Robotics in spine surgery: systematic review of literature.

PURPOSE: Over 4.83 million spine surgery procedures are performed annually around the world. With the considerable caseload and the precision needed to achieve optimal spinal instrumentation, technical progress has helped to improve the technique's safety and accuracy with the development of peri-operative assistance tools. Contrary to other surgical applications already part of the standard of care, the development of robotics in spine surgery is still a novelty and is not widely available nor used. Robotics, especially when coupled with other guidance modalities such as navigation, seems to be a promising tool in our quest for accuracy, improving patient outcomes and reducing surgical complications. Robotics in spine surgery may also be for the surgeon a way to progress in terms of ergonomics, but also to respond to a growing concern among surgical teams to reduce radiation exposure. METHOD: We present in this recent systematic review of the literature realized according to the PRISMA guidelines the place of robotics in spine surgery, reviewing the comparison to standard techniques, the current and future indications, the learning curve, the impact on radiation exposure, and the cost-effectiveness. RESULTS: Seventy-six relevant original studies were identified and analyzed for the review. CONCLUSION: Robotics has proved to be a safe help for spine surgery, both for the patient with a decrease of operating time and increase in pedicular screw accuracy, and for the surgical team with a decrease of radiation exposure. Medico-economic studies demonstrated that despite a high buying cost, the purchase of a robot dedicated for spine surgery is cost-effective resulting in lesser revision, lower infection, reduced length of stay, and shorter surgical procedure.

Artificial intelligence in spine surgery.

The continuous progress of research and clinical trials has offered a wide variety of information concerning the spine and the treatment of the different spinal pathologies that may occur. Planning the best therapy for each patient could be a very difficult and challenging task as it often requires thorough processing of the patient's history and individual characteristics by the clinician. Clinicians and researchers also face problems when it comes to data availability due to patients' personal information protection policies. Artificial intelligence refers to the reproduction of human intelligence via special programs and computers that are trained in a way that simulates human cognitive functions. Artificial intelligence implementations to daily clinical practice such as surgical robots that facilitate spine surgery and reduce radiation dosage to medical staff, special algorithms that can predict the possible outcomes of conservative versus surgical treatment in patients with low back pain and disk herniations, and systems that create artificial populations with great resemblance and similar characteristics to real patients are considered to be a novel breakthrough in modern medicine. To enhance the body of the related literature and inform the readers on the clinical applications of artificial intelligence, we performed this review to discuss the contribution of artificial intelligence in spine surgery and pathology.

Complications of spine surgery for metastasis.

The spinal column represents the third most common site for metastases after the lungs and the liver, and the most common site for metastatic bone disease. With life-extending advances in the systemic treatment of cancer patients, the surgical procedures performed for spinal metastases will increase, and their related complications will increase unavoidably. Furthermore, considering the high complication rates reported in the spinal literature regarding spine surgery overall, it becomes clear that a better understanding of complications that the cancer patients with spinal metastases may experience is necessary. This article aims to summarize and critically examine the current evidence for complications after spine surgery for metastatic spinal disease, in both the perioperative and postoperative period. This paper would be useful for the treating physicians of these patients in their clinical practice.

Lumbar disc herniation: long-term outcomes after mini-open discectomy.

PURPOSE: The outcomes of mini open discectomy in lumbar disc herniation are usually satisfying. Our study aims at finding if its results are still good at long-term follow-up. METHODS: We reviewed 552 patients operated between 1993 and 2013 by mini open discectomy procedure. Our main evaluation criterion is a modified Stauffer and Coventry classification applied during follow-up visits at three months, one year, five years, and every five years. The secondary criterion was the Oswestry Disability Index. RESULTS: The outcomes are considered good to very good in 87.3% of the cases at one year follow-up. These results deteriorate after an average follow-up of 14.7 years but remain satisfactory with 63.7%. The global decrease is 23.6%. The Oswestry Score decreases by 35 points at the same follow-up. In addition, 6.52% of patients required fusion at first revision and 1.08% at second revision. We also noticed 51 (9.2%) post-operative recurrences at the same level. In 23 (4.16%) of them, we proceeded to a new discectomy in an average interval of 41.4 months. At an adjacent level, 29 patients (5.2%) presented a new symptomatic disc herniation; among them, eight cases (1.44%) needed discectomy. The re-operative rate (including recurrent disc herniation and fusion for degenerative indications) is 10.68% at the last follow-up. CONCLUSIONS: Nearly 2/3 of our patient series keep satisfactory outcomes after about 15-year follow-up. The mini open discectomy remains a reliable surgical technique provided we respect the indications and surgical requirements. This procedure also avoids excessive instrumentation and its possible iatrogenic complications. Powerful randomized and controlled trials are needed to strengthen these deductions.

Surgical treatment of thoracic disc herniation: an overview.

BACKGROUND: Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord. METHODS: Literature review. RESULTS: Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications. CONCLUSION: Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

Current concepts for lumbar disc herniation.

PURPOSE: To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation. METHODS: A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation. RESULTS: Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. CONCLUSIONS: The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.

Cervical disc herniation: which surgery?

PURPOSE: Cervical disc herniation is a common pathology. It can be treated by different surgical procedures. We aimed to list and analyzed every available surgical option. We focused on the comparison between anterior cervical decompression and fusion and cervical disc arthroplasty. RESULTS: The anterior approach is the most commonly used to achieve decompression and fusion by the mean of autograft or cage that could also be combined with anterior plating. Anterior procedures without fusion have shown good outcomes but are limited by post-operative cervicalgia and kyphotic events. Posterior cervical foraminotomy achieved good outcomes but is not appropriate in a case of a central hernia or ossification of the posterior ligament. Cervical disc arthroplasty is described to decrease the rate of adjacent segment degeneration. It became very popular during the last decades with numerous studies with different implant device showing encouraging results but it has not proved its superiority to anterior cervical decompression and fusion. Anterior bone loss and heterotopic ossification are still to be investigated. CONCLUSION: Anterior cervical decompression and fusion remain the gold standard for surgical treatment of cervical disc herniation.

Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature.

INTRODUCTION: Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by a painful ulceration mimicking infection of the operative site. To this day, there is still no general agreement on the medical and surgical treatment of PG. This systematic review of the literature aims to summarise recent studies about post-operative PG in orthopaedic surgery to improve its medical and surgical management. METHOD: In April 2017, we carried out an exhaustive review of the literature in MEDLINE, PubMed and Cochrane databases. Key words were pyoderma gangrenosum, orthopaedic surgery, and surgical wound infection. We identified 183 articles. After excluding articles reporting idiopathic PG, cases secondary to non-orthopaedic surgery, and cases about other subtypes of dermatosis, 30 studies were identified. We only included articles reporting PG after orthopaedic or trauma surgery. RESULTS: Thirty-one cases of PG have been reported, 58% (18) of which were in women, whose mean age was 56.5 years. Clinical signs were constant, the most frequently affected site was lower limbs [77.4% (24)] and delay of symptom onset was two to 17 days. Systemic corticosteroid therapy was systematic, polyvalent immunoglobulins were used in two cases and immunosuppressive drugs in one. Negative pressure therapy was used in seven cases and hyperbaric oxygen in three. DISCUSSION: Delayed diagnosis leads to one or more surgical revisions, which could have been avoided by using early and adapted medical treatment. Early onset of a painful and infected ulcer at the operating site in a patient at risk of PG is an indicator that dermatologist advice is recommended before surgical debridement. Surgical revision, outside the inflammatory phase and/or covered by a systemic corticosteroid therapy, does not lead to PG relapse. LEVEL OF EVIDENCE: IV: Systematic revue of the literature.

High tibial osteotomy for medial osteoarthritis of the knee: 15 years follow-up.

We reviewed 192 patients (224 knees) to assess the results of HTO in medial gonarthrosis during the period 1982-2008. Median follow-up was about 15 years for 134 females and 58 males. Among the knees, 118 had an average opening wedge for varus angle of 13 degrees and 106 had closing wedges of 11 degrees. Knee Society scoring before osteotomies was 68/200 for opening wedge and 81/200 for closing wedge. Modified Ahlback classification showed preoperative grades I (n = 44), II (78), III (83) and IV (19). Healing delay was 55 days for closing and 70 for opening osteotomy. Twenty-nine knees were still painful. Twenty-eight patients were revised and 19 others had complications. After opening wedge osteotomy, scoring was 101/200 and valgus angle was 2 degrees. After closing wedge osteotomy, scoring was 94/200 and valgus angle was 4 degrees. Global results were as follows: very good, 12%; good, 30%; fair, 31%; and poor, 27%. HTO decreases stresses on medial compartments and widens joint space. The average of 5 degrees mechanical valgus at the time of osteotomy seems to be quite effective at the follow-up for at least ten years. Our indications are opening wedge for grades 1-3 and wide varus angle, until the age of between 65-70. Closing wedge is indicated for medium varus in younger patients.

Spinal Infections: An Update.

Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. The most common route for spinal infection is through hematogenous spread of the microorganism from a distant infected area. Most patients with spinal infections diagnosed in early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required. In either case, close monitoring of the patients with spinal infection with serial neurological examinations and imaging studies is necessary.

Posterior drawer after olecranization of the patella in posterior cruciate-injured knees: A cadaver study.

INTRODUCTION: Olecranization of the patella (OP) is a surgical technique that anchors the patella to the tibia using a Steinmann pin to reduce the posterior drawer in cases of acute posterior cruciate ligament (PCL) tears. The advantage of this procedure is that rehabilitation can start early with passive and active mobilization, all the while maintaining the reduced position. The primary objective of this cadaver study was to evaluate the reduction in the posterior drawer induced by OP. The hypothesis was that OP significantly reduces the posterior drawer at 0°, 45° and 90° flexion after isolated PCL transection. MATERIAL AND METHODS: A Steinman pin was inserted in 70° flexion on seven fresh cadaver knees. Changes in the posterior drawer were measured on radiographs at 0°, 45° and 90° flexion before and after adding a posterior load (150N) in the following sequence: intact knee, after PCL transection, after OP. Posterior translation was measured in millimetres. RESULTS: In unloaded knees, the posterior drawer was significantly reduced after OP in 45° flexion (4.1mm to-1.2mm, p<0.05) and 90° flexion (7.9mm to 3.8mm, p<0.05). When a posterior load was applied, the posterior drawer was significantly reduced in 0° flexion (4.9mm to 0.2mm, p<0.05), 45° flexion (6.7mm to 0.6mm, p<0.05) and 90° flexion (11.8mm to 7.6mm, p<0.05). DISCUSSION: Anchoring the patella to the tibia in 70° flexion led to a significant reduction in the posterior drawer after PCL transection in cadaver knees. Olecranization of the patella may help optimize the healing of an injured PCL treated conservatively. LEVEL OF EVIDENCE: III, controlled laboratory study.