How was spinal surgery activity maintained during the COVID-19 pandemic? Results of a French multicenter observational study.

INTRODUCTION: The French Society of Spinal Surgery (SFCR) offered guidelines during the COVID pandemic. The objective of this work was to report the organization and activity in spinal surgery during the first month of confinement across 6 centers in France. The secondary objective was to monitor the adequacy of our practices within the SFCR guidelines. MATERIAL AND METHODS: This prospective multicenter observational study reported spinal surgery activity in each institution from March 16 to April 16, 2020, as well as the organizational changes applied. Surgical activity was compared to that of the same period in 2019 in each center and evaluated according to the SFCR guidelines, in order to control the adequacy of our practices during a pandemic period. RESULTS: During the peak of the epidemic, 246 patients including 6 COVID-positive patients were treated surgically. The most significant drops in activity were found in Strasbourg (-81.5%) and Paris (-65%), regions in which the health situation was the most critical, but also in Bordeaux (-75%) despite less viral circulation. Operating rooms functioned at 20 to 50% of their normal capacity. There was a significant reduction in procedures for degenerative spine conditions or deformities, in line with the SFCR guidelines. CONCLUSION: Maintaining spinal surgery is possible and desirable, even in times of health crisis. The indications must be considered according to the emergency criteria developed by learned societies and adapted to health developments and to the technical possibilities of treatment, by center. LEVEL OF PROOF: IV.

Traumatic Fracture: Dislocation of Cervicothoracic Junction-Grand Round Presentation of C7-T1 Instabilities and Different Instrumentation Techniques.

INTRODUCTION: Acute traumatic cervicothoracic junction spinal lesions are rare disorders and poorly documented. We report a case of a traumatic cervicothoracic fracture-dislocation. We present our experience in the operative treatment of an unstable fracture-dislocation at the cervicothoracic junction. Materials and Method. A seventy-year-old man was transferred to our hospital. We found paresthesia in the corresponding dermatome of C7 and C8 bilaterally. Initial CT scan shows vertebral body fracture of T1 with retropulsion into the spinal canal and anteroposterior dislocation of cervicothoracic junction type C according to AOSpine subaxial injury. Traumatic disc material at C7-T1 was removed by anterior cervical discectomy and fusion of C6-T2. Fixation was done from C6 to T2 in the prone position. RESULTS: At one-year postoperative follow-up, radiographs revealed bony fusion at the level of C7-T1, and the patient had no major functional disability. CONCLUSION: We opted for the ventral-dorsal approach in our case for maximum stabilization and to prevent mechanical complications.

Anterior Cervical Idiopathic Hyperostosis and Dysphagia: The Impact of Surgical Management-Study of a Series of 11 Cases.

OBJECTIVE: To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. METHODS: This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. RESULTS: Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9 patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. CONCLUSIONS: Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

Multiple-rod constructs in adult spinal deformity surgery for pelvic-fixated long instrumentations: an integral matched cohort analysis.

PURPOSE: Multiple-rod constructs (Multi-Rod: extra rods for additional pillar support) are occasionally used in adult spinal deformity (ASD) surgery. We aimed to compare and analyze the general outcome of multi-rod constructs with a matched two-rod cohort, to better understand the differences and the similitudes. METHODS: This is a retrospective matched cohort study including patients with ASD that underwent surgical correction with long posterior instrumentation (more than five levels), pelvic fixation and a minimum 1-year follow-up. Matching was considered with demographical data, preoperative radiographical parameters, preoperative clinical status [health-related quality-of-life (HRQoL) scores] and surgical characteristics (anterior fusion, decompression, rod material, osteotomies). Postoperative radiographical and clinical parameters, as well as complications, were obtained. Univariate and multivariate analysis was performed regarding postoperative improvement, group variables comparison and parameters correlation. RESULTS: Thirty-three patients with multi-rod construct and 33 matched with a two-rod construct were selected from a database with 346 ASD-operated patients. Both groups had a significant improvement with surgical management in the radiographical and HRQoL parameters (p < 0.001). Differences between groups for the postoperative radiographical, clinical and perioperative parameters were not significant. Rod breakage was more frequent in the two-rod group (8 vs 4, p = 0.089), as well as the respective revision surgery for those cases (6 vs 1 p = 0.046). Risk factors related to revision surgery were greater kyphosis correction (p = 0.001), longer instrumentation (p = 0.037) and greater sagittal vertical axis correction (p = 0.049). CONCLUSION: No major disadvantage on the use of multi-rod construct was identified. This supports the benefit of using multi-rod constructs to avoid implant failure. These slides can be retrieved under Electronic Supplementary Material.

Traumatic posterior Atlanto-axial dislocation: case report of an atypical C1-C2 dislocation with an anterior arch fracture of C1.

BACKGROUND: An atypical case of a traumatic posterior C1-C2 dislocation with an anterior arch fracture of C1 is reported. A novel conservative treatment for this rare lesion is described. CASE PRESENTATION: An eighty-nine-year-old male fell off a ladder at home and presented with an acute traumatic cervical spine trauma, which we believe involved a distraction mechanism. The patient was neurologically intact; he denied any weakness, numbness or paresthesia. A preoperative CT-scan demonstrated a posterior dislocation with an anterior arch of C1 fracture. Conservative management was elected. Reduction was achieved by closed manual reduction under general anesthesia. A postoperative CT demonstrated a complete reduction of the atlanto-axial dislocation. CONCLUSION: Based on this case report and relevant literature, we present an unusual lesion of the upper cervical spine treated nonoperatively with closed manual reduction under general anesthesia. To date, there is no available consensus for the management of these lesions.

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.

Malignant triton tumor: Grand Round presentation of a rare aggressive case thoracolumbar spine tumor.

INTRODUCTION: We report a rare and aggressive case of malignant triton tumor (MTT) at the thoracolumbar junction with foraminal extension mistreated as schwannoma. MATERIALS AND METHODS: A 70-year-old man with a 2-year history of lower back pain and left L4 radiculopathy with no history of neurofibromatosis. RESULTS: Pre-operative MRI suggested a typical schwannoma. Upon complete marginal resection, histological findings revealed a MTT. The patient presented with a local and regional recurrence and died 10 months after surgery. MTTs are a subgroup of malignant peripheral nerve sheath tumors, which develop from Schwann cells of peripheral nerves or within existing neurofibromas, and display rhabdomyoblastic differentiation. CONCLUSION: Based on the Grand Round case and relevant literature, we present a case of a highly aggressive and fast-growing tumor with a very high local and distant recurrence. There is no consensus treatment plan available and patients usually die shortly after diagnosis.

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.

Radiographic Classification for Degenerative Spondylolisthesis of the Lumbar Spine Based on Sagittal Balance: A Reliability Study.

STUDY DESIGN: Inter- and intraobserver reliability study. OBJECT: To assess the reliability of a new radiographic classification of degenerative spondylolisthesis of the lumbar spine (DSLS). SUMMARY OF BACKGROUND DATA: DSLS is a common cause of chronic low back and leg pain in adults. To this date, there is no consensus for a comprehensive analysis of DSLS. The reliability of a new DSLS classification system based on sagittal alignment was assessed. METHODS: Ninety-nine patients admitted to our spinal surgery department for surgical treatment of DSLS between January 2012 and December 2015 were included. Three observers measured sagittal alignment parameters with validated software: segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Full body low-dose lateral view radiographs were analyzed and classified according to three main types: Type 1A: preserved LL and SL; Type 1B: preserved LL and reduced SL (≤5°); Type 2A: PI-LL ≥10° without pelvic compensation (PT <25°); Type 2B: PI-LL ≥10° with pelvic compensation (PT ≥25°); Type 3: global sagittal malalignment (SVA ≥40 mm). The three observers classified radiographs twice with a 3-week interval for intraobserver reproducibility. Interobserver reproducibility was calculated using Fleiss κ and intra-class coefficient. Intraobserver reproducibility was calculated using Cohen κ. RESULTS: Mean age was 68.8 ± 9.8 years. Mean sagittal alignment parameters values were the following: PI: 60.1° ± 12.7°; PI-LL was 12.2° ± 13.9°, PT: 24.7° ± 8.5°; SVA: 44.9 mm ± 44.6 mm; SL: 16.6° ± 8.4°. Intraobserver repeatability showed an almost perfect agreement (ICC > 0.92 and Cohen κ > 0.89 for each observer). Fleiss κ value for interobserver reproducibility was 0.82, with percentage agreement among observers between 88% and 89%. CONCLUSION: This new classification showed an excellent inter- and intraobserver reliability. This simple method could be an additional sagittal balance tool helping surgeons improve their preoperative DSLS analysis.

Paraspinal hibernoma: Grand Round presentation of a rare benign adipocytic tumor.

INTRODUCTION: We report an uncommon case of paraspinal hibernoma with a T12-L1 foraminal extension and discuss the potential differential diagnoses of paraspinal adipocytic tumors. MATERIALS AND METHODS: A 32-year-old woman consulted our department with a right subscapular and paraspinal mass. There was no associated neurological deficit. The MRI revealed a paraspinal adipocytic tumor with a T12-L1 right foraminal extension. Percutaneous biopsy suggested a diagnosis of hibernoma. RESULTS: Hibernoma is a rare and benign adipocytic tumor arising from embryologic remnants of brown fat. Specific MRI findings are discussed to differentiate hibernoma from other soft-tissue tumors. A planned marginal resection was undertaken with the final histopathology confirming the diagnosis of hibernoma. CONCLUSION: Based on the Grand Round case and relevant literature, we discuss a rare case of paraspinal hibernoma with a foraminal component and no recurrence at 3-year follow-up.

A new classification system for degenerative spondylolisthesis of the lumbar spine.

PURPOSE: There is no consensus for a comprehensive analysis of degenerative spondylolisthesis of the lumbar spine (DSLS). A new classification system for DSLS based on sagittal alignment was proposed. Its clinical relevance was explored. METHODS: Health-related quality-of-life scales (HRQOLs) and clinical parameters were collected: SF-12, ODI, and low back and leg pain visual analog scales (BP-VAS, LP-VAS). Radiographic analysis included Meyerding grading and sagittal parameters: segmental lordosis (SL), L1-S1 lumbar lordosis (LL), T1-T12 thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Patients were classified according to three main types-1A: preserved LL and SL; 1B: preserved LL and reduced SL (≤5°); 2A: PI-LL ≥10° without pelvic compensation (PT < 25°); 2B: PI-LL ≥10° with pelvic compensation (PT ≥ 25°); type 3: global sagittal malalignment (SVA ≥40 mm). RESULTS: 166 patients (119 F: 47 M) suffering from DSLS were included. Mean age was 67.1 ± 11 years. DSLS demographics were, respectively: type 1A: 73 patients, type 1B: 3, type 2A: 8, type 2B: 22, and type 3: 60. Meyerding grading was: grade 1 (n = 124); grade 2 (n = 24). Affected levels were: L4-L5 (n = 121), L3-L4 (n = 34), L2-L3 (n = 6), and L5-S1 (n = 5). Mean sagittal parameter values were: PI: 59.3° ± 11.9°; PT: 24.3° ± 7.6°; SVA: 29.1 ± 42.2 mm; SL: 18.2° ± 8.1°. DSLS types were correlated with age, ODI and SF-12 PCS (ρ = 0.34, p < 0.05; ρ = 0.33, p < 0.05; ρ = -0.20, and p = 0.01, respectively). CONCLUSION: This classification was consistent with age and HRQOLs and could be a preoperative assessment tool. Its therapeutic impact has yet to be validated. LEVEL OF EVIDENCE: 4.

Is it safe to perform lumbar spine surgery on patients over eighty five?

PURPOSE: The purpose of this study was to evaluate the safety and tolerance of lumbar spine surgery in patients over 85. MATERIALS AND METHODS: Patients over 85 years of age with LSS who underwent decompression surgery with or without fusion between February 2011 and July 2014 were included. Comorbidities, autonomy (Activities of Daily Life and Braden scales), surgical parameters and complications (Clavien-Dindo classification) were collected. A telephone survey was performed to assess survival and patients' satisfaction at last follow-up. RESULTS: Mean follow-up was 27.4 ± 7.6 months (range, 18-65). Mean age was 87.5 ± 2.7 years (range, 85-97). Mean ADLs and Braden scores were, respectively, 4.3 ± 1.2 and 20.2 ± 1.4. Fifteen patients had associated spondylolisthesis. Nineteen minor complications (grade I and II, 38.7%), five moderate complications (grade III, 10.2%) and six major complications (grade IV and V, 12.2%) occurred. The perioperative mortality rate was 0.02%. At last follow-up, 41 patients were very satisfied (83.7%), five patients were satisfied (10.2%) and three patients were not satisfied (6.1%). Fusion did not affect the incidence of complications (p = 0.3) nor the average number of complications per patient (p = 0.2). CONCLUSION: Advanced age should not be a contraindication to lumbar spine surgery provided careful preoperative selection is performed. This study reported a high satisfaction rate and a low mortality rate at the price of a high number of complications, most of which being minor.

Bone substitutes in adolescent idiopathic scoliosis surgery using sublaminar bands: is it useful? A case-control study.

INTRODUCTION: In order to avoid pseudarthrosis in adolescent idiopathic (AIS) patients, it is recommended to bring additional bone graft or substitute. Modern rigid instrumentations have been shown to provide less pseudarthroses even without bone substitutes. The aim of our study was to determine the impact of using bones substitutes on fusion rates in adolescent idiopathic scoliosis patients undergoing PSF with sublaminar bands. METHOD: AIS patients scheduled to undergo PSF with sublaminar bands were prospectively enrolled into this study and not given any bone substitutes (no-substitute group). Data were collected and analyzed in patients with at least two years of follow-up. Pseudarthrosis was diagnosed if at least one of the following was present: persistent back pain, hardware failure, loss of correction greater than 10°. The results were compared to a control group who received bone substitutes for the same surgical procedure. RESULTS: Eighty-eight patients were included. For the whole cohort, the mean age was 14.8 years old and the mean follow-up was 30.9 months. For the 'no-substitute' group (n = 44), the mean Cobb angle was 56° pre-operatively, 20.1° post-operatively, and 22° at final follow-up. The fusion rate was not statistically different between the two groups (97.7% vs 95.5%, p = 0.56). At last follow-up, one pseudarthrosis occurred in the 'no substitute' group and two in the control group. DISCUSSION: This is the first study to determine the impact of bone substitutes in AIS fusion using sublaminar bands. In our study, the use of local autologous bone graft alone resulted in a fusion rate of 97.7% despite the use of more flexible instrumentation. The high rate of fusion in AIS patients is more probably due to the healing potential of these young patients rather than to the type of instrumentation. CONCLUSION: The use of additional bone graft or bone substitutes may not be mandatory when managing AIS. LEVEL OF EVIDENCE: 4.

One-Level Lumbar Degenerative Spondylolisthesis and Posterior Approach: Is Transforaminal Lateral Interbody Fusion Mandatory?: A Randomized Controlled Trial With 2-Year Follow-Up.

STUDY DESIGN: A monocentric open-label randomized controlled trial (MRCT). OBJECTIVE: Comparison of clinical and radiological outcomes between isolated instrumented posterior fusion (PLF) and associated instrumented posterior fusion and interbody fusion by transforaminal approach (PLF + TLIF) for patients suffering from one-level lumbar degenerative spondylolisthesis (DS) undergoing surgery. SUMMARY OF BACKGROUND DATA: DS is a common cause of symptomatic lumbar stenosis. PLF has shown better clinical outcome than decompression with noninstrumented posterolateral fusion. TLIF with interbody cage showed better fusion rate than PLF. There is a need for randomized controlled trials to compare PLF with and without TLIF as to clinical and radiological outcomes. METHODS: This is a MRCT comparing PLF and TLIF techniques in surgical treatment of DS. Sixty patients were included in a secured database from 2009 to 2011 and randomized into two groups: 30 PLF with posterior pedicle screws and intertransverse autologuous graft, and 30 TLIF in which an interbody fusion by transforaminal approach was added. Data included clinical (pain and disability), surgical (blood loss and operating time), and radiological (alignment and fusion) parameters at baseline and 2-year follow-up. Comparison was made by Student t test and Chi-square test. RESULTS: There was a significant improvement in each group for pain and disability but no difference between the groups. Radiographic assessment showed better posterolateral fusion rate for TLIF without superiority in segmental lordosis improvement. A case of deformity cascade with spino-pelvic mismatch at baseline was noted in PLF. CONCLUSION: Posterior decompression and instrumented fusion is an efficient technique that proved its significant clinical benefit in the surgical treatment of DS. TLIF did not show its superiority neither in clinical nor alignment parameters despite a better fusion rate. These results suggest that TLIF is not mandatory in this specific indication. Sagittal alignment analysis by standing full-body images should be considered in DS care. LEVEL OF EVIDENCE: 2.