Team management in complex posterior spinal surgery allows blood loss limitation.

PURPOSE: The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding. METHODS: We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( -)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL. RESULTS: One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p < 0.05; OR 3.38) and performing a PSO (p < 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p < 0.05; OR 2.48) and higher BMI (p < 0.05; OR 2.15) were associated to a more significant post-operative HBL. CONCLUSION: With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.

Computed Tomography Intraoperative Navigation in Spinal Surgery: Assessment of Patient Radiation Exposure in Current Practices.

BACKGROUND: Patient radiation exposure associated with the use of computed tomography (CT) navigation during spinal surgeries was widely compared with other intraoperative imaging techniques. The aim of this study is to explore the use of navigation with regard to current spinal surgery practices and the technical limitations of such imaging systems. METHODS: Dosimetric data from 101 patients who underwent intraoperative, CT-navigated spine surgery were retrospectively collected. The study population was divided into 3 groups according to the primary surgical indication. The number of CT image acquisitions per patient, the field length, and the time of exposure per acquisition during a single surgery were compared as well as the radiation dose emitted to patients. RESULTS: Dose-length products (DLP) per acquisition were 678.52, 656.8, and 649.36 mGy·cm with no significant difference for spinal deformity (SD), degenerative disease (DD), and vertebral fracture (VF) procedures, respectively. Analyzing the number of CT image acquisitions per patient revealed that repeated intraoperative scans were often performed for patients who were suffering from an SD due to technical limitations of the navigation. As a consequence, the cumulative dose was higher in the SD group (DLP total = 1175 mGy·cm) than in the DD (DLP total = 762.74 mGy·cm) and VF (DLP total = 649.36 mGy·cm) groups. CONCLUSIONS: CT navigation is an efficient intraoperative imaging technique that reduces the rate of surgical complications, but its technical limitations lead to an increased risk of patient radiation exposure, especially for complex surgeries where multiple scanning acquisitions are needed. CLINICAL RELEVANCE: To avoid patient's overexposure, spine surgeons should minimize the number of intraoperative acquisitions while considering the complexity of the surgery and the limitations of the guidance system. The use of dual guidance systems has also to be considered according to the benefit-risk balance between patient's outcomes and radiation dose exposure.

Original Surgical Treatment and Long-term Follow-up for Chronic Inflammatory Demyelinating Polyradiculoneuropathy Causing a Compressive Cervical Myelopathy: Review of the Literature.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic relapsing disease of unknown aetiology. The diagnosis of this disease is still very complicated. The treatment is medical but, in some cases, a surgical decompression might be required. In rare cases it develops a radicular hypertrophy that can cause a cervical myelopathy; this pathology should be put in differential diagnosis with neurofibromatosis 1 and CharcotMarie-Tooth (CMT) syndromes. The cases of CIDP cervical myelopathy reported in the literature are rare and even more rarely a surgical decompression was described. Here we report a first and unique case of CIDP cervical myelopathy treated with an open-door laminoplasty technique with 10-year postoperative follow-up (FU). The surgical decompression revealed to be effective in stopping the progression of myelopathy without destabilizing the spine. The patient that before surgery presented a severe tetraparesis could return to walk and gain back his self-care autonomy. At 10-year FU he did not complain of neck pain and did not develop a cervical kyphosis. In case of cervical myelopathy caused by radicular hypertrophy, CIDP should be kept in mind in the differential diagnosis and an open-door laminoplasty is indicated to stop myelopathy progression.

A painful unknown: sacroiliac joint diagnosis and treatment.

The sacroiliac joint (SIJ) is a complex anatomical structure located near the centre of gravity of the body.Micro-traumatic SIJ disorders are very difficult to diagnose and require a complete clinical and radiological examination.To diagnose micro-trauma SIJ pain it is recommended to have at least three positive provocative specific manoeuvres and then a radiologically controlled infiltration test.Conservative treatment combining physiotherapy and steroid injections is the most common therapy but has a low level of efficiency. SIJ thermolysis is the most efficient non-invasive therapy.SIJ fusion using a percutaneous technique is a solution that has yet to be confirmed on a large cohort of patients resistant to other therapies. Cite this article: EFORT Open Rev 2020;5:691-698. DOI: 10.1302/2058-5241.5.190081.

Mismatch between rod bending and actual post-operative lordosis in lumbar arthrodesis with poly axial screws.

BACKGROUND: The question of rod bending is essential during posterior lumbar fusion. The role of posterior instrumentation during spinal surgery remains to be defined. Despite an appropriate bending, a mismatch between rod lordosis and lumbar lordosis can occur. There is no study on the link between rod bending and lordosis. The purpose of this study was to evaluate parameters that explain the mismatch between lumbar lordosis and rod bending in lumbar surgery using polyaxial screws. HYPOTHESIS: Radiological parameters explain the mismatch between the rod and the lordosis. METHODS: This study was monocentric, retrospective, descriptive and analytic. All patients with posterior L3L5 fusion in an university-affiliated hospital in 2017 were included. Patients with past surgical history of anterior fusion on the levels L3L5, Coronal malalignment with a Cobb angle superior to 5°, the use of dynamic fixation systems were excluded. We measured on immediate post-operative standing profile x-ray: pelvic incidency, lumbar lordosis, lordosis of the instrumented segment, the distance between posterior wall and rod (EcarT) which reflect how homogeneously the screws are put in depth, the angle between screw and rod (thetaMA), the angle between screw and superior endplate (lambdaMA), the rod lordosis. Univariate and multivariate analysis were conducted to see if there was a link between all those parameters and the mismatch: vertebral lordosis-rod lordosis. RESULTS: A total of 74 patients were included, mean age was 67. Eighteen were 360° fusion and 56 were postero-lateral fusions. There was no statistical association between demographic data, pelvic parameters, use of interbody devices and the mismatch. There was a statistical association between thetaMA, lambdaMA, EcarT and the mismatch (P<0,0001). A multivariate linear regression model was developed to create a new index: Mismatch analysis index. CONCLUSION: Our study is the first on the link between rod bending and lumbar lordosis. Three radiologic factors are involved in not obtaining the planned lordosis in short lumbar fusion with polyaxial screws. Two factors depend on the way the surgeon positions screw parallel to the superior vertebral endplate(lambdaMA), and with a homogeneous depth (EcarT). And the last factor: ThetaMA is depending on the surgical technique (compression on screws, osteotomies, monoaxial screws, use of interbody devices). LEVEL OF EVIDENCE: IV.