs of the entire spine were analyzed preoperatively, in the early postoperative period (3 to 6 months) and at a minimum follow-up of 2 years. The following parameters were measured: pelvic parameters, C7 sagittal tilt (C7ST), spinosacral angle (SSA), maximum lumbar lordosis (LL), lordosis at slipped level (LS), slip percentage. The analysis compared patients treated by PLF and TLIF and determined the impact of slip reduction. RESULTS: One hundred and three patients were included in the study (71% women). The mean follow-up was 38 months. The mean age was 69 years. Seventy-seven patients (75%) underwent PLF. Comparing the preoperative and early postoperative data identified 5.4% better spondylolisthesis reduction in the TLIF group than the PLF group (-8.9±9.5% vs -3.5±7.6%; p=0.04) that was not maintained at the final follow-up. The fusion rate was comparable between groups: 94% in APL and 89% in TLIF (p=0.7). The overall complication rate was 46% in the TLIF group versus 33% in the PLF group (p=0.35). A comparison based on whether or not the slip was reduced found significant improvement in the reduction group of the SSA by more than 6° (6.8°±6° vs 0.5°±7.4°; p=0.04). The fusion rate was 91% in the reduced group and 95% in the non-reduced group (p=0.81); the complication rate was 44% versus 28% in the non-reduced group (p=0.10). CONCLUSION: This study shows that slip reduction helps to improve the sagittal alignment by increasing the SSA when treating LDS. Posterolateral fusion and TLIF produce comparable radiographic outcomes at 2 years postoperative in the segmental lordosis, slip reduction, global sagittal alignment and fusion rate. LEVEL OF EVIDENCE: IV.

Validation of the Total Disability Index (TDI) in French Version.

INTRODUCTION: The Total Disability Index (TDI) questionnaire has been developed to provide a more complete assessment of low back and neck pain, as they frequently co-occur. This study aimed at validating the TDI questionnaire in French, to determine if it could be used in France. HYPOTHESIS: The TDI French version is valid, reproducible and comparable to the English version. METHODS: This multicentric study prospectively included French-speaking volunteers, both patients admitted for spine surgery in two specialized spine centers and healthy individuals. Healthy subjects were recruited among students of an engineering school and medical staff. A booklet was given to the participants containing a Lumbar and Cervical Visual Analog Scale (respectively LVAS and CVAS), and the French versions of Oswestry Disability Index (ODI), Neck Disability Index (NDI) and TDI questionnaires. Statistical analysis included Cronbach's α calculation for internal consistency assessment, correlation analysis with ODI and NDI items for convergent validity, principal component analyses and factor analysis. Discriminant validity was assessed by comparing healthy subjects and patients using Student's t tests, and floor and ceiling effects search. RESULTS: 71 participants were included, with 34 (48%) healthy volunteers and 37 (52%) patients. Mean age was 45.2±19.6 years and 57% of the cohort were males. Internal consistency was good: Cronbach's α was calculated at 0.96 (95%CI: [0.95-0.98]). For each TDI item, a high correlation was found with ODI corresponding items, between 0.81 and 0.97 (p<0.001), and good correlation with NDI items, ranging from 0.65 to 0.96 (p<0.001). TDI correlated also with LVAS and CVAS (respectively 0.70 and 0.65, p<0.001). Principal component analyses indicated good correlation between the TDI items and between each item and TDI total score. Factor analysis indicated two main factors explaining 77% of TDI variance, constituted by all TDI items. Regarding discriminative validity, healthy subjects and patients presented significantly different TDI scores (p-values ≤0.01 for each item). Barplot representations of each TDI item revealed no major floor nor ceiling effects. CONCLUSION: This study confirms the reliability, feasibility and validity of the Total Disability Index questionnaire in its French version. Its validation allows its use in France. LEVEL OF EVIDENCE: II.

Pedagogy in spine surgery: developing a free and open-access virtual simulator for lumbar pedicle screws placement.

PURPOSE: Simulators for pedicle screws placement range from basic sawbones to virtual reality. Yet, they remain expensive and often require specific devices. No free online virtual simulator has yet been developed. The goal was to design a freely accessible Web-based simulator. METHODS: The computer simulator consisted of a lumbar spine, a red box hiding the pedicles and five pairs of screws. After inserting the screws, the red box was removed to assess their position. A validation study was conducted with 24 medical students randomized into a simulation and a control group. All had a basic course on pedicle screws. The 12 simulation group students performed two sessions on computer. All 24 students then conducted a final common step on sawbones. The number of misplaced screws, types of breaches, and simulation times were analyzed. RESULTS: In the final sawbones simulation, 96 real screws were studied. Control group misplaced 50% of their screws compared with only 20.8% in the simulation group (p < 0.05). More careful, simulation group students were slower to insert their real screws. Over the two computer simulations, the rate of misplaced screws decreased (12.5% vs. 38.3%), showing a good handling of the simulator. Students were able to analyze and correct their pedicle breaches. CONCLUSION: This tool is the first free online lumbar pedicle screws simulator. Simulation helped students to better position the final real screws on sawbones. This project showed it was possible to create a free educational tool with no special equipment. LEVEL OF EVIDENCE: Level 3.

Impact of a multidisciplinary team meeting on patient-reported outcomes at 2 years after lumbar surgery: A prospective comparative exploratory study.

Failed back surgery syndrome is a challenge. We hypothesized that a multidisciplinary team meeting (MTM) may be useful to select patients who are the most likely to benefit from lumbar surgery. We conducted an observational, prospective, comparative, exploratory study. We aimed to compare core clinical patient-reported outcomes at 2 years after lumbar surgery between patients who attended a MTM and those who did not. Patients who underwent lumbar surgery for a degenerative disease, in a single academic orthopedic department, between January and September 2018, were consecutively screened. Eligible patients were surveyed between April and June 2020. Patient-reported outcomes included lumbar and radicular pain, spine-specific activity limitations and health-related quality of life assessed via self-administered questionnaires. Outcomes were compared between respondents who attended the MTM and those who did not. Overall, 211 patients underwent lumbar surgery, 108 were eligible and 44 included: 11 attended the MTM and 33 did not. Mean participants' age was 57.4 (15.4) years, symptom duration was 14.8 (15.3) months, lumbar pain was 51.3 (18.2) and radicular pain was 53.4 (18.6). At 2 years, we found no evidence that lumbar and radicular pain, activity limitations and health-related quality of life differed between the 2 groups. The decrease was -26.8 (41.1) versus -20.8 (30.4) in lumbar pain and -25.5 (43.0) versus -19.5 (27.5) in radicular pain, in participants who attended the MTM versus those who did not, respectively. We found no evidence that core clinical patient-reported outcomes at 2 years after lumbar surgery differed between participants who attended the MTM and those who did not. However, the exploratory design of our study does not allow concluding that MTMs do not have an impact.

Lumbar Spine Posttherapeutic Imaging.

Management of patients after lumbar spine surgery or interventional radiology can be complex, and postoperative imaging patterns are often poorly understood by nonspecialized radiologists. This article focuses on postoperative imaging features of the lumbar spine in five clinical settings (with corresponding interventions): vertebral osteoporotic fractures (percutaneous vertebroplasty and vertebral augmentation), lumbar disk herniation (surgical diskectomy and percutaneous interventional radiology), lumbar spinal stenosis (surgical decompression), lumbar spondylolisthesis (surgical decompression and fusion), and degenerative scoliosis (techniques of osteotomies).For each intervention, we discuss imaging indications, depending if the patient is asymptomatic or if there are suspected complications, describe normal and pathologic imaging features, and present key points.

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.

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic.

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in China, various measures have been adopted in order to attenuate the impact of the virus on the population. With regard to spine surgery, French physicians are devoted to take place in the national plan against COVID-19, the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients. A three levels stratification was elaborated with Level I: Urgent surgical indications, Level II: Surgical indications associated to a potential loss of chance for the patient and Level III: Non-urgent surgical indications. We also report French experience in a COVID-19 cluster region illustrated by two clinical cases. We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.

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.

Iliocava junction to L4-L5 disc anatomical relationship in L5-S1 isthmic spondylolisthesis.

BACKGROUND: Anterior lumbar interbody fusion finds a place in L5-S1 isthmic spondylolisthesis (ISPL) treatment. Extension of this arthrodesis at L4-L5 level is sometimes required. Anterior approach of the L4L5 disc is considered difficult due to the anatomical relationship between the iliocava junction (ICJ) and the spine. HYPOTHESIS: Does the lumbosacral deformation induced by ISPL allows anterior approach of L4-L5 disc between the iliac? STUDY DESIGN: Retrospective radiographic analysis of consecutive patients. METHODS: This retrospective imaging study of a continuous series of 97 patients treated for an L5-S1 ISPL involved radiological parameters specific to ISPL and pelvic-sagittal balance. The distance between the ICJ and the L4 lower endplate was measured in millimeters. The factors influencing this distance were sought in order to identify a predictive model of high ICJ. RESULTS: The ICJ took a cranial position with respect to the L4-L5 disc with an average distance of 1.8mm±16.4. This distance was statistically higher in the case of high-grade ISPL (p<0.01). The high ICJ position was correlated with a high Taillard index (r=0.39; CI95% [0.13; 0.61]; p<.001) and a low lumbar-sacral angle (LSA) (r=-0.33; CI95% [-0.56; -0.06]; p<0.01). Among the parameters specific to spino-pelvic statics, pelvic incidence, pelvic tilt and lumbar lordosis had similar correlations (r>0.30). CONCLUSION: ISPL induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the ICJ. The anterior approach technique of L4-L5 disc in the presence of an L5-S1 ISPL is possible between the iliac veins for the large displacement and low LSA forms. LEVEL OF EVIDENCE: IV, retrospective analysis.

More complications in cervical than in non-cervical spine tuberculosis.

Purpose: Cervical spine tuberculosis (CST) is a rare disease that may lead to severe neurological complications. The goal of the study was to compare the characteristics of patients with CST with those of patients with non-cervical spine tuberculosis (NCST).Methods: Between 1997 and 2016, we reviewed all cases of proven tuberculosis from a cohort of spine infections in a tertiary care hospital. Clinical, biological, and imaging data were collected at baseline and after treatment.Results: Fifty-one cases of spine tuberculosis were included: 14 with CST on imaging (27%) and 37 with no cervical localization. Median age was 39 y. Demographic characteristics, duration of symptoms and neurological findings of spine compression were similarly present at presentation in CST and NCST patients. On imaging, lesions were more often multifocal in CST than in NCST patients (9/14 [64%] versus 10/37 [27%], p = .014). Spinal surgery was required in 32/51 (63%) patients. At the end of follow-up (median: 20 months), cure rates were similar in CST and NCST patients but motor and/or sensitive functional sequel were more frequent in CST than NCST patients (6/14 [43%] versus 2/37 [5%], p = .003).Conclusions: Cervical involvement is present in more than a quarter of patients with spinal tuberculosis. Patients with CST had more frequent neurological sequelae than patients with NCST. This was mainly due to a more multifocal disease at presentation. Screening for cervical localization should be systematic in patients with spinal tuberculosis even in the absence of cervical symptoms.

Surgery is safe and effective when indicated in the acute phase of hematogenous pyogenic vertebral osteomyelitis.

BACKGROUND: The overall benefit of surgical management in the acute phase of hematogenous pyogenic vertebral osteomyelitis remains difficult to evaluate because of the balance between potential functional benefit versus complications of surgery. METHODS: Between 2000 and 2013, in a tertiary care hospital, we analyzed a cohort of patients with hematogenous pyogenic vertebral osteomyelitis treated surgically and compared them to those treated medically. Neurologic deficit (using the ASIA impairment scale) and pain (using the analgesic level required) 4 months later, recurrences and infection-related deaths 12 months later were evaluated. A propensity score was developed to adjust for nonrandomized allocation to surgery. RESULTS: Ninety patients were included (mean age 64 years, 63% male); 28 (31%) were treated surgically. After adjustment for the propensity score, the improvement in neurological deficit at 4 months did not differ between surgical and medical treatment (p = .82), but the reduction of pain tended to be greater in surgical versus medical treatment (p = .051). Recurrences of infection (5%) and infection-related deaths (12%) occurred at similar rates in both groups at 12 months (p = 1.00 for both). CONCLUSIONS: Patients with hematogenous pyogenic vertebral osteomyelitis requiring surgery improved equally as non-surgical patients in terms of neurological deficit and residual pain. This result was not hampered by increased complications related to surgery. When indicated, surgery is safe and effective in patients suffering from hematogenous pyogenic vertebral osteomyelitis.

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.