[Radiation protection in spine surgery: an example of reliable and reproducible means]. / Radioprotection du personnel médico-soignant lors de chirurgie du rachis - Un exemple de moyen fiable et reproductible.

During spine surgery, the use of imaging is increasingly systematic, exposing medical and nursing staff to ionizing radiation, which is correlated with an increasing carcinogenic risk, as highlighted by the WHO. Robotic systems allow a decrease of this exposure but are expensive and complicated. Reliable, cost-effective, and simple alternatives including a radiographer specialized in radiation protection, a portable radiation shield and a modification of radioscopy system were evaluated in our facility. Surface (Hs), depth (Hp) and lens (Hc) exposure data were analyzed from April 2018 to April 2021. Our results are globally conclusive for all of them, with an average decrease of 47,2% for Hc.

Lors d'opérations du rachis, l'utilisation de l'imagerie est de plus en plus systématique, exposant le personnel médico-soignant aux rayonnements ionisants corrélés à l'augmentation du risque carcinogène, comme souligné par l'OMS. Les systèmes robotiques permettent une diminution de cette exposition mais sont coûteux et compliqués. Des alternatives fiables, rentables et simples, impliquant un technicien en radiologie spécialisé en radioprotection, un bouclier de protection portatif et une modification du système de radioscopie, ont été évaluées dans notre établissement. Les données concernant l'exposition en surface (Hs), en profondeur (Hp) et au cristallin (Hc) ont été analysées d'avril 2018 à avril 2021. Nos résultats sont concluants pour les trois valeurs, avec une diminution moyenne de 47,2 % pour Hc.

Radial Nerve Neuropraxis due to Compression by C-Arm Fluoroscopy in Spine Surgery: A Case Report.

INTRODUCTION: Peripheral nerve injury is a well-known surgical complication related to the position of the patient. Moreover, in spine surgery, prone position for prolonged period places the patient at increased risk. The aim of this study was to report a case of a radial nerve neuropraxis due to compression by C-arm fluoroscopy during spine surgery. Case Presentation. An 81-year-old-female underwent a posterior spinal fixation L2-S1 due to lumbar spinal stenosis. In the recovery room, she presented an hematoma at the posterolateral part of her arm associated with a wrist drop due to radial nerve neuropraxis. The patient was referred to an occupational therapist and fully recovered four months later. After analysis of the patient positioning during the intervention, we came to the conclusion that this radial nerve injury was very possibly due to a compression by the C-arm fluoroscopy during the surgery. CONCLUSION: Our case describes a rare case of compression of the radial nerve during lumbar spine surgery, which is an unexpected complication as the site of the nerve injury is not at all related to the surgery itself, but to the position of the patient. Although C-arm fluoroscopy is essential, spine surgeons should be aware of this possible complication related to its use in order to avoid it.

Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial.

BACKGROUND: The optimal duration of antibiotic therapy for treating orthopaedic implant infections after surgical drainage and complete implant removal is unknown. METHODS: This was a single-centre, unblinded, prospective trial randomizing (1:1) eligible patients to either 4 or 6 weeks of systemic, pathogen-targeted antibiotic therapy. Clinical trial registration number: ClinicalTrials.gov (NCT0362209). RESULTS: We analysed 123 eligible patients (62 in the 4 week antibiotic arm and 61 in the 6 week arm) in the ITT analysis. The patients' median age was 64 years, 75 (61%) were men and 38 (31%) were immunocompromised. The most common types of infection treated included: two-stage exchange procedure for prosthetic joint infection (n = 38); orthopaedic plate infection (44) and infected nail implants (11). The median duration of post-explant intravenous antibiotic therapy was 4 days. Overall, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. During follow-up, four patients had a clinical recurrence with a pathogen other than the initial causative agent. We noted recurrence of clinical infection in four patients in the 4 week arm and three patients in the 6 week arm (4/62 versus 3/61; χ2 test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment. CONCLUSIONS: We found no statistically significant difference in the rates of clinical or microbiological remission between patients randomized to only 4 compared with 6 weeks of systemic antibiotic therapy after removal of an infected osteoarticular implant.

[Adult scoliosis: surgical management]. / Scoliose de l'adulte : prise en charge chirurgicale.

Adult scoliosis is a common condition. Symptoms could be very debilitating. Surgical management requires a clear assessment of the functional impact of scoliosis, the failure of conservative treatments and precise analysis of radiological investigations (full spine views, dynamic X-rays and MRI). Surgical techniques (anterior and posterior approaches, minimal invasive techniques, osteotomies, all spine instrumentation) must be tailored to each patient. The main goals of surgery are treatment of symptoms, correction of deformity in coronal and sagittal plane and achievement of a solid fusion. Despite a high rate of complications, surgical treatment of adult scoliosis is associated with a better quality of life for patients.

La scoliose de l'adulte est une pathologie fréquente qui peut être très handicapante. La prise en charge chirurgicale, après échec des traitements conservateurs, nécessite une évaluation objective de l'impact fonctionnel de la scoliose pour le patient et une analyse systématique des investigations radiologiques (radiographie de colonne totale, clichés dynamiques et IRM). Les techniques chirurgicales (double abord, chirurgie mini-invasive, ostéotomies, longs montages) doivent être adaptées à chaque patient. Les buts principaux de la chirurgie sont de traiter les symptômes, corriger la déformation dans les plans coronal et sagittal, et obtenir une fusion solide. Malgré les complications potentielles, le traitement chirurgical de la scoliose permet d'offrir aux patients une meilleure qualité de vie.

Evaluation of the Modern Luque Trolley Construct for the Treatment of Early-onset Scoliosis Using a Gliding Implant in an Immature Animal Model.

STUDY DESIGN: This was an experimental animal study. OBJECTIVE: To determine biological compatibility, stability, and growth potential of the Trolley Gliding Vehicle (TGV) used in a novel surgical technique for guided spinal growth. SUMMARY OF BACKGROUND DATA: Current treatments for early-onset scoliosis maintaining spinal growth consist of posteriorly based spinal constructs requiring repetitive lengthening. Such interventions have a high rate of complications. Using a muscle-sparing technique, a modified dual-growing rods construct, and new sliding spinal anchors, we aimed to test a modern Luque Trolley construct in an immature animal model. MATERIALS AND METHODS: Six matched pairs of 3-month-old lambs were randomized to an observation or a surgical group and were followed for 9 months. The surgical group was subjected to implantation of a modern Luque Trolley construct with the new TGV inserted using a minimally invasive transmuscular technique capturing the spine and the 2 overlapping rods on either side. Physical examinations and imaging were performed at routine intervals, with a subsequent necropsy. RESULTS: The spines of the study group grew 96% between the instrumented segments compared with the control group without evidence of implant failure. In total, 42% of the fixed anchors (pedicle screws) and 13.90% of the TGV were loose. All 6 animals had some heterotrophic bone formation tracking along the rods (<20%) mainly originating from the distal anchor point. We identified 19 unplanned spontaneous facet arthrodesis out of the 132 mobile facets found between the fixed proximal and distal anchors. An additional 10 facets spontaneously fused proximal to the most proximal instrumented implants. CONCLUSIONS: Implantation of a modern Luque construct with TGV allows for spinal growth in a nonscoliotic animal model. Implant loosening was likely mechanical as no signs of reactive inflammatory reaction were found. Reduction of heterotrophic ossification and spontaneous facet arthrodesis remains a challenge in the management of immature spine.

Radiation exposure using the O-arm® surgical imaging system.

PURPOSE: This study was conducted to characterise the O-arm® surgical imaging system in terms of patient organ doses and medical staff occupational exposure during three-dimensional thoracic spine and pelvic examinations. METHODS: An anthropomorphic phantom was used to evaluate absorbed organ doses during a three-dimensional thoracic spine scan and a three-dimensional pelvic scan with the O-arm®. Staff occupational exposure was evaluated by constructing an ambient dose cartography of the operating theatre during a three-dimensional pelvic scan as well as using an anthropomorphic phantom to simulate the O-arm® operator. RESULTS: Patient organ doses ranged from 30 ± 4 µGy to 20.0 ± 3.0 mGy and 4 ± 1 µGy to 6.7 ± 1.0 mGy for a three-dimensional thoracic spine and pelvic examination, respectively. For a single three-dimensional acquisition, the maximum ambient equivalent dose at 2 m from the iso-centre was 11 ± 1 µSv. CONCLUSION: Doses delivered to the patient during a three-dimensional thoracic spine image acquisition were found to be significant with the O-arm®, but lower than those observed with a standard computed tomography examination. The detailed dose cartography allows for the optimisation of medical staff positioning within the operating theatre while imaging with the O-arm®.

Variables associated with remission in spinal surgical site infections.

BACKGROUND: There is few medical literature regarding factors associated with remission after surgical and medical treatment of postoperative spine infections. METHODS: Single-centre case-control study 2007-2014. Cluster-controlled Cox regression model with emphasis on surgical and antibiotic-related parameters. RESULTS: Overall, we found 66 episodes in 48 patients (49 episodes with metalwork) who had a median follow-up of 2.6 years (range, 0.5 to 6.8 years). The patients had a median of two surgical debridements. The median duration of antibiotic therapy was 8 weeks, of which 2 weeks parenteral. Clinical recurrence after treatment was noted in 13 episodes (20%), after a median interval of 2 months. In 53 cases (80%), the episodes were considered as in remission. By multivariate analyses, no variable was associated with remission. Especially, the following factors were not significantly related to remission: number of surgical interventions [hazard ratio (HR) 0.9; 95% confidence interval (CI), 0.8-1.1]; infection due to Staphylococcus aureus (HR 0.9; 0.8-1.1), local antibiotic therapy (HR 1.2; 0.6-2.4), and, duration of total (HR 1.0; 0.99-1.01) (or just parenteral) (HR 1.0; 0.99-1.01) antibiotic use. CONCLUSIONS: In patients with post-operative spine infections, remission is achieved in 80%. The number of surgical debridement or duration of antibiotic therapy shows no association with recurrence, suggesting that individual risk factors might be more important than the duration of antibiotic administration.

Treatment challenges associated with bone echinococcosis.

OBJECTIVES: In this literature review, we concentrate on epidemiology and therapy of osseous echinococcosis, with an emphasis on the recurrence risk. METHODS: Literature review 1930-2012. RESULTS: We retrieved 200 publications based upon single case reports or case series, mostly from resource-poor settings. Among the 721 rural patients (22% females; median age 37 years), 60% of all reported cases were from the Mediterranean region and almost all patients were immune competent. Echinococcus granulosus was identified as the most frequent species. Most infections involved a single bone (602/721; 83%) and often the spine (321 cases; 45%). In eight cases (8/702; 1%), a secondary bacterial surgical site infection was reported. Surgical intervention was performed in 702 cases (97%), with single intervention in 687 episodes (95%). Complete excision of the lesion was possible in only 117 episodes (16%). Albendazole was by far the most frequently used agent in monotherapy with various dosages, while mebendazole in monotherapy was less frequent (32 cases). The median duration of antihelminthic therapy was 6 months (range 0.7-144 months). There were 124 recurrences (17%) after a median delay of 2 years (range 0.4-17 years). In multivariate analysis, the presence of visceral organ involvement increased the odds of recurrence by 5.4 (95% CI 3.1-9.4), whereas the number of surgical interventions, the duration of antihelminthic therapy or the use of hypertonic saline did not influence recurrence. CONCLUSIONS: Bone echinococcosis is a rare parasitic disease. While treatment modalities vary considerably, combined surgical and medical approaches are the standard of care with a 17% risk of recurrence.

Epidemiology of adverse events and Clostridium difficile-associated diarrhea during long-term antibiotic therapy for osteoarticular infections.

OBJECTIVE: Osteoarticular infections require several weeks of antibiotic therapy, but little is known about the epidemiology of adverse events (AE) including symptomatic Clostridium difficile-associated diarrhea during treatment in these patients. METHODS: Cohort study (1996-2011) at a tertiary hospital non-endemic for clostridial ribotype O27. Patients with previous C. difficile episodes and metronidazole treatment were excluded. RESULTS: A total of 393 episodes were identified. Median age of patients was 69 years; 122 were immune-suppressed. All patients received antibiotic treatment for a median of 8 weeks, including 2 weeks intravenously (range, 0-9 weeks). Oral rifampin (600 mg/d) was used in combination in 167 (42%) episodes. A relatively small number of episodes (115/393; 29%) were complicated by AE (diarrhea, nausea, cholestasis, gastric intolerance to rifampin, rash, and mycosis), of which 41 (36%) led to treatment modification. AE occurred mainly after a median of 21 days. Fourteen patients (14/393; 3.6%) developed symptomatic C. difficile diarrhea. By multivariate Cox regression analysis, total duration of antibiotic therapy, and intravenous administration were significantly associated with AE (all p < 0.01). Regarding symptomatic C. difficile infection, rifampin (hazard ratio 0.21; 95% CI, 0.05-0.97) protected from diarrhea, but not gender or age. Hospital stay was significantly longer among patients with AE than patients without (median 78 vs. 42 d; p < 0.01). CONCLUSIONS: AE were frequent and were observed in 29% of patients treated for osteoarticular infections and prolonged the hospital stay. In contrast, diarrhea due to C. difficile was rare, while oral rifampin might act protectively against it.

[Musculoskeletal tumours misdiagnosed as sport injuries]. / Tumeurs musculo-squelettiques diagnostiquées a tort comme lésions sportives.

During our medical activity, we would necessarily be confronted with sport related complaints. Most of the diagnosed pathologies belong to the inflammation category and other traumas. However, as we will see in this review, we sometimes discover musculoskeletal tumours from different origins. One should never underestimate non-developing or slowly developing conditions among athletes, and to keep in mind a possible oncologic diagnosis. A critical assistance for diagnosis is given by the medical imagery with MRI being the leading technique. The aim is to avoid any delay in making the correct diagnosis, and therefore to avoid a more severe prognosis that would lead to a more radical surgery for either benign or malign tumours.