Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery.

OBJECTIVE: To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France. METHODS: Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up. RESULTS: A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%). CONCLUSIONS: This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.

Assessment of the Radiation Exposure of Surgeons and Patients During a Lumbar Microdiskectomy and a Cervical Microdiskectomy: A French Prospective Multicenter Study.

OBJECTIVE: Cervical and lumbar disk herniations are the most frequently carried out procedures in spinal surgery. Often, a few snapshots during the procedure are necessary to validate the level or to position the implant. The objective of this study is to quantitatively estimate the radiation received by a spine surgeon and patient during a low-dose radiation procedure. METHODS: We conducted a prospective multicenter study in France from November 2014 to April 2015. Four spine centers were monitored for radiation received by surgeons during interventions for lumbar disk herniation and cervical disk herniation. RESULTS: A total of 134 patients were included. For lumbar disk herniation, the average exposure for the surgeon was 0.584 µSv on the chest, 5.291 µSv on the lens, and 9.295 µSv on the hands per procedure. For these procedures, the dose area product (DAP) was 94.2 ± 198.4 cGy·cm(2), and the fluoroscopic time was 10.2 ± 16.9 seconds. For a herniated cervical disk, the average exposure for the surgeon was 0.122 µSv on the chest, 3.106 µSv on the lens, and 7.143 µSv on the hands per procedure. For these procedures, the DAP was 35.7 ± 72.1 cGy·cm(2), and the fluoroscopic time was 19.7 ± 13.7 seconds. CONCLUSIONS: Exposure to x-rays for surgeons and patients during surgery for lumbar disk herniation is higher than during surgery for cervical herniation disk. Our results show that radiation exposure to the spine surgeon is still far below the annual dose limits.

Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients.

PURPOSE: To investigate the incidence of surgical-site infection (SSI) and determinate the risk factors of SSI in the context of spinal injury. METHODS: From February 1, 2011 to July 31, 2011, for a multicentre cohort of patients with acute spinal injury, we prospectively censored those with SSI for at least 12 months. We recorded epidemiologic characteristics and details of surgical procedure and postoperative care for each patient. We calculated the incidence of SSI at 1, 3 and 12 months after surgery. Univariate and multivariate analysis were used to establish the association of risk factors and SSI. We studied clinical outcomes by a visual analog scale for pain and physical and mental component summaries (PCS and MCS) of the Medical Outcomes Survey 36-Item Short Form (SF-36). RESULTS: At 1 year, among 518 patients, we recorded 25 SSI events, with median occurrence at 16 days (25-75 % quartile: 13-44 days). Incidence of SSI was 3.2 % (95 % confidence interval [1.9-5.3 %]) at 1 month, 3.7 % (95 % [2.2-5.8 %]) at 3 months and 4.6 % (95 % CI [3-6.9 %]) at 12 months. On multivariate analysis, age, presence of diabetes and surgical duration were predictors of SSI (p = 0.009, p = 0.047, and p = 0.015 respectively). At 12 months, infected and non-infected patients did not differ in pain (p = 0.58) or SF-36 PCS (p = 0.8) or MCS (p = 0.68). CONCLUSIONS: In this large prospective multicentre study in the context of spinal injury, we obtained an equivalent incidence rate and risk factors of SSI as found in the literature for elective spinal surgery.

Glycemic instability of non-diabetic patients after spine surgery: a prospective cohort study.

PURPOSE: Blood glucose (BG) dysregulation is a well-known condition for patients sustaining medical adverse events, such as sepsis or myocardial infarction. However, it has never been described following spine surgery. Our purpose was to assess postoperative glycemic dysregulation of non-diabetic patients undergoing spine surgery and determine if this is related to any complications within a 3-month postoperative period. METHODS: All the non-diabetic patients undergoing spine surgery in our center were prospectively included over a 6-month period. BG capillary measures were collected from the preoperative fasting period to the end of postoperative Day 3, six times a day. Patients were followed for 3 months after surgery. RESULTS: Data collected from 75 patients were eventually analyzed. A significant increase of BG level was observed from the preoperative to the second postoperative hour (P < 0.0001), remaining significantly elevated until Day 3 (P < 0.0001). Significant correlations were found between perioperative factors (age, smoking, revision status, instrumentation, operation time, blood loss and transfusion) and glycemic parameters. Day 2 mean BG level was found significantly higher for patients surgically revised than those not revised (P = 0.04). CONCLUSIONS: Non-diabetic patients experience a statistically significant increase in BG levels in the first 3 days following a spine surgery. This increase in BG might be correlated with postsurgical complications.

Influence of transforaminal lumbar interbody fusion procedures on spinal and pelvic parameters of sagittal balance.

INTRODUCTION: Restitution of sagittal balance is important after lumbar fusion, because it improves fusion rate and may reduce the rate of adjacent segment disease. The purpose of the present study was to describe the impact of transforaminal lumbar interbody fusion (TLIF) procedures on pelvic and spinal parameters and sagittal balance. MATERIALS AND METHODS: Forty-five patients who had single-level TLIF were included in this study. Pelvic and spinal radiological parameters of sagittal balance were measured preoperatively, postoperatively and at latest follow-up. RESULTS: Age at surgery averaged 58.4 (±9.6) years. Mean follow-up was 35.1 months (±4.1). Twenty-nine percent of the patients exhibited anterior imbalance preoperatively, with high pelvic tilt (17.6° ± 7.9°). Of the 32 (71%) patients well balanced before the procedure, 22 (70%) had a large pelvic tilt (>20°), due to retroversion of the pelvis as an adaptive response to the loss of lordosis. Three dural tears (7%) were reported intraoperatively. Interbody cages were more posterior than intended in 27% of the cases. Disc height and lumbar lordosis at fusion level significantly increased postoperatively (p < 0.05 and p < 0.001). Pelvic tilt was significantly reduced (p < 0.01) postoperatively, whereas the global sagittal balance was not significantly modified (p = 0.07). CONCLUSION: Single-level circumferential fusion helps patients reducing their pelvic compensation, but the amount of correction does not allow for complete correction of sagittal imbalance.

[A case of epithelioid hemangioma of the spine]. / Un cas d'hémangiome épithélioïde du rachis.

Epithelioid hemangioma is a rare and benign vascular tumor, most often occurring in the skin. Numerous other localizations, including bones, have been reported. The overall favorable clinical outcome of cutaneous epithelioid hemangioma is now well documented, but it still remains debated in osseous localization, as local recurrences and metastases have been described. We report a case of epithelioid hemangioma of the spine occurring in a 25-year-old male, and discuss main differential diagnoses. Recent studies tend to demonstrate that osseous epithelioid hemangioma, as cutaneous epithelioid hemangioma, should be considered as a benign tumor. Histologically, epithelioid hemangioma consists of a vascular proliferation with diffuse or lobular pattern and features vascular spaces lined by epitheliod endothelial cells with numerous lymphocytes and eosinophils. The main differential diagnosis is represented by epithelioid hemangioendothelioma, the surgical treatment of which must be more aggressive. Precise histological diagnosis is essential for accurate clinical management and to avoid overtreatment.

Individual probability of allogeneic erythrocyte transfusion in elective spine surgery: the predictive model of transfusion in spine surgery.

BACKGROUND: The aim of this study was to generate a score based on preoperative characteristics and predictive of the individual probability of allogeneic erythrocyte transfusion in patients undergoing elective thoracolumbar spine surgery. METHODS: Two hundred thirty consecutive patients were retrospectively included over a 15-month period (derivation set). Preoperative independent predictors of erythrocyte transfusion from the day of surgery until postoperative day 5 were determined by multivariable analysis, from which a model of individual probability of transfusion was derived and prospectively validated in 125 additional patients (validation set). RESULTS: Four preoperative independent predictors were associated with transfusion: age older than 50 yr (adjusted odds ratio = 4.9 [2-13.5]), preoperative hemoglobin level less than 12 g/dl (adjusted odds ratio = 6.9 [3.1-17.2]), fusion of more than two levels (adjusted odds ratio = 6.7 [3.1-15.2]), and transpedicular osteotomy (adjusted odds ratio = 19.9 [5.6-98.2]). A 0-4 score (0 = no risk, 4 = maximum risk) predictive of allogeneic transfusion was derived by weighting estimate parameters for each variable in a multivariable logistic regression model. Discriminating capacity of the score was 0.86 [0.81-0.92] in the receiver operating characteristics in the derivation sample and 0.83 [0.75-0.91] in the validation sample. The observed transfusion rates in the validation set and the individual probabilities of erythrocyte transfusion from the score were well correlated (y = 0.98x + 0.04; P < 0.0001), and the observed differences were not statistically different (goodness-of-fit chi-square, P = 0.125). The score was also correlated with the number of erythrocyte units transfused (Spearman rho = 0.61; P < 0.0001). CONCLUSION: The Predictive Model of Transfusion in Spine Surgery may be useful in clinical practice to identify patients undergoing spine surgery at risk of massive bleeding and encourage erythrocyte-saving strategies in these patients.

Sacral and lumbar-pelvic morphology in high-grade spondylolisthesis.

Numerous authors have stressed the importance of posterior arch, vertebral bodies, and intervertebral disk dysplastic changes in lumbosacral spondylolisthesis. An extensive morphologic analysis was conducted of the lumbosacral junction in a series of 100 consecutive patients presenting with severe lumbosacral spondylolisthesis. Statistical correlations were found between the pelvic incidence, sacral slope, and pelvic tilt, as found in healthy volunteers. A statistical relationship exists between the lumbosacral kyphosis and pelvic parameters that explains the global sagittal "balance" of this pathological posture. A well-defined morphological criterion, the "S1 index," strongly correlated with the severity and stiffness of lumbosacral spondylolisthesis.

Is there a sagittal imbalance of the spine in isthmic spondylolisthesis? A correlation study.

Recent studies suggested a predominant role of spinopelvic parameters to explain lumbosacral spondylolisthesis pathogeny. We compare the pelvic incidence and other parameters of sagittal spinopelvic balance in adolescents and young adults with developmental spondylolisthesis to those parameters in a control group of healthy volunteers. We compared the angular parameters of the sagittal balance of the spine in a cohort of 244 patients with a developmental L5-S1 spondylolisthesis with those of a control cohort of 300 healthy volunteers. A descriptive and correlation study was performed. The L5 anterior slipping and lumbosacral kyphosis in spondylolisthesis patients was described using multiple regression analysis study. Our study demonstrates that the related measures of sagittal spinopelvic alignment are disturbed in adolescents and young adults with developmental spondylolisthesis. These subjects stand with an increased sacral slope, pelvic tilt and lumbar lordosis but with a decreased thoracic kyphosis. Pelvic incidence was significantly higher in spondylolisthesis patients as compared with controls but was not clearly correlated with the grade of slipping. We showed the same "sagittal balance strategy" in spondylolisthesis patients as in the control group regarding correlations between pelvic incidence, sacral slope, pelvic tilt and lumbar lordosis. We believe that the lumbosacral kyphosis is a stronger factor than pelvic incidence which need to be taken into account as a predominant factor in theories of pathogenesis of lumbosacral spondylolithesis. We thus believe that increased lumbar lordosis associated with L5-S1 spondylolisthesis is secondary to the high pelvic incidence and is an important factor causing high shear stresses at the L5-S1 pars interarticularis. However, the "local" sagittal imbalance of the lumbosacral junction is compensated by adjacent mobile segments in the upper lumbar spine, the pelvis orientation and the thoracic spine. The result is not optimal but a satisfactory global sagittal balance of the trunk, even in the most severe grade of slipping.

Intra and inter-observer reliability of determining degree of pelvic incidence in high-grade spondylolisthesis using a computer assisted method.

Pelvic incidence was described as a fundamental parameter to describe spino-pelvic balance. In high-grade spondylolisthesis, severe dystrophic changes of the upper sacral endplate may be responsible for technical difficulties in pelvic incidence measurement. We propose to evaluate the reliability of PI measurement in high-grade spondylolisthesis patients and to compare the manual method with a computer-assisted method. In 30 high-grade spondylolisthesis patients, pelvic incidence was measured by manual and computer-assisted technique by the Spineview software package. We statistically assessed agreement between the manual and the computer-assisted technique, the intra-observer and the inter-observer reliability of the computer-assisted technique. Significant correlation was found (Spearman's rank R = 0.921 with P<0.001) between manual and computer-assisted results. The paired t test (t = 0.979 with P<0.001) and the intraclass correlation coefficient (ICC) were also significant. Intra- and inter-observer reliability of the computer-assisted technique were excellent with Spearman's rank correlation from 0.964 to 0.985 with P<0.001, a paired t test from 0.978 to 0.983 with P<0.001) and an ICC from 0.986 to 0.992. Intra- and inter-observer repeatability were better with the computer-assisted method than with the manual technique. We proved the reliability and repetability of a computer-assisted angular measurement method in high-grade spondylolisthesis patients. This validated measurement technique could be now used to measure the main parameters of the sagittal balance of the spine in further studies on spondylolisthesis patients.

Radiological assessment of lumbosacral dystrophic changes in high-grade spondylolisthesis.

OBJECTIVE: To analyse radiographic correlates for the clinical status of patients and the deformation reducibility of high-grade lumbosacral spondylolisthesis. We also clarify the clinical and radiographic correlates of a new parameter for S1 dystrophy, the "S1 index". DESIGN AND PATIENTS: One hundred cases of high-grade isthmic lumbosacral spondylolisthesis were reviewed. We noted the dystrophic changes in the cranial sacral endplate, and the caudal endplate of L5. The severity of the spondylolisthesis was evaluated by measuring the lumbosacral kyphosis. The clinical status and the deformation reducibility (dependent on the stiffness of the deformation) were compared with these dystrophic patterns, the sagittal slope of S1 and S2 endplates and a sacral morphological marker, the S1 index. RESULTS: Lumbosacral kyphosis was less severe in cases with dystrophic changes of the posterior cranial edge of S1 and/or of the posterior caudal edge of L5 but its reducibility was worse. These patients were more functionally impaired. We describe and analyse this situation as a partial lumbosacral disc failure responsible for the less severe L5 slipping. The S1 index was strongly correlated with the grade of slipping, the lumbosacral kyphosis and its reducibility. We noted the same configuration among patients with a smaller S1 index, i.e. vertical S1 and S2 vertebral bodies associated with more severe but more reducible lumbosacral kyphosis. CONCLUSION: Analysing specific criteria, we think it is possible to note progressive dystrophic changes according to the natural history of lumbosacral spondylolisthesis. We think that repeated measurements of these morphological parameters in patients diagnosed with a low-grade lumbosacral spondylolisthesis could be helpful in the early detection of evolving lumbosacral kyphosis and L5 slipping.