Instrumented L5-S1 interbody graft with IFUSE implant using the reverse Bohlman technique.

BACKGROUND: In case of high sacral slope, anterior lumbosacral fusions can be performed by retroperitoneal or transperitoneal approach using a reversed Bohlman technique with an autologous corticocancellous fibular graft. The use of a trans-lumbosacral implant can avoid the iatrogenic effects but currently, there is no implant specifically designed for this fusion technique. Could the IFUSE implant from SI BONE replace a fibular graft to avoiding the iatrogenic effect induced by sampling during a Reverse Bohlman technique? PATIENTS AND METHODS: We present the case of a 38-year-old woman with L5S1 interbody pseudarthrosis after posterior fixation for grade 2 L5-S1 spondylolisthesis with isthmic lysis of L5, and that of a 69-year-old woman who underwent a posterior T4 fusion to the pelvis for degenerative scoliosis. Both required a trans-lumbosacral instrumented fusion via an anterior approach using the reverse Bohlman technique. Surgical technique was described. RESULTS: There were no perioperative or postoperative complications. At 6 months, the patients reported a decrease in lumbar and radicular symptomatology. There were no infectious, neurological or vascular complications. CT-scans confirmed the good position and stability of the IFUSE implant. DISCUSSION: We present an innovative interbody grafting technique adapted to spines with high pelvic incidence. The surgical technique is safe, minimally invasive, and reduces surgical iatrogeny. The short and medium-term results are positive but require longer-term follow-up and a larger cohort.

Early Revision Surgery for Distal Adding-On Correction in Lenke 1 and 2 Adolescent Idiopathic Scoliosis.

Objective To evaluate the outcome of an early revision strategy for postoperative distal adding-on (DAO) after Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) surgery. Summary of background data Improper choice of the lowest instrumented vertebra (LIV) is a major cause of postoperative imbalance and unsatisfactory results in AIS surgery. The long-term consequences of such imbalance remain unclear. Early corrective surgery has not been described. Methods We retrieved the records of operated AIS patients at the former institution of the senior author. There were 18 cases of early revision by one-level distal extension of instrumentation and fusion. Patients were reoperated based on progressive distal local imbalance and clinical lumbar asymmetry. Several local and global balance parameters were compared on serial long-standing radiographs before and after the index surgery, before and after the revision surgery, and at the last follow-up. The Kruskal-Wallis test was used for the comparison of the results. A value of p<0.05 was considered significant. Results All patients were female with a mean age of 13.9 years. The mean delay between the two surgeries was 8.4 months and the last follow-up was at 32.5 months after the revision surgery. Unsatisfactory results after the index surgery were reflected by a progressive increase in disc angulation below the lowest instrumented vertebra (LIV) and an increased tilt and rotation of the LIV+1. The clinical lumbar shift was also accentuated from 19 mm to 25 mm. Revision surgery significantly reduced local and global balance parameters. There was a decrease in the LIV translation (from 26 mm to 19 mm) and of the wedging below it (from 7.9° to 1.3°) and a better positioning of the LIV+1 with less tilt (from 14.6° to 3.6°), translation (from 22.2 mm to 13.8 mm) and rotation (from 20° to 15°). The clinical lumbar shift was reduced from 25 mm to 3.6 mm. Global coronal and sagittal balance were also ameliorated. All results were maintained at a mean follow-up of 32.5 months from the revision surgery. No complications were noted and there was no need for a blood transfusion. Conclusion The revision surgery proposed in this paper is simple with low morbidity and may be considered as a fine-tuning of the failed index surgery. Further studies are needed to evaluate the long-term consequences of treated and untreated postoperative distal adding-on in AIS surgery.

Quantifying the Spinal Lordosis Ratio Unique to the Type of Spinal Sagittal Alignment in a Normal Population.

STUDY DESIGN: Data collection of radiological parameters in non-pathological adult spines. OBJECTIVES: Establishing a baseline database for measurements of the spinal lordosis ratio between upper and lower arcs of the lumbar spine unique to each type of spine described by Roussouly's classification. Illustrating the importance of correct rationing of the upper and lower arcs. METHODS: Standardised standing true lateral plain radiographs of the spine (including base of skull and proximal femurs) from 373 adult volunteers were obtained. Exclusion criteria : any history of disease involving the spine, pelvis, hips or lower limbs. Incidental detection of any spinal deformity on radiography also excluded further participation in this study. Sacro-pelvic parameters data collected : Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), location of Inflection Point, number of vertebras in the spinal lordosis and type of Roussouly's spine. Values of upper arc, lower arc and spinal lordosis ratio (SLR) was determined. RESULTS: Bivariate analysis revealed statistically significant (P < .0001) correlation between the types of sagittal spinal alignments based on Roussouly's classification and the SLR. Type 1: SLR .76 ± .17, Type 2: SLR .60 ± .18, Type 3 with anteverted pelvis: SLR .53 ± .11, Type 3: SLR .49 ± .12, Type4: SLR .41 ± .11. CONCLUSION: With this data we are able to quantify the ratio of lumbar lordosis unique to each type of Roussouly's spine. It functions as a guide when planning lumbar spine surgeries in order to restore the SLR correctly and thus prevent post-op complications such as proximal junction kyphosis.

Evolution of the Surgical Management of Lung Cancer Invading the Spine: A Single Center Experience.

For patients with locally advanced non-small cell lung cancer invading the spine, induction chemoradiotherapy combined with radical en bloc resection is the key to obtaining long-term survival. With time, our operative technique evolved to a two-step surgery as we experienced numerous perioperative complications during one step surgery. The aim of our study was to assess postoperative morbimortality and long-term survival of both techniques. We retrospectively reviewed all patients who underwent en bloc resection for lung cancer invading the spine between October 2012 and June 2020. Every patient underwent induction therapy. Sixteen patients were included: nine patients were operated on with one step surgery, seven patients were operated on with two step interventions. Twenty-five percent of patients had major perioperative complications and 56.2% of patients had major post-operative complications. Patients in the "one step" group tended to have more perioperative complications whereas patients in the "two step" group tended to have more post-operative complications. Overall 3-year survival was 40% in the one-step and 86% in the two-step surgery group. Although our practice has been improved by two-step interventions, post-operative morbidity remains significant. As long term survivals are encouraging, this type of treatment should still be proposed for highly selected patients, in specialized centers.

Radiographic outcomes and complications after L4 or L5 pedicle subtraction osteotomy for fixed sagittal malalignment in 102 adult spinal deformity patients with a minimum 2-year follow-up.

PURPOSE: The objective of this retrospective study was to provide the radiographic outcomes and complications for pedicle subtraction osteotomy (PSO) performed at the low lumbar spine, i.e., L4 or L5 for ASD patients with fixed sagittal malalignment. METHODS: ASD patients who underwent L4 or L5 PSO with a minimum 2-year follow-up were included. Preoperative and postoperative radiographs, and complications were collected. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), thoracic kyphosis (TK), sagittal vertical axis (SVA), spinal lordosis (SL) ratio and global tilt (GT) on standing long-cassette radiographs. RESULTS: A total of 102 patients from 2 spinal centers were analyzed. 66 patients underwent PSO at L4 and 36 patients at L5. From preoperatively to the final follow-up, significant improvements occurred in LL (from - 31° to - 52°), SVA (from 13 to 5 cm), and GT (from 44° to 27°) (all, p < 0.05). 12 patients had transient neurological deficits, and 8 patients had persistent neurological deficit. 23 patients underwent revision for PJK (2), pseudarthrosis (10), neurological deficit (2), epidural hematoma (1), or deep surgical site infection (8). No PJK was observed in any of the patients with L5 PSO. CONCLUSIONS: PSO at the level of L4 or L5 remains a challenging technique but with an acceptable rate of complications and revisions. It enables correction of fixed sagittal malalignment in ASD patients with a globally satisfactory outcome. In comparison with L4 PSO, L5 PSO patients did not show PJK as a mechanical complication. Distal lumbar PSO at the level of L5 may represent one of the factors that may help preventing the proximal junctional kyphosis complication.

Rehabilitation and lumbar surgery: the French recommendations for clinical practice.

BACKGROUND: Indications and techniques of rehabilitation differ widely across types of lumbar surgery, including timing (before or after surgery) and prescriptions (surgeons but also medical or paramedical professionals). OBJECTIVES: This project aimed to build consensual recommendations for practice in this context. METHODS: The SOFMER methodology was used to establish recommendations for physical medicine and rehabilitation: a steering committee defined the types of lumbar surgery involved and developed the main questions to be addressed; a scientific committee performed a literature review for grading evidence and proposed the first version of recommendations, which were discussed during a dedicated session at the national Physical and Rehabilitation Medicine congress; then an e-Delphi method with cross-professional experts was used to finalise recommendations and reach a multidisciplinary consensus. RESULTS: The main questions developed were the value of rehabilitation before and after surgery, timing and type of rehabilitation, benefit of supervision and instrumental rehabilitation, value of patient education, and complementary interventions concerning rehabilitation for discectomy, fusion, and disc prosthesis (excluding decompression for spinal stenosis). The literature review identified 60 articles, but for several of the questions, no article in the literature addressed the issue. The multidisciplinary scientific committee analysed the literature and addressed the questions to propose the first version of a set of 23 recommendations. The congress session failed to answer all questions or to reach consensus for all items. After a three-step e-Delphi, 20 recommendations were retained, for which consensus among experts was reached. The recommendations are applicable only to patients without a neurological lesion. CONCLUSIONS: These recommendations provide important and consensual knowledge to assist clinicians in decision-making for rehabilitation in lumbar surgery. Despite many of the recommendations relying exclusively on expert opinion rather than published evidence, this approach is an important advance to improve concordance among healthcare professionals.

Pseudarthrosis in adult spine deformity surgery: risk factors and treatment options.

PURPOSE: Highlight risk factors for pseudarthrosis in long-segment spinal fusions, collect the approaches carried to address this complication. METHODS: Patients with ASD and fusion of ≥ 4 levels with minimum follow-up (FU) of ≥ 2 years were included. Full-body X-rays were done preoperatively, < 3 months and ≥ 2 years. Oswestry disability index (ODI), Scoliosis Research Society-22 and SF36 assessed pre- and postoperatively. The relationship between demographic, surgical and radiological variables with the development of pseudarthrosis was evaluated. RESULTS: Out of 524 patients included, 65 patients (12.4%) developed pseudarthrosis and 53 underwent revision surgery. Notably, 88% of pseudarthrosis cases are associated with fusion length (OR = 1.17, 95% CI = 1.05-1.292, p = 0.004), osteotomy requirement (OR = 0.28, 95% CI = 0.09-0.85, p = 0.025), pelvic fixation (OR = 0.34, 95% CI = 0.13-0.88, p = 0.026) and combined approaches (OR = 3.29, 95% CI = 1.09-9.91, p = 0.034). Sagittal alignment is not related to the rate of pseudarthrosis. Health related and quality of life scores were comparable at last FU between patients revised for pseudarthrosis and those that didn't require revision surgery (ODI = 28% no revision and 30% revision group). CONCLUSIONS: Pseudarthrosis is not related to malalignment, but with the surgical techniques employed for its treatment. Anterior approaches with anterior support decrease the rate by 30%, while long fusions, osteotomies and pelvic fixation increase its rate.

Revisiting thoracic kyphosis: a normative description of the thoracic sagittal curve in an asymptomatic population.

PURPOSE: Thoracic kyphosis (TK) remained in the shadow of lumbar lordosis. Based on Berthonnaud and Roussouly segmentation, TK is divided into two arches: upper TK (UTK) and lower TK (LTK). The purpose of this study is to propose a normative description of the TK arches in an asymptomatic adults' population and their correlation with spinal and pelvic parameters. METHODS: This is an observational study performed on asymptomatic healthy Caucasians volunteers aged between 18 and 45 years. Each patient had a standardized standing biplanar full spine X-rays. Using KEOPS®, sacropelvic parameters and global spinal parameters (LL, TK) as well as the inflexion point location were measured. The upper lumbar lordosis angle (ULL) as well as LTK and UTK was calculated. Patients were classified according to Roussouly morphotypes of normal spine. RESULTS: A total of 373 adults (F/M = 1.4/1) were enrolled with mean age of 27 years. Mean UTK averaged 25.8°, while mean LTK averaged 19.8° (p < 0.001). UTK angle values were statistically the same in the five different Roussouly spinal shapes (p > 0.05), while LTK values were variable among different Roussouly spine subtypes (p < 0.05). Finally, TK showed the highest correlation with the LL mainly with the ULL (Pearson = 0.66). CONCLUSION: In asymptomatic young adults, thoracic kyphosis is composed by two unequal arches, a stable UTK and a variable LTK, with an apex around T8 and T9 vertebra, depending on the spinal morphotype according to Roussouly classification. This should be taken into consideration when analyzing spine sagittal compensation and preparing corrections to minimize risk of mechanical complications.

A new classification for coronal malalignment in adult spinal deformity: a validation and the role of lateral bending radiographs.

PURPOSE: Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. METHODS: Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. RESULTS: Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. CONCLUSIONS: Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.

Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study.

PURPOSE: To evaluate the incidence of mechanical complications in patients with adult spine deformity (ASD) treated by restoring the normal shape according to the Roussouly classification. METHODS: This is a retrospective multicentric study with a minimum follow-up of 2 years. Patients operated on with fusion for ASD (minimum performed fusion: L2 to sacrum) were included. Patients with a history of previous spinal fusion of more than three levels were excluded. Spinal and pelvic parameters were measured on the preoperative and the immediate postoperative follow-up. All mechanical complications were recorded. RESULTS: A total of 290 patients met the criteria of inclusion with a minimum follow-up of 2 years. Mechanical complications occurred in 30.4% of the cohort. The most common complication was PJK with an incidence of 18% while nonunion or instrumentation failure (rod breakage, implant failure) occurred in 12.4%. 66% of the patients were restored to the normal shape according to the Roussouly classification based on their PI and had a mechanical complication rate of 22.5%, whereas the remaining 34% of patients had a complication rate of 46.8% (p < 0.001). The relative risk for developing a mechanical complication if the algorithm was not met was 3 (CI 1.5-4.3; p < 0.001) CONCLUSION: In the recent literature, there are no clear guidelines for ASD correction. Restoring the sagittal spinal contour to the normal shapes of Roussouly according to the PI could serve as a guideline for ASD treatment. Ignoring this algorithm has a threefold risk of increased mechanical complications. We recommend this algorithm for treatment of ASD. LEVEL OF EVIDENCE: IV cross-sectional observational study. These slides can be retrieved under Electronic Supplementary Material.

Sacral doming progression in developmental spondylolisthesis: a demonstrative case report with two different evolutions.

STUDY DESIGN: Demonstrative case report of two different evolutions in developmental spondylolisthesis. To our knowledge spontaneous sacral doming reconstruction and healing has never been previously reported. METHODS: Presentation of two cases with developmental spondylolisthesis and no sacral dome that had at the beginning a similar presentation and finally evolved in different ways. RESULTS: Initially, both cases were without sacral dome. In the first case, sacral dome appeared and completely healed in presence of a stable elongata pars and stable spondylolisthesis. In the second case, apparition, progression of sacral dome, rolling up of L5 and spondylolisthesis occurred in the presence of lytic defect in the pars. CONCLUSION: Sacral doming is secondary to L5 abnormal position regarding to S1. The mechanism of sacral doming looks like as an osteochondritis phenomena. Loss of support of the sacral plateau by sacral rounding may induce high grade spondylolisthesis.

Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis: a morphological classification of 120 cases.

PURPOSE: To analyze the relationship between the cervical spine and global spinal-pelvic alignment in young patients with idiopathic scoliosis based on a morphological classification, and to postulate the hypothesis that cervical kyphosis is a part of cervico-thoracic kyphosis in them. METHODS: 120 young patients with idiopathic scoliosis were recruited retrospectively between 2006 and 2011. The following values were measured and calculated: cervical angles (CA), cervico-thoracic angles (CTA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), spinal sacral angle (SSA), hip to C7/hip to sacrum, thoracic kyphosis (TK), lumbar lordosis (LL), Roussouly sagittal classification, Lenke Type Curve and Lumbar Modifier. The cervical curves were classified as lordosis, straight, sigmoid and kyphosis. They were categorized into four groups as cervical non-kyphosis group (CNK Group), cervical kyphosis group (CK Group), cervical-middle-thoracic kyphosis group (CMTK Group), and cervical-lower-thoracic kyphosis group (CLTK Group) according to their morphological characters of sagittal alignments. All parameters were compared and analyzed among groups. RESULTS: The incidence of cervical kyphosis was 40 % (48/120). The CA and the CTA were in significant correlation (r = 0.854, P = 0.00). The cervical spine alignments were revealed to be significantly different among groups (r = 85.04, P = 0.00). Significant differences among groups in CA, CTA and TK were also detected. A strong correlation between the group type and Lenke Lumbar Modifier was still seen (P < 0.05). Fisher's exact test revealed that the individual vertebral body kyphosis and wedging were directly related to the overall cervical kyphosis (P = 0.00, respectively). CONCLUSION: The cervical kyphosis is correlated with global sagittal alignment, and is a part of cervico-thoracic sagittal deformity in young patients with idiopathic scoliosis. Despite the deformity in cervical alignment, the global spine could still be well-balanced with spontaneous adjustment. The correlation between our grouping based on the morphological characteristics of the sagittal alignments and Lenke Lumbar Modifier suggests that the coupled motion principle be appropriate to explain the modifications both in coronal and sagittal planes.

Complications and Morbidities of Mini-open Anterior Retroperitoneal Lumbar Interbody Fusion: Oblique Lumbar Interbody Fusion in 179 Patients.

STUDY DESIGN: A retrospective study including 179 patients who underwent oblique lumbar interbody fusion (OLIF) at one institution. PURPOSE: To report the complications associated with a minimally invasive technique of a retroperitoneal anterolateral approach to the lumbar spine. OVERVIEW OF LITERATURE: Different approaches to the lumbar spine have been proposed, but they are associated with an increased risk of complications and a longer operation. METHODS: A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. The technique is described in terms of: the number of levels fused, operative time and blood loss. Persurgical and postsurgical complications were noted. RESULTS: Patients were age 54.1 ± 10.6 with a BMI of 24.8 ± 4.1 kg/m(2). The procedure was performed in the lumbar spine at L1-L2 in 4, L2-L3 in 54, L3-L4 in 120, L4-L5 in 134, and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Surgery time and blood loss were, respectively, 32.5 ± 13.2 minutes and 57 ± 131 ml per level fused. There were 19 patients with a single complication and one with two complications, including two patients with postoperative radiculopathy after L3-5 OLIF. There was no abdominal weakness or herniation. CONCLUSIONS: Minimally invasive OLIF can be performed easily and safely in the lumbar spine from L2 to L5, and at L1-2 for selected cases. Up to 3 levels can be addressed through a 'sliding window'. It is associated with minimal blood loss and short operations, and with decreased risk of abdominal wall weakness or herniation.