Thoracogenic scoliosis: coronal deformity progression in paediatric patients.

PURPOSE: To assess the risk of developing thoracogenic scoliosis (THS) in paediatric patients, depending on the side of lateral thoracotomy (LT) and of spine deviation in the coronal plane by means of logistic regression and scoliosis-free survival analyses. METHODS: A total of 307 consecutive patients undergoing LT were retrospectively reviewed; 32 patients met the inclusion criteria: 1) underwent LT and developed THS; 2) age < 15 years at LT; 3) clinical and radiographic follow-up ≥ 5 years. Patients were divided into ipsilateral group (convexity ipsilateral to LT) and contralateral group (convexity contralateral to LT). RESULTS: The mean follow-up was 10 ± 4.7 in the ipsilateral group (n = 13) and 12 ± 4.8 years in the contralateral group (n = 19). The contralateral group underwent LT at a younger age (4.4 vs 6.4 years, p = 0.55), developed more severe coronal deformity (27.8° vs 18.9°, p = 0.15), had higher rate of THS > 20° (47.5% vs 38.4%; p = 0.34) and > 45° (21.1% vs 0%; p = 0.99). The mean time from LT to THS diagnosis was 4.2 ± 2.9 in ipsilateral group and 5.5 ± 4.2 years in contralateral group. Left-side LT (p = 0.03) and age > 5 years (p = 0.01) showed a lower risk of THS diagnosis. The group variable had a statistically significant effect on the risk of developing THS > 45° (p = 0.03). CONCLUSION: In this series, children that developed THS with a convexity contralateral to the side of LT had more severe and progressive coronal spine deformity. LEVEL OF EVIDENCE: III.

Thoracogenic scoliosis: a retrospective review of 129 pediatric patients with a mean follow-up of 10 years.

PURPOSE: To determine the midterm outcome of lateral thoracotomy (LT) in skeletally immature patients concerning thoracogenic scoliosis development and lung parenchyma resection (LPR) extent. METHODS: In total, 129 children met the inclusion criteria: (1) LT during the study period; (2) skeletally immature at the time of LT; (3) clinical and radiographic follow-up of at least 3 years; and (4) no spinal or thoracic deformity on radiographs before LT. Patients were grouped according to their underlying disease, age at LT, and LPR extent. Radiographic parameters were assessed. Kaplan-Meier survival curves and univariate and multivariate analysis were performed. RESULTS: Of 129, 108 patients underwent pneumonectomy (9; 9.1%), lobectomy (79; 61.2%), segmentectomy (20; 15.5%) and 21 patients LT without LPR. The mean age at LT and at last radiological follow-up was 5.5 years (birth-17.8) and 15.2 years (3.4-33.2). The mean follow-up was 10 years (3-28.1). Scoliosis developed on average 5.3 years after LT. The mean Cobb angle was 22.1° (11-90°); > 10° in 37/129 patients (28.7%), of whom 5/129 (3.9%) had > 45°. The average vertebral rotation was 16.2° (2-43°; grade 0-II). RVAD was 26.5° (8°-33°) and 15.3° (2-43°) in patients with Cobb > 45° and ≤ 45°. Gender, age at surgery, and extent of LPR were not risk factors for post-thoracotomy scoliosis (p > 0.05), although younger patients developed a more severe deformity. CONCLUSION: Although post-thoracotomy scoliosis is not associated with significant rotation, the risk of curve progression > 45° is relatively high. Regular follow-up is required as scoliosis may develop several years after LT with or without LPR.

Common carotid artery medialization and fracture dislocation of the cervical spine.

PURPOSE: To describe the management of the discovery of a retropharyngeal carotid artery in the context of a cervical dislocation. DESCRIPTION OF THE CASE: A 68-year-old female presented acute neck pain and incomplete tetraplegia following a fall on the stairs. Radiographs, contrast-enhanced computed tomography scan and magnetic resonance of the cervical spine revealed a C5-C6 bi-articular dislocation. A detailed preoperative assessment of the images discovered a medialization of the left common carotid artery. An external reduction and a left anterior cervical approach allowed a careful management of the vascular variation and an anterior C5-C6 arthrodesis. At six months, a full neurological recovery was assessed and radiographs demonstrated successful fusion of the cervical arthrodesis. DISCUSSION/CONCLUSION: Anatomical features such as medialization of the common carotid artery may affect patients with traumatic cervical spine injuries. The severity of the traumatic bone lesions should not overshadow the preoperative analysis of the adjacent anatomical structures encountered during the surgical approach, even in an emergency situation.

Kinematics or Kinetics: Optimum Measurement of the Vertical Variations of the Center of Mass during Gait Initiation.

BACKGROUND: During gait, the braking index represents postural control, and consequently, the risk of falls. Previous studies based their determination of the braking index during the first step on kinetic methods using force platforms, which are highly variable. This study aimed to investigate whether determining the braking index with a kinematic method, through 3D motion capture, provides more precise results. METHODS: Fifty participants (20 to 40 years) performed ten trials in natural and fast gait conditions. Their braking index was estimated from their first step simultaneously using a force platform and VICON motion capture system. The reliability of each braking index acquisition method was assessed by intraclass correlation coefficients, standard error measurements, and the minimal detectable change. RESULTS: Both kinetic and kinematic methods allowed good to excellent reliability and similar minimum detectable changes (10%). CONCLUSION: Estimating the braking index through a kinetic or a kinematic method was highly reliable.

Exposure of medical staff to radiation during osteosynthesis of proximal femoral fracture: descriptive analysis and comparison of different devices.

BACKGROUND: The use of fluoroscopy is necessary during proximal femoral fracture (PFF) osteosynthesis. The frequency of these procedures justifies a description of radiation exposure and comparisons between different techniques and between the different surgical team members. METHODS: This observational prospective and comparative study includes a series of 68 patients with PFF receiving osteosynthesis. Radiation exposure was assessed for all members of the operating team. The radiation dose measurements for the different members of the surgical team during PFF osteosynthesis were compared. The factors affecting the radiation dose were investigated. RESULTS: The mean active dosimeter readings for each operation were 7.39 µSv for the primary surgeon, 3.93 µSv for the assistant surgeon, 1.92 µSv for the instrument nurse, 1.25 µSv for the circulating nurse, and 0.64 µSv for the anaesthesiologist, respectively. Doses decreased significantly between these different members of the medical team (all p < 0.001). The dose also varied with patient age and BMI, as well as with fluoroscopy time and operating time, but not with type of fracture or type of osteosynthesis. CONCLUSION: Medical staff receives significantly different doses depending on their position in relation to the radiation source. Operating time and fluoroscopy time are the modifiable factors that affect the radiation dose. The radiation doses received by the different members of the medical teams involved in proximal femur osteosynthesis procedures all fall below the doses recommended by the International Commission on Radiation Units and Measurements.

Ultrasound biomechanical anatomy of the soft structures in relation to the ulnar nerve in the cubital tunnel of the elbow.

BACKGROUND: Chronic ulnar nerve entrapment worsened by elbow flexion is the most common injury, but rare painful conditions may also be related to ulnar nerve instability. The posterior bundle of the medial collateral ligament (pMCL) and the retinaculum, respectively form a soft floor and a ceiling for the cubital tunnel. The aim of our study was to dynamically assess these soft structures of the cubital tunnel focusing on those involved in the biomechanics of the ulnar nerve. METHODS: Forty healthy volunteers had a bilateral ultrasonography of the cubital tunnel. Elbows were scanned in full extension, 45° and 90°, and maximal passive flexion. Morphological changes of the nerve and related structures were dynamically assessed on transverse views. RESULTS: Both the pMCL and the retinaculum tightened with flexion. During elbow flexion, the tightening of the pMCL superficially moved the ulnar nerve remote from the osseous floor of the retroepicondylar groove. A retinaculum was visible in all 69 tunnels with stable nerves (86.3%), tightened in flexion, but absent in 11 tunnels with unstable nerves (13.7%). The retinaculum was fibrous in 60 elbows and muscular in nine, the nine muscular variants did not significantly influence the biomechanics of stable nerves. Stable nerves flattened in late flexion between the tightened pMCL and retinaculum, whereas unstable nerves transiently flattened when translating against the anterior osseous edge of the groove. CONCLUSION: The retinaculum and the pMCL are key structures in the biomechanics of the ulnar nerve in the cubital tunnel of the elbow.

Double-level degenerative spondylolisthesis: what is different in the sagittal plane?

PURPOSE: Degenerative spondylolisthesis (DS) is a common disease. The importance of sagittal malalignment in the DS population has been widely described. However, there is no study reporting sagittal alignment analysis in double-level DS. This study aims to analyze patients with double-level DS and compare them with single-level DS patients in terms of demographic and radiographic data. METHODS: Retrospective multicenter (n = 13) study. Adult patients with one (uni_DS) or two-level DS (multi_DS) were included. Sagittal radiographic parameters were measured by an experienced observer: pelvic, spinal and global parameters with C7 sagittal tilt (C7 tilt, angle between the center of C7 vertebral body and the middle of the sacral endplate with the vertical reference line). After a descriptive analysis, radiographic and demographic data were compared between single and multi_DS. RESULTS: 78 patients were included in multi_DS group and 576 in uni_DS group. Multi_DS were older than uni_DS (70.2 ± 9.4 vs 66.9 ± 10.6 years, p = 0.009). C7tilt was greater in multi_DS (6.2° ± 5.3 vs. 4.8° ± 3.8, p = 0.003). Multi_DS had a greater pelvic incidence (62.4° ± 11.3 vs. 58.3° ± 11.1, p = 0.002). Pelvic tilt was larger in multi-DS (26.0° ± 7.5 vs. 22.6° ± 8.1, p = 0.001). L4S1 lordosis represented 40.4 % of the LLmax in multi_DS and 45.8 % in uni_DS group (p = 0.013). CONCLUSIONS: Multi_DS have different sagittal alignment than single DS with greater PI. In multi_DS, malalignment is more important with larger anterior tilt, loss of lumbosacral lordosis and more compensatory mechanisms such as pelvic retroversion. These findings highlight the need for an adapted surgical correction in these older patients with greater sagittal malalignment.

Sagittal spinopelvic alignment in 654 degenerative spondylolisthesis.

PURPOSE: Degenerative spondylolisthesis (DS) is common degenerative spinal disease. Recent studies highlighted relationship between DS and high pelvic incidence (PI). Moreover, impact of spinopelvic alignment on clinical outcomes has been emphasized. We aimed at describing epidemiologic and sagittal spinopelvic parameters in patients with DS, comparing them with asymptomatic volunteers, and determining a classification of DS patients. METHODS: In this retrospective multicenter study of prospectively collected data, any adult patients treated for lumbar DS were included. Demographic data as well as radiographic parameters such as PI, pelvic tilt (PT), maximal lumbar lordosis (LLmax), lumbosacral lordosis, thoracic kyphosis, and C7tilt were recorded. DS patients were compared to 709 asymptomatic, age-matched volunteers. Cluster analyses were used to classify patients in homogenous groups. RESULTS: 654 patients were included (72 % female, 67 years). DS patients had greater PI (58.8° vs. 53.2°, p < 0.001) and C7tilt (p < 0.001). LLmax and lumbosacral lordosis were significantly smaller in the DS group. Cluster analysis allowed for the identification of 2 groups of patients according to C7tilt-159 patients with anterior C7tilt and 495 with normal C7tilt. In each group, 3 subgroups were found with different PI and sagittal spinopelvic parameters. CONCLUSION: Predominance of high PI and female gender was emphasized in DS population. Moreover, these findings highlighted the importance of sagittal alignment analysis in DS with 24 % of patients with anterior malalignment and in the remaining 76 % (normal C7Tilt), more than 50 % had pelvic retroversion. Consequently, DS sagittal malalignment should lead to specific surgical correction adapted to each subgroup of patients.

CT analysis of C2 pedicles morphology and considerations of useful parameters for screwing.

INTRODUCTION: Surgery of cervical spine steadily requires realizing posterior osteosynthesis. The anchoring of instrumentation in C2 steadily constitutes an important stake of prognosis. Pedicle screwing is one of the best options and remains associated with a low morbidity. The aim of this CT study is to provide, from a wide population, the descriptive anatomical parameters of C2 pedicles. The data enable this analysis of feasibility of C2 pedicles screwing. MATERIALS AND METHODS: A continuous and retrospective series have explored 100 CT scans of the cervical spine without finding C2 fracture. The software OSIRIX v5.0.2 has been used. The dimensions of the pedicles in C2 as length, diameter, and distance from the vertebral foramens have been measured from the preset posterior entry point. Their orientation has been described in the axial and sagittal plan by the pedicle transverse angle, the sagittal angle and the pedicle-lamina angle used as a visible mark during the procedure. At least, the feasibility of pedicle screwing has been evaluated using a diameter criterion higher than 4 mm. RESULTS: The dimensions analysis of 200 studied pedicles has found an average length as 26.18 mm, an average diameter as 5.18 mm and an average distance between the entry point and the vertebral foramen as 9.06 mm. Their orientations have an average PTA as 36.6° and a SA as 25.8°. The average of the PLA was 81.3. The screwing feasibility has been evaluated as 92.5 % in the whole series. CONCLUSION: These morphological data come from a large series give some help for the C2 pedicle screwing preoperative planning. These lean on 3D measures but also on accessible mark during the procedure and despite the difference of the patient orientation. A CT preoperative planning of the pedicle screwing remains essential because more than 7 % of the pedicles have a diameter lower than 4 mm.

A prospective multicenter randomized study comparing the SpineJack system and nonsurgical management with a brace in acute traumatic vertebral fractures: the SPICO study.

OBJECTIVE: The objective of this study was to evaluate the efffectiveness of a titanium vertebral augmentation device (SpineJack system) in terms of back pain, radiological outcomes, and economic burden compared with nonsurgical management (NSM) (bracing) for the treatment of vertebral compression fractures. Complications were also evaluated for both treatment methods. METHODS: A prospective multicenter randomized study was performed at 9 French sites. Patients (n = 100) with acute traumatic Magerl type A1 and A3.1 vertebral fractures were enrolled and randomized to treatment with the SpineJack system or NSM consisting of bracing and administration of pain medication. Participants were monitored at admission, during the procedure, and at 1, 12, and 24 months after treatment initiation. Primary outcomes included visual analog scale back pain score, and secondary outcomes included disability (Oswestry Disability Index [ODI] score), health-related quality of life (EQ-5D score), radiological measures (vertebral kyphosis angle [VKA] and regional traumatic angulation [RTA]), and economic outcomes (costs, procedures, hours of help, and time to return to work). RESULTS: Ninety-five patients were included in the analysis, with 48 in the SpineJack group and 47 in the NSM group. Back pain improved significantly for all participants with no significant differences between groups. ODI and EQ-5D scores improved significantly between baseline and follow-up (1, 12, and 24 months) for all participants, with the SpineJack group showing a larger improvement than the NSM group between baseline and 1 month. VKA was significantly lower (p < 0.001) (i.e., better) in the SpineJack group than in the NSM group at 1, 12, and 24 months of follow-up. There was no significant change over time in RTA for the SpineJack group, but the NSM group showed a significant worsening in RTA over time. SpineJack treatment was associated with higher costs than NSM but involved a shorter hospital stay, fewer medical visits, and fewer hours of nursing care. Time to return to work was significantly shorter for the SpineJack group than for the NSM group. There were no significant differences in complications between the two treatments. CONCLUSIONS: Overall, there was no statistical difference in the primary outcomes between the SpineJack treatment group and the NSM group. In terms of secondary outcomes, SpineJack treatment was associated with better radiological outcomes, shorter hospital stays, faster return to work, and fewer hours of nursing care.

Intraspinal Extradural Degenerative Cervical Cyst Treated by Anterior Cervical Discectomy and Fusion: A Surgical Alternative to the Posterior Approach, about One Case.

Introduction: Intraspinal extradural arthrosynovial cysts, which belong to the spectrum of degenerative spinal diseases are mainly located at lumbar level and their location at cervical level joint is therefore unusual. The most common surgical approach for symptomatic arthrosynovial cervical cyst remains a direct resection of the cyst by a cervical hemilaminectomy with or without a posterior arthrodesis. However, another surgical approach may also be discussed when considering the cyst as a result of a local spinal instability or hypermobility. Case Report: We report in this work the case of a patient with cervical radiculopathy due to intraspinal extradural compressive arthrosynovial cervical cyst which was treated by anterior discectomy and fusion without direct resection of the cyst. The post-operative radiological control performed at 3 months showed a complete regression of the cyst with a patient pain-free. To the best of our knowledge, this is the first case of intraspinal cervical degenerative cyst at C7-T1 level treated by anterior approach and fusion without direct cyst resection. Conclusion: For the treatment of a joint spinal cervical cyst, the anterior approach is a relevant option that gives the advantages to respect the posterior cervical muscles and articular structures.

Sacropelvic fixation with iliosacral screws: applications and results in adult spinal deformities.

STUDY DESIGN: Retrospective radiographic and clinical review. OBJECTIVE: To determine the feasibility of iliosacral screw fixation in adult spinal deformations. SUMMARY OF BACKGROUND DATA: Pelvic fixation is one of the most challenging instrumentation problems. The poor bone quality frequently found within the sacrum and the large lumbosacral loads with cantilever pullout forces across this region explain its frequent failure. METHODS: Fourteen adult patients undergoing pelvic fixation using iliosacral screws with a minimal follow-up of 24 months were analyzed for radiographic outcomes. Radiographic data included the localization of the spinal deformity, the Cobb angle, T4-T12 thoracic kyphosis, L1-S1 lumbar lordosis, the T9 tilt, the pelvic parameters, and the POA. Mechanical and infectious complications were also noted. RESULTS: The lumbo-pelvic correction was performed with a large reduction of the POA in every case. The frontal and sagittal corrections obtained with this procedure were considered as being effective. There were no mechanical complications due to failure of the instrumentation, loss of sacral fixation, or loss of lumbar lordosis at the time of the last follow-up. One patient experienced local infection on the left iliosacral screw without any residual functional sequel. DISCUSSION: Iliosacral screwing can offer a pelvic fixation reliable enough to allow restoration of 3-dimensional trunk balance. This technique has a quite short learning curve and adequately permits frontal and sagittal corrections, increases stability, and decreases instrumentation-related complications. Our observations suggest that it is applicable to pelvic fixation in adult surgery.

Unusual Presentation of Lumbar Surgical Site Infection: A Case Study of Early Onset Pasteurella multocida Infection after Arthrodesis.

BACKGROUND Infection is a serious surgical complication that significantly increases morbidity rates and health care expenses. Most human Pasteurella multocida infections are soft-tissue infections caused by dog or cat bites. Pasteurella multocida (P. multocida) is present in the oral, nasopharyngeal, and upper respiratory tract microbiota among cats, dogs, and other domestic or wild animals. Here, we report a case of lumbar surgical site infection caused by this bacterium. CASE REPORT A 70-year-old diabetic and overweight woman had a Pasteurella multocida surgical site infection after lumbar arthrodesis carried out for lumbar stenosis associated with spondylolisthesis. The patient had been in contact with her cat and claimed to have simply slept with it in her bed. Multiple antibiotic therapies and 3 debridement-irrigations with change of spinal implants during the last revision were needed. CONCLUSIONS Infections caused by P. multocida are rare and most often occur as a result of animal scratches or bites, but can sometimes occur after simple contact with an animal. Surgical site infection of spinal arthrodesis due to Pasteurella multocida implies treatment difficulties. In case of Pasteurella multocida infection of lumbar spinal arthrodesis, even in the early period, implant removal seems to be useful to limit the appearance of biofilm more specific to this micro-organism.

Implications of cage impactions in single-level OLIF treatment of degenerative spondylolisthesis.

INTRODUCTION: Cage impactions (CI) of Oblique Lumbar Interbody Fusion (OLIF) appear to be a frequent mechanical complication with a potential functional impact. OBJECTIVES: To determine the rate of CI occurrence, their risk factors and clinical implications in the case of combined single-level arthrodesis. METHOD: A retrospective analysis of prospectively collected data was performed. All our patients with degenerative spondylolisthesis initially underwent OLIF combined with pedicle screw fixation (PSF). Intraoperative control with an image intensifier and a standard radiograph in the immediate postoperative period made it possible to assess the occurrence of CI, depending on the position of the implant. Secondary subsidence was sought on the standing radiological examination using EOS biplanar radiography during follow-up. The pelvic parameters were analyzed, as well as the occurrence of bone fusion. The clinical evaluation was made at≥1 year, by the Oswestry Disability Index (ODI), the walking distance (WD) and the Visual Analogue Scale (VAS). RESULTS: In all, 130 patients out of the 131 included were analyzed. A CI occurred in 25.3% (n=33) of cases and of these, 94% (n=32) occurred intraoperatively. Postmenopausal women had more CI with an odds ratio (OR) of 5.8 (P=0.034). The "CI" group had a 9.5% lower ODI score than the "non-CI" group (P=0.0040), but both provided excellent ODI gains of 30.8±16 and 32.9±15.5% (P<0.0001). An "anterior" position of the implant allowed a greater gain in lumbar lordosis (P<0.001) but was associated with greater CI occurrence (P<0.001), with an OR of 6.75 (P=0.0018). CONCLUSION: The occurrence of intraoperative cage impaction is a frequent event when performing OLIF. Postmenopausal women have an approximately 6 times greater risk of impaction than men, and patients with an "anterior" implant placement have a 7 times greater risk than with central placement. The negative impact of cage impactions on the clinical score (ODI) was significant after one year of follow-up. LEVEL OF EVIDENCE: IV, non-comparative cohort study.

Fusion and clinical outcomes of lumbar interbody fusion for low-grade isthmic spondylolisthesis.

INTRODUCTION: Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique. HYPOTHESIS: The various interbody fusion strategies provide satisfactory fusion rates and clinical results. METHODS: A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF)+posterolateral fusion (ALIF+PLF: n=60), and ALIF+percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R), Oswestry Disability Index (ODI) and Short Form 12 (SF12). RESULTS: Among the 129 patients, 85.3% showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p<0.001) and VAS-R (p<0.0001), ODI (p<0.001) and SF12 physical (PCS) (p<0.01) and mental component sores (MCS) (p<0.001) all showed significant improvement at 12months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p<0.0001) and radicular pain (p<0.05), ODI (p<0.0001) and SF12 PCS (p<0.01). At 12months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p<0.004) and VAS-L ratings (p<0.001) than Lenke 1-2 patients. CONCLUSION: Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results. LEVEL OF EVIDENCE: IV.

Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF.

INTRODUCTION: Circumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques-TLIF versus ALIF plus posterior instrumentation-for low-grade isthmic spondylolisthesis in adults. MATERIALS AND METHODS: This was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1-3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion. RESULTS: The cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18-79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=-0.3295; p=.021). CONCLUSION: ALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis. LEVEL OF EVIDENCE: III; multicenter comparative study.

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.

Posterior vertebral column resection for pediatric rigid spinal deformity.

INTRODUCTION: Surgery for pediatric spinal deformity may involve vertebral osteotomies in complex cases. Vertebral column resection (VCR) is the most technically demanding procedure, with the severest morbidity. It can use a double anterior and posterior approach (APVCR), though a single posterior approach (PVCR) is gaining in popularity. HYPOTHESIS: PVCR provides effective correction with acceptable morbidity in children. METHOD: A single-center retrospective series included spinal deformities treated by PVCR. Surgical data and global pelvic-spinal balance parameters were analyzed. RESULTS: Sixteen PVCRs were performed in 13 patients, with a mean age of 14.1±2.8 years. Mean operative time was 411±54minutes. Mean preoperative rigid principal Cobb angle was 74.3°. Mean correction was 64.3% postoperatively, without significant correction loss at last follow-up. Mean blood loss was 941±221ml. The cell-saver enabled 92.3% autologous transfusions, with 53.4% homologous transfusions. Transient monoplegia and permanent psoas deficit were observed during the postoperative period. Radiologic follow-up found 4 non-unions requiring revision. CONCLUSION: PVCR provided major correction of rigid spinal deformity in children. Complications mainly comprised mechanical or neurological incidents. LEVEL OF EVIDENCE: IV, non-comparative cohort study.

Posterior hinge fixation for the treatment of unstable traumatic sacroiliac joint injuries.

INTRODUCTION: Posterior hinge fixation (PHF) is a sacroiliac joint fixation method indicated for the surgical treatment of unstable pelvic ring fractures (tile C). HYPOTHESIS: PHF yields good functional outcomes based on the Majeed score at more than 1 year of follow-up. METHODS: A single-center, retrospective study of patients who had a Tile C pelvic ring fracture, who were operated by PHF and who were evaluated at a minimum follow-up of 1 year. The functional outcome was determined using the Majeed score and pain was evaluated by the patients using a visual analog scale (VAS). The preoperative, intraoperative and postoperative data, complications and sequelae were documented. A CT-scan was done at least 1 year after the surgical treatment to determine the SI joint's reduction and fusion. RESULTS: Included were 22 patients (59% men) who had a mean age of 37.3±11.9 years; 21 of these patients were reviewed at a mean of 4.8±4 years. The mean Majeed score at the final assessment was 76.4 points±15.3, with 24% of patients having excellent results (n=5), 53% having good results (n=11), 19% having average results (n=4) and 5% having poor results (n=1). The mean pain level on VAS was 28±23mm. Of the eight surgical site infections, seven occurred in the PHF (88%). CT-scans taken at 1 year postoperative were compared to the preoperative scans. The pelvic opening was reduced by -9±6 (p<0.01), SI diastasis by -11mm±9 (p<0.001), vertical displacement by-7mm±8 (p<0.001), symphysis opening by -15mm±15 (p<0.001), median transverse diameter by -10mm±9 (p<0.001) and bispinal diameter by -5mm±7 (p<0.001). SI fusion was confirmed in 43% of patients (n=9). CONCLUSION: PHF is a surgical instrumentation method that provides satisfactory long-term reduction of Tile C pelvic ring fractures. The clinical outcomes are good or excellent in 77% of cases. The perioperative morbidity is marked by surgical site infections, all of which healed. LEVEL OF EVIDENCE: IV; retrospective, non-comparative cohort study.

Optoelectronic Study of Gait Kinematics in Sagittal Spinopelvic Imbalance.

OBJECTIVE: Degenerative processes induce loss of lumbar lordosis and anterior sagittal imbalance (ASI). Optoelectronic study provides kinematic analysis of movement and can also detect ASI. The aim of the present study was to assess gait kinematic modifications induced by ASI. METHODS: Thirty-five healthy male volunteers were subjected to reversible ASI induced by wearing a kyphotic thermoformed thoracolumbar corset. The deformation was assessed by C7 tilt on EOS (EOS Imaging, Paris, France) full-spine views. Ten optoelectronic gait recordings were made with corset and 10 without. Gait kinematic parameters (stride length, walking speed, rhythm), gait balance parameters (center of mass braking index, stride width, double support time) and spinal sagittal balance parameters (C7T10S1, C7´S1' and spinal angles) were averaged. Adjusted analysis distinguished direct ASI impact from locomotor factors. RESULTS: The corset-induced ASI produced +15° change in C7 tilt (P < 0.0001), -7.4° in C7T10S1 (P < 0.0001), +66.2 mm in C7´S1' (P < 0.0001), and +13.1° in spinal angle (P < 0.0001). Radiographic and optoelectronic data correlated significantly. Stride length (P < 0.0001) and rhythm (P = 0.0003) were significantly reduced, contributing to a reduction in walking speed (P < 0.0001), and strongly influencing double support time (ß = -0.38; 95% confidence interval [CI]: -0.69; -0.06). Center of mass braking index was significantly reduced (P < 0.0001) and significantly influenced by ASI (ß = -0.51; 95% CI: -0.78; -0.28). Stride width was significantly increased by ASI (P < 0.0001), independently of rhythm and stride length. CONCLUSIONS: ASI induced by a kyphotic corset was detectable on the optoelectronic system, leading to significant changes in gait kinematics. Locomotor parameters were significantly reduced. Balance parameters were significantly and directly altered by ASI.