Surgery of the deformities in ankylosing spondylitis: our experience of lumbar osteotomies in 31 patients.

Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery for rare indications. The authors report 31 lumbar osteotomies. The goal is to correct the deformity through a posterior limited approach and to minimise the neurological risks. The modifications developed by the authors for monosegmental closing wedge osteotomies are explained. The posterior resection is rhomboid shaped with a bilateral lamina removal. An osteotomy is performed in a forwards direction on the lateral aspects of the vertebral body without bone resection. This osteoclasty allows progressive vertebral body compression. Pediclectomy is associated if the corresponding foramen at the osteotomy level becomes too narrow in the process of redressing the spine. The resection level is adjusted so that superior and inferior posterior arches come into contact with a good compression. The authors point out the risk of lateral translation. Before the osteotomy, the two adjacent vertebrae are implanted with 5-mm cylindrical pedicular screws, so that posterior fixation can be carried out at any time. Posterior monobloc fixation allows for very great compression of the osteoclasty. The authors compare the results of their experiences in opening and closing osteotomy. They progressively changed their technique for closing osteotomies, because of published vascular complications and mechanical risks (instability and pseudarthrosis in opening osteotomies). Closing osteotomy also minimises the risk of stenosis with radicular compression or traction if an important correction is performed. The level of the osteotomy varied in this series, which had a correction rate of up to 75 degrees. The choice of level depends on secondary effects on pelvic position and projection of the centre of gravity. The preferred procedure remains a monosegmental correction because it is faster and easier, with minimum bleeding. Short monobloc posterior fixation is sufficient to maintain reduction and to obtain stability from posterior compression.

Dynamic anatomy of the acetabulum: an experimental approach and surgical implications.

The deformations and stresses acting on the acetabular rim have not been very precisely documented. The authors present a study based on an experimental simulation of hip loading with anatomic correlations. 122 dissections were performed in order to define the anatomic aspect of the roof (and especially of Byers's "area 17") and the intermediate area between the anterior and posterior acetabular cornua. Ten fresh cadavers were tested on the lines of previous studies on monopodal or bipodal loading. An extensometric study was performed with special attention to the transverse acetabular ligament, supra-acetabular area and obturator foramen. The area 17 of Byers is a transitional zone and the mobility of the posterior cornu is 3 times that of the anterior cornu. Resection of the acetabular ligament modifies the displacement of the posterior cornu under loading but has no influence on deformation of the oburator foramen. The biomechanical behavior of the acetabular roof in the standing position is influenced by the conditions of monopodal or bipodal loading and by femoral rotation, but a tendency to extrusion was constantly noted.

[Extensive pseudotumoral lumbar spine lesions of vascular origin]. / Lésions extensives rachidiennes lombaires pseudo-tumorales d'origine vasculaire.

Extensive remodeling of the anterior aspect of the lumbar spine was observed in two patients with a ruptured aneurysm of the abdominal aorta. Both patients survived as the rupture was contained in the first case and involved a false anastomotic aneurysm in the second. The patients presented with a clinical picture compatible with advanced stage cancer and a radiologic aspect showing anterior erosion of the vertebral bodies, suggestive of very advanced spondylodiscitis. The diagnosis was made on the basis of ultrasound and CT-scan evidence. There was no parallel relationship between the size of the ectasia and the spinal remodelling. A hypothetical pathogenic mechanism involving the intermittent pulsation of the aneurysm and ischaemia of the vertebral bone is proposed.

[Destabilization after surgical treatment of narrow lumbar canal: when should arthrodesis be performed?]. / Déstabilisation après cure chirurgicale de canal lombaire étroit: quand faut-il faire une arthrodèse?

Post-operative spine displacement occurs by excessive or aggravated vertebral sliding. Sex and age, anatomics factors (pre-operative displacement, intersomatic discs quality, hyperlordosis) and operative factors (extensive laminectomy, artherectomy) are predisposing factors. The risk of post-operative vertebral displacement is calculated by a fine pre and per-operative analysis of these pre-disposing factors: Tolerance to post-operative spinal displacement cannot be foreseen and surgical recovery may be difficult whenever.

[Surgical treatment of symptomatic thoracic disk hernia: anterior or posterolateral approach?]. / Traitement chirurgical des hernies discales dorsales symptomatiques: abord antérieur ou postéro-latéral?

From 1981 to 1994, 16 patients with 18 thoracic disk hernias due to degenerative disease (n = 13), trauma (n = 4) or Scheuermann's disease (n = 1) received surgical treatment. Most were situated from T6 to T12. There were 10 medial hernias and 8 lateral hernias. Symptom duration was a mean 23 months at surgery including spinal pain (n = 13) and spinal syndrome (n = 9). Posterolateral access was used in 13 cases and the anterior route in 2, both requiring a graft. After a follow-up of 5 years 1 month, functional and subjective results were excellent or good in 83% of the cases, acceptable in 6% and poor in 11%. Two failures with the posterolateral route corresponded to one patient with initial trauma-induced paraplegia and another with neurological aggravation after the first laminectomy. In our experience, the posteriolateral route is preferred to allow good visual control even in cases involving several levels. Secondary laminectomy may be performed without risking displacement. The presence of the Adamkiewicz artery on the same side and at the same level dictates use of the anterior route which may soon be replaced by video-assisted thoracoscopy to avoid resection of the rib.

[Surgery of the upper cervical spine in rheumatoid arthritis. Indications and results apropos of 28 cases]. / La chirurgie du rachis cervical supérieur dans la polyarthrite rhumatoïde. Indications et résultats à propos de 28 cas.

PURPOSE OF THE STUDY: The goal of this study was to precise indications and surgical techniques for stabilisation with or without decompression of the upper cervical spine instability in rheumatoid arthritis. MATERIAL AND METHODS: 28 patients presenting upper cervical spine disease have been reviewed (mean age 57 years). These patients had been suffering from severe diffuse arthritis during an average of 14.5 years. The anterior atlanto-axial dislocation was most frequent (25 times), 1 posterior dislocation and 2 vertical dislocations. Odontoid lysis was noted 19 times. A subluxation of the lower cervical spine was present in 12 patients. SURGICAL TECHNIQUE: C1-C2 arthrodesis was performed 12 times (9 times with a loop wire and 3 isthmo-pedicular screws C2-C1), occipito-cervical arthrodesis with plates 16 times. Operative traction was necessary 5 times. The associated surgical gestures included 3 times a laminectomy, 2 times an enlargement of the occipital foramen, 1 section of the Arnold nerve. In 2 patients was associated a fixation of the lower cervical spine. RESULTS: With an average of 27 months follow-up, functional results (classified according to Ranawat's criteria) were satisfactory in 14 patients, improved in 7 patients, unchanged in 4 and bad in 3. The reduction of the anterior displacement in 25 patients was complete 11 times, partial 17 times and null 3 times. The reduction of the vertical displacement was complete once, partial 3 times. Arthrodesis fusion was obtained in 19 cases, 5 times it was a fibrous union and 4 pseudarthrosis occurred, all with C1-C2 loop wire. The rate of complications was high: 2 infections on bone site grafting requiring reoperation, 2 infections with secondary septicemia after lack of reduction. DISCUSSION AND CONCLUSION: Occipito-cervical arthrodesis is necessary as soon as the patient presents neurological signs. When there is an anterior dislocation associated with vertical dislocation, if there is posterior dislocation in case of osteoporosis of the posterior C1-C2 arc, or destabilisation of the lower cervical spine. C1-C2 arthrodesis is suggested when there is no important neurological signs, when displacement is limited to a pure anterior dislocation and in young patient with good bone quality.

Post operative infections of the spine: technique, indications and results of the surgical treatment - A retrospective study of 90 cases.

Post operative infection in spine surgery is a well known complication. The authors studied a series of 90 patients in accordance with an homogenous strategy based on the excision of necrotic and infected tissues, associated with appropriate antibiotics.The results are analyzed according to the degree of infection (which is based on the type of germs and their associations), and type of patients, the delay in diagnosis and the anatomical extension of the infected lesions.Making a difference between superficial and deep infection is of no therapeutic value and may lead to wrong and inadequate treatment.One must separate the common infections (which are due to germs as staphylococcus aureus or others from the urinary or digestive tract), and severe infections (which are either due to a per operative massive and deep contamination, or associated with patient's poor general condition).This series is mainly about posterior approaches to the spine, with or without osteosynthesis. Technical problems for treatment depend on the site of infection, particularly at the thoracic kyphosis level, or at the lumbar level where the muscle necrosis can be extensive. At the cervical level, the infection of an anterior approach mandates a check on the respiratory and digestive tracts.Removing the osteosynthesis is not mandatory in post operative spinal infections, as it may induce severe mechanical destabilization. An anterior approach is not necessarily required in the case of a posterior infection, except with massive contamination of an anterior graft. In some cases, posterior lumbar interbody fusion can lead to the indication for anterior cage removal.Pseudarthrosis of an infected spine, initially treated to obtain fusion, is still the worst complication. In case of previous posterior infection, even a severe one, fusion can still be obtained through a secondary anterior or posterior approach for grafting, with or without osteosynthesis.In this series, there was no neurological complication due to infection.However, eight diceases occured in weak patients with neurological involvement. This points out the importance of the general treatment associated with the surgery, and the necessity of a thorough assessment. a thorough assessment.RéSUMé: Les infections post-opératoires représentent une complication largement documentée dans le domaine de la chirurgie du rachis. Les auteurs étudient une série de 90 patients traités selon une stratégie homogène basée sur l'excision des tissus nécrosés et infectés associée à l'utilisation d'un traitement antibiotique adapté. Les résultats sont analysés en fonction du degré d'infection (basé sur le type de germe et leurs associations) de l'état des patients, du délai pour le diagnostic et de l'étendue anatomique des lésions infectieuses. L'opposition entre infection superficielle et profonde semble sans intérêt sur le plan thérapeutique et peut conduire à un traitement insuffisant ou mal adapté.Il est important de séparer les infections classiques (qui sont dûes à des germes comme le staphylocoque doré ou d'autres germes provenant de la sphère urinaire ou digestive) et les infections sévères (qui sont soit dûes à une contamination per-opératoire massive et profonde ou associées à des patients dont létat général est déficient).Cette série est principalement basée sur les abord postérieurs du rachis avec ou sans ostéosynthèse. Les problèmes techniques pour le traitement dépendent du site de l'infection: aux niveaux thoracique et lombaire, la nécrose musculaire peut être très extensive. Au niveau cervical, l'infection d'un abord antérieur impose de vérifier l'intégrité du tractus aéro-digestif.L'ablation initiale du matériel n'est pas nécessaire dans beaucoup de cas d'infections post-opératoires car elle peut induire des destabilisations sévères et des complications mécaniques supplémentaires. Un abord antérieur n'est pas forcément nécessaire en cas d'infection postérieure mises à part les contaminations massives d'une greffe antérieure ou une infection d'une cage intervertébrale réalisée pour une fusion intersomatique par voie postérieure.La pseudarthrose des greffes sur un rachis infecté qui a été traité initialement pour obtenir une fusion reste encore la plus sévère des complications. Dans les cas d'infections postérieures même sévères, la fusion peut être encore obtenue secondairement grâce à un abord antérieur ultérieur ou même un abord postérieur pour des greffes complémentaires avec ou sans ostéosynthèse.Dans cette série, les auteurs ne signalent aucune complication neurologique dûe à l'infection. Néanmoins, 8 décès sont à déplorer chez des patients fragiles avec signes neurologiques initiaux. Ceci souligne l'importance du traitement général associé à la chirurgie et la nécessité d'un bilan complet de ces malades.

[Spinal metastases of thyroid origin. Apropos of a series of 37 cases]. / Métastases rachidiennes d'origine thyroïdienne. A propos d'une série de 37 cas.

PURPOSE OF THE STUDY: Define a specific therapeutic for spinal metastasis from thyroidal origin. MATERIAL: A retrospective series of 37 patients treated between January 1978 and January 1993 was made. The sex ratio was 29 women for 8 men with an average age of 59.5. The prevalent histology has a vesicular type (19 cases which represents 51 per cent). The metastasis are mostly found at the dorsal level (48.6). METHODS: The different parameters analysed for this study of 37 patients were: invaded segment of the vertebra (anterior, middle, posterior or total), Tokuhashi score, epiduritis extent, patient age, histological type and iodiosensibility. RESULTS: Out of 37 patients, 3 were lost for follow-up, 7 metastasis were treated carcinologically ("en bloc" resection). 30 were treated palliatively depending on the clinical symptoms: neurological, mechanical, or pain. The osseous metastasis exists in 56 per cent of the cases at the time the primitive neoplasy was discovered, and their presence burdens the final prognostic. 21 patients died with an average survival of 21 months, 13 patients survived with a mean follow-up of 50 months, 50 per cent of the patients had a vertebra totally involved with only 13 patients with neurological signs (4 Frankel A, 3 Frankel B, 4 Frankel C and 2 Frankel D). DISCUSSION: The analysis of the results shows that the pejorative criteria in case of vertebral metastasis of thyroidal cancer are the score of Tokuhashi inferior to 7, the whole affected vertebra, the epiduritis on 3 levels, the age of the patient superior to 65 and the idiosensibility of the metastase. The surgery do called carcinological gives very good results with 5 surviving patients out of 7. CONCLUSION: When reading this study it seems that, in front of vertebral metastasis from thyroidal origin, we should choose the most radical therapeutic attitude as much as possible. This strategy finds its justification by the fact that the thyroidal cancer spreads out slowly giving a survivorship superior to 12 months in case of metastatic vertebral affection. The importance of the tumoral reduction is connected with the efficiency of the iodiotherapy (for differentiated histological types). This is a considerable adjuvant treatment for this kind of cancer.

Fracture of the occipital condyle: case report and review of the literature.

Fracture of the occipital condyle is a rare injury that can be easily overlooked. We report a patient with an occipital condyle fracture who presented with pyramidal syndrome and normal plain radiographs. The diagnosis was made by high-resolution computed tomographic scanning with sagittal and coronal reconstructions and magnetic resonance imaging. Surgical treatment was deferred because of spontaneous recovery. This fracture should be considered whenever a trauma patient presents neck pain and plain cervical spine radiographs show no abnormalities.

Haematological effects of postoperative autotransfusion in spinal surgery.

A prospective, randomized, controlled study was performed to determine the haematological and biochemical changes and clinical safety of postoperative autotransfusion (Solcotrans Orthopedic Plus system) in patients undergoing spinal surgery. Fifty patients were studied and were randomly allocated to Control (n = 25) and Solcotrans (n = 25) groups. Both groups had their postoperatively drained blood collected into the Solcotrans reservoir but only the Solcotrans group had this salvaged blood considered for reinfusion. After a 5-h postoperative collection period, analysis of the shed blood showed a haematocrit of 0.26 +/- 0.11, few platelets (80 +/- 63 10g.l-1), a fibrinogen level of less than 0.1 g.l-1 and a high level of D-dimers. The salvaged blood did not clot and aerobic and anaerobic culture produced no growth. The volume of blood collected was greater than 200 ml in 21 patients in the Solcotrans group who were autotransfused (384 +/- 101 ml, range 200-600 ml), and in 16 patients in the Control group. Within 15 min following completion of reinfusion of the salvaged blood there was a significant, but moderate decrease in platelet count (181 +/- 74 vs 223 +/- 90 10g.l-1, P < 0.001) and fibrinogen concentrations (2.1 +/- 0.8 vs 2.3 +/- 0.9 g.l-1, P < 0.02), and an increase in circulating D-dimers (P < 0.001) and plasma free haemoglobin concentrations (236 +/- 155 vs 82 +/- 79 mg.l-1, P < 0.001). Prothrombin time (PT) and activated partial thromboplastin time (APTT) did not increase, and potassium concentrations were not significantly affected.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative autologous transfusion in emergency surgery for spine trauma.

Although numerous studies have reported the use of intraoperative blood salvage in elective spine, cardiac, and vascular surgery, very few have assessed its efficiency during emergency surgery after spine trauma. We therefore retrospectively analyzed 238 cases of patients with spine trauma who had emergency surgery. Three variables were significantly associated with the risk of perioperative blood transfusion: thoracolumbar spine injury, a preoperative hematocrit < 35%, and an Injury Severity Score > 20. Among the 118 patients who received blood transfusions, 53 benefitted from intraoperative blood salvage using the Cell-Saver apparatus (Cell-Saver group) and 65 did not (control group). The Cell-Saver enabled a 47% reduction in homologous blood requirements (743 +/- 1191 mL vs. 1403 +/- 1453 mL, p < 0.008) and a 45% reduction in the number of patients who received homologous blood (45% vs. 82%, p < 0.001). Between these two groups, no significant differences were observed in the evolution of hematocrit, platelet count, and hemostasis values, but a slight increase in postoperative blood loss was noted in the Cell-Saver group (465 +/- 383 mL vs. 301 +/- 292 mL, p < 0.01). In conclusion, the efficiency of intraoperative blood salvage in emergency surgery for spine trauma is high and similar to that previously reported in elective spine surgery. The cost-effectiveness of this technique may be improved by appropriate selection of the patient.

[Neurologic complications of surgery of the spine in adults]. / Complications neurologiques de la chirurgie du rachis de l'adulte.

Spine surgery exposes to neurological complications. There were 170 immediate complications of spine surgery at Pitiè-Salpétrière Hospital out of 2,855 reviewed (5.95%) during 9 years. The nature of the complication (radicular or medullar), severity and evolution were quite different but less than 2.76% where permanent. Among them, 1.43% were major neurological complications. The "high risk" etiologies were cervical stenosis and primitive malignant tumors. The major cause for these complications was due to surgical procedure in 60% of the cases.

[Reduction and osteosynthesis with pin fixation of wrist fractures. A comparative study between Kapandji's and Py's techniques]. / Réduction et synthèse par brochage des fractures du poignet. Etude comparative entre la technique de Kapandji et la technique de Py.

MATERIAL: 62 fractures of the distal radius were treated by pin fixation: Kapandji's intra focal pinning in 28 cases (Group "K") and Py's elastic pinning in 34 cases (group "P"). The two groups were comparable as to the type of fractures (Castaing classification). Theoretical principles were analyzed and compared. RESULTS: Final radiographic results showed the same proportion (75 per cent) of anatomic reduction in both groups. There were 21.4 per cent (6/28) hyporeductions in group K, and 23.5 per cent (8/34) hypereducations in group P. Hyporeduction was moderate with good functional results. Hypereduction in group P was often associated with bad functional results, 5 out of the 6 bad results of all the cases. The functional result, with a follow up of 7 months (4 to 10), was 76 per cent of excellent and good results, 85 per cent in group K, 70 per cent in group P. DISCUSSION: Kapandji's technique seemed more reliable than Py's technique. We propose a technical variation to minimize hyporeduction in Kapandji's technic: increasing the pin's angulation. CONCLUSION: Py's technic conserves one indication: intra operative failure of Kapandji's technique in very osteoporotic bone.

[Somatosensory evoked potentials during spinal orthopedic surgery in adult patients]. / Potentiels évoqués somesthésiques au cours des interventions orthopédiques sur le rachis de l'adulte.

Somatosensory evoked potentials (SEPs) were recorded in 165 patients from 185 operations for scoliosis and major spinal distortions, lumbar or cervical stenosis, post-traumatic malunions, or tumors. They were obtained by percutaneous stimulation of right and left median and tibial posterior nerves, and recorded on the scalp as recently, motor potentials (MPs) have also been obtained, by a trans-spinous stimulation rostral to the level of intervention. The protocol consists of pre- and post-operative recordings, as well as a continuous intra-operative monitoring. Neuromonitoring is justified in operations implying neurological risks, particularly scoliosis. A durable disappearance of SEPs and MPs was always associated with post-operative neurological disorders. Transient disappearances, not associated with neurological disorders, have been observed during certain manoeuvres such as vertebral traction, osteosynthesis, placing trans-pedicular screws or hooks, leading the surgeon to modify the operation. The role of medullary ischemia on the degradation of electrophysiological signals, obvious in cardiovascular decompensations, seems predominant in the post-operative occurrence of neurological impairment. During the post-operative period, SEPs allow one to discriminate between organic disorders and subjective complaints; they help in diagnosing hematomas, and distinguish between radicular and spinal cord injuries.

Partial cervicosternotomy: a useful anterior surgical approach to the cervicothoracic junction.

Access to the cervicothoracic junction, whether by lower anterior cervical or transthoracic approach, is particularly difficult. The authors propose partial cervicosternotomy which allows the T3-T4 disk to be reached satisfactorily in 50% of cases and in the remaining 50% allows direct anterior control of the upper two thirds of T3. The advantage of this approach is that it provides direct access to the cervicothoracic junction without leading at the same time to the reconstruction problems caused by the uni- or bilateral sternoclaviculotomies proposed until now. A detailed anatomical study of the arrangement of the intercostal vessels shows that this strictly median approach presents no risk to the medullary vessels thanks to the abundant anastomoses in this region. However, the use of this method may be limited if the aortic vessels have an anomalous origin. Pre-operative angiography is therefore necessary each time T3 must be reached. This approach has already been successfully used in tumor surgery for excision and reconstruction of lesions involving the cervicothoracic region.

[Deformations of acetabulum with load before and after prosthetic implantation. An experimental study by extensometry]. / Les déformations du cotyle en charge avant et après l'implantation prothétique. Etude expérimentale par extensométrie.

Using fresh cadavers pelves, an experimental model of unipodal stance was performed. The skeleton (femurs, pelvis and 2 lumbar vertebrae) was connected to the machine by non constrained junctions. Muscles (gluteus, iliacus and rectus abdominis) were simulated. Using this model, monopodal stance could be maintained under load. Strain measurements were performed on the periphery of the acetabulum. Results showed that periacetabular strains were dependent on the mobility of the lower lumbar intervertebral discs as well as on the type equilibrium (uni or bipodal). It was remarkable that the blockage of intervertebral rotations (experimental lombo-sacral arthrodesis) increased acetabular stiffness. The influence of total hip replacement was also studied. Periacetabular strains remained important around cementless press-fit cups. This would plead for a non weight bearing postoperative period in clinical practice of cementless arthroplasty. Important deformations also persisted around conventional cemented cups, justifying further research to limit periacetabular deformations around total hip prostheses, in the hope of limiting the rate of late acetabular loosening.

[Effects of postoperative autotransfusion in prosthetic surgery of the hip with the ConstaVac device]. / Effets de l'autotransfusion postopératoire au cours de la chirurgie prothétique de hanche avec le dispositif ConstaVac.

A new device for postoperative autotransfusion (ConstaVac, Stryker) was assessed after total hip replacement in 43 patients, mean age 63 +/- 13 years. Intraoperative blood was administered to 27 patients (63%), autologous blood only in 19, homologous blood only in 6 and both autologous and homologous blood in 2. The blood shed during an average 5-hour postoperative period had an haematocrit of 23 +/- 7% and included only few platelets (72 +/- 83 G.l-1). It did not clot as it contained there was less than 0.1 g.l-1 of fibrinogen and a high concentration of D-dimers. In 30 patients (70%), the amount of blood thus collected exceeded 200 ml. An average of 327 +/- 131 ml were subsequently retransfused to these patients. Postoperative autotransfusion induced a moderate but significant decrease in platelet counts (205 +/- 66 vs. 224 +/- 67 G.l-1, p < 0.02) and fibrinogen concentrations (2.3 +/- 0.7 vs. 2.4 +/- 0.6 g.l-1, p < 0.03), and an increase in circulating D-dimers (p < 0.001). Coagulation tests, free plasma haemoglobin and potassium concentrations were not significantly altered. Since the haematocrit of the blood lost was lower than that of the patients', the haematocrit did not increase significantly. Posttransfusion shivering occurred in two patients (7%). Bacteriological cultures of the lost blood and of venous samples obtained after postoperative autotransfusion remained sterile. Postoperative autotransfusion is a simple technique with few side-effects, which might be safely associated with other methods used to decrease the rate of homologous blood transfusion.

Treatment of lower cervical spinal injuries--C3 to C7.

Injuries of the lower cervical spine are categorized according to the morbid anatomy of the lesion. Most often, such injuries are successfully treated by surgery through a posterior approach. After anatomic restoration, internal fixation with plates and screws provides for stability and arthrodesis. Of 221 cases of lower cervical spine injuries, posterior stabilization was accomplished in 89%. There was no secondary displacement in 85% of cases.