Insulin-pump use in everyday practice: data from an exhaustive regional registry in France.

AIM: The aim of this study is to evaluate the effectiveness and safety of continuous subcutaneous insulin infusion (CSII) under real-life conditions among all patients treated with CSII in the south of Paris. METHODS: The 42 diabetologists practising in the region enrolled all patients treated with CSII or admitted for CSII initiation. During the study visit, the data for pump use and clinical results were recorded. RESULTS: Data were obtained for 424 patients, mean age 44.2+/-15.6 years, disease duration 18.7+/-10.6 years, including 339 treated with CSII for longer than three months (mean duration: 3.5+/-3.5 years; range: 3-258 months). Most of the patients (N=285, 84.8%) had type 1 diabetes; 44 (13.1%) had type 2 diabetes. In patients treated for more than three months, HbA1c decreased significantly between CSII initiation (9.1+/-1.9%) and the study visit (7.8+/-1.4%; P<0.0001). Patients with HbA1c >9%, using the pump, experienced a significant 0.9% improvement in their HbA1c levels with CSII versus multiple daily injections (P=0.001). The number of episodes of moderate hypoglycaemia was 2.7+/-2.5 per patient per week; of severe hypoglycaemia, 0.34 per patient per year and of ketoacidosis, 0.11 per patient per year. Factors significantly associated with HbA1c levels included amount of physical activity, pregnancy, HbA1c at CSII initiation and number of glucose self-determinations. Those associated with the number of moderate hypoglycaemia episodes were basal rate number, female gender and HbA1c level. HbA1c was negatively correlated with moderate hypoglycaemia (P<0.001), but not with severe hypoglycaemia. CONCLUSION: This 'pump' registry establishes the effectiveness of CSII in everyday practice, yet underscores the risks of severe hypoglycaemia and ketosis episodes. It could help diabetologists to improve patient training programmes and follow-up.

Spinal deformity and instability after multilevel cervical laminectomy for spondylotic myelopathy.

STUDY DESIGN: A retrospective radiographic and medical record analysis of 58 patients. OBJECTIVES: To describe the incidence and consequences of cervical spinal deformity and instability after multilevel laminectomy in adult patients with myelopathy caused by cervical spondylosis and to determine the usefulness of preoperative dynamic roentgenographic films in the prevention of postoperative destabilization. SUMMARY OF BACKGROUND DATA: Extensive cervical laminectomy has been widely used in the treatment of progressive myelopathy secondary to stenotic conditions. Complications of this procedure, including spinal instability, accelerated spondylotic changes, postoperative spinal deformity, and constriction of the dura mater by formation of extradural scar tissue formation have been recognized. However, the frequency of these complications is probably overestimated, and their effect on clinical outcome remains unknown. METHODS: Fifty-eight patients older than 30 years who underwent a laminectomy at more than three levels without fusion for myelopathy secondary to cervical spondylosis were reviewed retrospectively with an average follow-up of 3.6 years. Functional results were evaluated according to the Japanese Orthopaedic Association's scoring system. Lateral views in neutral position, in flexion, and in extension of the preoperative cervical roentgenograms were analyzed in comparison with the last follow-up films to identify the changes in the curvature of the cervical column, in the range of motion of the neck, and in the intervertebral angular mobility and anteroposterior displacement of the vertebral bodies and finally to quantify the incidence of spinal instability. RESULTS: In 18 patients (31%), postoperative changes in the type of cervical spine curvature developed. Fifteen patients (25%) had destabilization at one or more levels. Deformities of the cervical spine occurring after surgery do not appear to cause symptoms or neurologic abnormalities. Destabilization required repeat surgery in 3 patients. All the levels appearing to be destabilized on the postoperative films were hypermobile on the preoperative dynamic radiographs. Preoperative olisthesis Without hypermobility is not a factor of risk in postoperative destabilization. CONCLUSIONS: The use of preoperative dynamic radiographs should improve the selection of patients undergoing laminectomy for the treatment of multilevel cervical cord compression. Dynamic radiographs may also reinforce the need for such adjunctive procedures as fusion and instrumentation, to prevent postoperative destabilization. Preoperative olisthesis with hypermobility in sagittal or horizontal planes must be fused and instrumented.

The diagnosis of disc sequestration.

Sequestration of a disc herniation is an important cause of failure of chemonucleolysis. It therefore is important to recognize this particular variety of disc herniation before considering enzymatic discectomy. In order to determine the clinical and myelographic signs of sequestration, we reviewed the charts, myelograms, and surgical findings of 98 patients operated on for a disc herniation. A correlation was made between the three anatomic types of disc herniation found during surgery and the clinical and myelographic signs observed preoperatively. No characteristic clinical sign was found. No pathognomonic myelographic features were discovered. However, when the myelographic defect appears irregular and at a distance from the disc space, sequestration should be highly suspected.

Surgical findings and results of surgery after failure of chemonucleolysis.

The purpose of this study, based on a consecutive series of 350 patients treated by chemonucleolysis in a 6-year period, is to analyze the causes of failure in 38 patients who underwent subsequent surgery. The most common cause of failure in this series was lateral recess stenosis, encountered in 16 of 38 patients. In contrast a sequestrated disc was found in only four patients. Failure of the enzyme to "digest" the protruded fragment was the cause of persisting sciatica in 11 other patients. No abnormality or recurrence at another level was found in the remaining patients. The success rate of surgery was 70%. The best results were obtained when a sequestrated disc or lateral stenosis was disclosed.

Cervical pseudarthrosis in ankylosing spondylitis. A case report.

STUDY DESIGN: This report illustrates two different cases of cervical pseudarthrosis in ankylosing spondylitis. OBJECTIVES: To point out the extreme rarity of this condition at cervical level, to discuss the pathogenesis, and to stress the necessity of surgical management. SUMMARY AND BACKGROUND DATA: Pathogenesis of pseudarthrosis in ankylosing spondylitis is discussed. Several factors are involved: trauma, which may be major or minor and undetected; stress fracture; and inflammatory changes. Major trauma was the cause of pseudarthrosis in the first patient, whereas stress fracture and inflammatory changes were the probable causes in patient 2. In patient 1 there were signs and symptoms of cord compression. Patient 2 was referred because of functional disability resulting from kyphosis and because of potential neurologic risk. METHODS: Cervical fusion was performed in both patients. Patient 1 underwent posterior fusion; patient 2 had combined fusion. Patient 1 also underwent a lamineotomy. RESULTS: The course of the disorder after surgery was uneventful in both patients. Neurologic symptoms subsided in patient 1; kyphosis was corrected in patient 2. Both patients resumed their preoperative activities. Follow-up evaluation was done 6 years after surgery in patient 1 and 2 years after surgery in patient 2. CONCLUSIONS: Pseudarthrosis of the cervical spine in ankylosing spondylitis is extremely rare. Presentation of the two patients was different in terms of pathogenesis and signs and symptoms. Surgical treatment is advocated for this disorder.

Radiologic and computed tomography image evaluation of bone regrowth after wide surgical decompression for lumbar stenosis.

STUDY DESIGN: Retrospective study of bone regrowth after decompressive surgery for lumbar spinal stenosis. OBJECTIVES: To assess bone regrowth at the operation site, to compare the bone regrowth rate calculated from plain radiographs with computed tomographic image examinations, to determine the effects of bone regrowth on clinical outcome, and to investigate the factors promoting bone regrowth. SUMMARY OF THE BACKGROUND DATA: Moderate or marked bone regrowth in a surgical defect has been reported in most patients after decompression for lumbar spinal stenosis. Postoperative bone regrowth is related to recurrence of neurologic symptoms in the middle of and later on in follow-up periods. METHODS: Twenty-three patients who underwent decompressive surgery for lumbar spinal stenosis, with an average follow-up of 8 years, were evaluated retrospectively regarding the degree of bone regrowth at the posterior arch. Early postoperative radiographs and computed tomographic images were compared with those obtained at final follow-up. Bone regrowth at the operation sites was evaluated as a regrowth percentage of the original laminectomy site. RESULTS: Decompressive surgery caused bone regrowth to occur at the operation site in most of the patients. However, this regrowth was mild because the mean bone regrowth rate evaluated from plain radiographs averaged 11% and from computed tomographic images 7.7%. In only 20% of the patients was the bone regrowth rate more than 20%. Changes were found to be more elevated at the facet joint level than at the pedicle level. Evaluations of regrowth obtained from plain films and computed tomographic image examinations were compared. Radiographs seemed to overestimate the bone regrowth. The association of postoperative spinal instability with the development of new bone was statistically significant. No relation between bone regrowth and clinical outcome was found. CONCLUSIONS: Bone regrowth in a surgical defect occurs in most patients after posterior decompression. In this study the bone regrowth rate was mild and did not affect the clinical outcome.

A randomized, double-blind study to compare low-dose with standard-dose chymopapain in the treatment of herniated lumbar intervertebral discs.

Postoperative low-back pain and spasm are the main drawbacks of chymopapain chemonucleolysis. To investigate if low-dose chymopapain could reduce this adverse reaction, without modifying the efficacy, 118 patients with persistent low-back and radicular pain due to a lumbar disc herniation underwent chemonucleolysis. 60 patients were randomly selected to receive 2 mL of standard-dose chymopapain (4,000 units) and 58 to receive 2 mL of low dose (2,000 units). The clinical outcome was assessed on study days 1, 30, and 60, and after 1 year by physicians who were unaware of the treatment, and on the basis of the patients' self evaluation. At day 60, Chemonucleolysis was rated as successful in 81% of the cases by the investigator and in 80% by the patient's self assessment. The percentage of good results was remarkably similar in the two treatment groups and this finding was confirmed after 1 year. There was some evidence that the low-dose treatment resulted in less frequent postoperative back pain but the difference was not statistically significant. Moreover, a comparable incidence of acute low-back pain and spasm was observed in the two treatment groups. Low-dose chemonucleolysis appears to be as effective as the standard dose, but the use of 2,000 units does not significantly lower the postoperative back pain.

Treatment of lumbar disc herniation by chymopapain chemonucleolysis. A report on 120 patients.

Ninety of 120 patients with herniated lumbar discs who received an intradiscal injection of chymopapain achieved successful recovery. Sixteen of the 21 patients who underwent subsequent surgery had a good result. Study of the unsuccessful cases showed that disc sequestration and lateral stenosis were the major organic causes of failure. Certain radiologic criteria suggestive of sequestration and of important segmental stenosis are described. They appear to be a contraindication to chemonucleolysis. Psychogenic pain components and the failure of the enzyme to hydrolyse the nuclear proteoglycans in a few cases were the other two causes of poor results. A survey of postchemonucleolysis computed tomographic scans suggested that, although capable of digesting nuclear material in most cases, chymopapain may also work through an "anti-inflammatory" mechanism.

Unstable degenerative spondylolisthesis of the cervical spine.

Unstable degenerative spondylolisthesis of the cervical spine is very rare. Slip usually occurs at the C3 on C4 or C4 on C5 levels, immediately above a stiff lower cervical spine. There are two clinical patterns: that with neurological involvement causing cervicobrachial pain or myelopathy and that with neck pain alone. The diagnosis can be made by flexion/extension radiography. All of our eight patients had localised fusion, three anterior and five posterior, and all had satisfactory results one to seven years after operation.

[Chemonucleolysis in the treatment of sciatica caused by herniated disk]. / La chimionucléolyse dans le traitement des sciatiques par hernie discale.

Chemonucleolysis is an effective treatment of sciatica due to herniated lumbar disc after conservative treatments have failed. Provided the proper technique is applied and the patients are well selected (complete herniation or herniation within a narrow spinal canal being excluded), surgery can be avoided in the majority of cases. Chemonucleolysis does not in any way complicate subsequent surgery if required and post-nucleolysis surgery gives the same results as first intention surgery. The method, therefore, should not be regarded as an alternative to surgery but as the last stage of conservative treatment. Allergic reactions are the only true side-effects and require special precautions.

[Postoperative analgesia: epidural injection of dexamethasone sodium phosphate]. / Analgésie postopératoire: injection péridurale de phosphate sodique de dexaméthasone.

Epidural administration of steroids has been suggested for the prevention of postoperative epidural fibrosis after lumbar lamino-arthrectomy. In order to assess the efficacy of this technique on pain occurring after such surgery, the demand of pentazocine during the first 24 postoperative hours was studied in 39 patients randomly assigned to two groups. Pain intensity was assessed by a five-point verbal scale (0: none; 1: poor; 2: moderate; 3: severe; 4: very severe) at five intervals (0-4, 5-8, 9-12, 13-16 and 17-24 h). The patients in group T (n = 20) did not receive any steroid, whereas those in group C (n = 19) were given, just after the end of surgery, a single dose of dexamethasone (4 mg) via an epidural lumbar catheter previously inserted by the surgeon. In group T, 18 patients required one or several intramuscular injections of pentazocine, whereas only three patients of group C (p less than 0.001) did so. Patients in group T expressed more severe pain (4 moderate, 12 severe, 3 unbearable) than those patients who had received steroids (1 moderate, 1 severe, 1 unbearable). As a consequence, they requested more pain killer (30 injections vs 8 injections, respectively; p less than 0.001) and sooner than patients of the steroid group (8 h vs 12 h; p less than 0.05). It was concluded that epidural administration of dexamethasone was helpful in preventing postoperative pain after lumbar lamino-arthrectomy.

[Instability of the cervical spine caused by arthrosis. An unusual form of degenerative spondylolisthesis]. / Instabilité du rachis cervical par arthrose. Une forme particulière de spondylolisthésis dégénératif.

A case of a patient with spondylolisthesis between C4 and C5 is reported. There were neurological signs of spinal cord involvement and the lesions were essentially those of a posterior degenerative arthrosis with disc degeneration at other levels. This severe instability was cured by an anterior interbody fusion.

[Remodeling of the spinal canal after comminuted fracture of the spine. Apropos of a case]. / Remodelage du canal rachidien après fracture comminutive du rachis. A propos d'une observation.

A burst fracture of T 12, without neurological impairment, was treated by plaster cast. Prior to treatment, there was a significant narrowing of the spinal canal, due to posterior displacement of a bone fragment. This was not modified by treatment, as the narrowing was unchanged on the second CT scan, done eight days later. At 17 months, there was no more narrowing on the CT scan, as a consequence of vertebral body remodeling. The patient had no pain and performed several sport activities.

[Lumbar stenosis with scoliosis. Symptomatologic study and surgical treatment of 39 cases]. / Les sténoses lombaires avec scoliose. Etude sémiologique et traitement chirurgical de 39 cas opérés.

In 39 cases of narrowed lumbar spinal canal associated with a scoliosis, the authors have studied the role played by deviation of the spine and the origin of the narrowing. It seemed that central stenosis with intermittent claudication was more frequent when a scoliosis was present. In more than half of the cases, the level of the compression was at the junction of the curves. After failure of conservative treatment, the surgical procedure performed was the same as in straight spines. The results were satisfactory in 90 p. 100 as regards root involvement and intermittent claudication. However 7 patients had increased low back pain after surgery, 3 of them being disabled. In young patients with curves of more than 30 degrees with noticeable rotation, straightening with arthrodesis appeared to be worthwhile rather than simple posterior laminectomy. In other cases a posterior liberation of the cord associated with limited posterolateral fusion is indicated.

[Isthmic spondylolisthesis with spontaneous development in adults. Apropos of 8 cases]. / Spondylolisthésis isthmiques spontanément évolutifs de l'adulte. A propos de 8 cas.

Eight cases of progressive deterioration in spondylolisthesis in adults have been observed. In 7 cases, the displacement was between the 4th and 5th lumbar vertebra and only once between the 5th lumbar vertebra and the sacrum. The mean age of the patients was 37 years. Several factors leading to this deterioration are considered - disc degeneration, antero-posterior imbalance of the spine and inadequate fixation of the 4th lumbar vertebra to the ilium.

[Surgery in failure of nucleolysis of lumbar disk hernia]. / La chirurgie dans les échecs de la nucléolyse des hernies discales lombaires.

The authors have reviewed 206 cases of sciatica treated by Chemonucleolysis. Thirty-two had to be operated on later. This treatment was more frequently needed at L4/L5 level than at the lumbosacral level. Most of the failures of Chemonucleolysis were related to lateral spinal stenosis (13 cases). In 4 cases it was due to disc extrusion either at the time of the Chemonucleolysis (2 cases) or appearing later (2 cases). Nine failures were due to subligamentous disc herniation. Two cases were operated on for the onset of sciatica at another level, repeated treatment with Chemonucleolysis being contra-indicated. In 3 cases, the surgical exploration did not discover the cause of the sciatica. The surgical cases were not impeded by the preceding Chemonucleolysis and no adhesions were found. The results were similar to those observed after primary surgery - about two-thirds of satisfactory results. They were better when a herniation at another level was found or in cases of disc extrusion than in cases of spinal cord stenosis or sub-ligamentous herniae. They were poor when the cause of the sciatica was not found.

[Double occurrence of a giant-cell tumour (author's transl)]. / Tumeur à cellules géantes bifocale. Un cas.

The authors report a case of giant-cell tumour of the lower end of the radius treated by resection-arthrodesis of the wrist with cure of the lesion for 9 years. There then appeared, in the same hand, a second giant-cell tumour at the level of the first metacarpal bone which was not an extension of the first lesion. It was treated by prosthetic replacement of the first metacarpal bone. A review of the literature has shown 13 similar cases of polycentric giant-cell tumours.

[Treatment of giant cell tumors of the sacrum. Apropos of an observed case]. / Traitement des tumeurs à cellules géantes du sacrum

A case of giant cells tumor of the sacrum, invading a large part of the sacral body, the buttock is reported. The sacro-rectal space and the sacral canal with the cauda equina were compressed. Complete avulsion was performed, each nerve being closely dissected. Clinical recovery with roentgenographic aspect of bone healing is still present, three years and a half post-operatively.

[Avascular necrosis of the femoral head following fracture of the neck. Early diagnosis using radioactive tracers]. / Nécrose avasculaire de la tête fémorale après fracture du col. Diagnostic précoce par traceur radioactif

The authors have injected Sr85 intravenously and studied its fixation in samples taken from the femoral head with a trephine in the course of reduction and fixation of fractures of the femoral neck. Thirty-eight cases were studied, of which ten developed secondary avascular necrosis of the femoral head. All the patients were followed up for more than three years. The standard technique is described in detail. The authors consider that this technique was valid. All the necroses were able to be predicted. The examination of the samples took about 15 minutes during the operation. The method makes it possible to choose between internal fixation and prosthetic replacement.

[Lateral lumbar disk hernia]. / Les hernies discales lombaires latérales.

Lateral lumbar disc herniations (L.D.H.) develop in the foramen, and compress the nerve root against the overlying vertebral pedicle. In our study of L.D.H. from the clinical, radiographical, and therapeutical aspects, we reviewed 23 cases selected from the 590 patients treated for discal herniation from 1984 to 1987. The frequency of L.D.H. in this series was 3.8 per cent. The clinical pattern brings out some suggestive signs of L.D.H. (frequency of cruralgia, a seldom very positive Lasegue's test, the paucity of spinal signs, non impulsive pain). Saccoradiculography and discography rarely evidenced the L.D.H.. The T.D.M. was the investigation of choice on condition that it was correctly used. When the image was doubtful, disco-CT confirmation should be proceeded too. This latter method of investigation enabled the possibility of sequestration to be explored. 14 patients were treated by chemonucleolysis, with 9 successful outcomes. The 5 failures were cases where chemonucleolysis should not have been indicated, mainly due to associated osseous stenosis. 9 patients underwent immediate surgery with good results in each case.