Management of thoracolumbar fracture in France. Analysis of practices and radiologic results of a cohort of 407 thoracolumbar fractures.

BACKGROUND: Thoracolumbar fractures are a public health issue due to their severity and frequency. Management varies according to demographic, clinical and radiologic features, from non-operative treatment to extensive fusion. In the two last decades, improvements and new techniques have emerged, such as kyphoplasty and percutaneous approaches. The main goal of this study was to describe the management of thoracolumbar fractures in France in 2018. HYPOTHESIS: The study hypothesis was that management of thoracolumbar fractures in France has progressed in recent decades. MATERIAL AND METHODS: The files of 407 adult patients operated on between January 1, 2015 and December 31, 2016 for T4-L5 thoracolumbar fracture in 6 French teaching hospitals were retrospectively reviewed, at a mean follow-up at 10.2±8.2 [1; 42] months. Demographic, surgical and postoperative radiological data were collected. p-values<0.05 on Student test were considered significant. RESULTS: Five hundred and thirty-one fractures were analyzed (27% of patients presented more than one fracture). Surgery consisted in internal fixation for 56% of patients, including 17% with associated kyphoplasty; 29% had fusion, and 15% stand-alone kyphoplasty. Surgery used an open posterior approach in 54% of cases, and a percutaneous approach in 46%. Initial sagittal angulation was not a significant decision criterion for screwing (p=0.8) or for a secondary anterior approach in case of fusion (p=0.6). Immediate postoperative sagittal correction was significantly better with an open than a percutaneous approach (p=0.004), but without significant difference at last follow-up (p=0.8). Correction at last follow-up was significantly better with anterior associated to posterior fusion (p=0.003). DISCUSSION: Management of the thoracolumbar fractures has progressed in France in recent years: 46% of surgeries used a percutaneous approach, compared to 28% in 2013; 90% used a posterior approach only, compared to 83% in 2013; rates of combined approach were unchanged, at 6%. Twenty-five percent of burst fractures were treated by fusion, possibly due to lack of preoperative MRI in 79% of cases. LEVEL OF EVIDENCE: IV, retrospective cohort study.

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic.

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in China, various measures have been adopted in order to attenuate the impact of the virus on the population. With regard to spine surgery, French physicians are devoted to take place in the national plan against COVID-19, the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients. A three levels stratification was elaborated with Level I: Urgent surgical indications, Level II: Surgical indications associated to a potential loss of chance for the patient and Level III: Non-urgent surgical indications. We also report French experience in a COVID-19 cluster region illustrated by two clinical cases. We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.

Influence of positioning of L4-5 disc prostheses on functional outcomes and sagittal balance: 2-year follow-up of a cohort of 38 patients.

OBJECTIVE: The main objective of this study was to evaluate the influence of L4-5 total disc replacement (TDR) positioning on functional outcome at the 2-year follow-up. The secondary objective was to assess its influence on sagittal balance. METHODS: Prospective data were compiled for 38 single-level L4-5 ProDisc-O TDRs. Anteroposterior placement (APP) was the distance between the center of the implant and the center of the L5 endplate divided by the total length of the L5 endplate. This ratio was expressed as a percentage (APP 0%-49%, anterior off-centering; 50%, perfect centering; and 51%-100%, posterior off-centering). The patients were divided into 3 groups depending on the APP and using quartile values: group 1, anterior placement (APP 0%-46%); group 2, central placement (APP 46.1%-52%, the 2 central quartiles); and group 3, posterior placement (APP 52.1%-100%). The sagittal balance parameters assessed were overall lordosis, segmental lordosis, and pelvic incidence. Adequate lordosis was defined for each patient according to their pelvic incidence. The Oswestry Disability Index and visual analog scale (VAS) scores for back and leg pain were assessed. RESULTS: The average APP was 48% (range 40%-64%). There were 10 patients in group 1, 18 in group 2, and 10 in group 3. There was a significant difference in functional outcomes among the 3 groups. APP influenced the VAS back (p = 0.04) and VAS leg (p = 0.05) scores. Group 1 consistently showed the highest performance scores. No significant association between APP and the sagittal balance parameters was found. Patients who had preoperative sagittal imbalance or those who significantly modified their balance after the surgery had the poorest outcomes. CONCLUSIONS: Disc prostheses at L4-5 seem to provide better functional outcome when they are positioned anteriorly to the center of the vertebral body.

Scoliosis in Patients With Friedreich Ataxia: Results of a Consecutive Prospective Series.

STUDY DESIGN: Prospective monocentric study. OBJECTIVES: To describe the radiologic characteristics and evolution of spinal shapes in a pediatric cohort of patients with Friedreich ataxia (FA). SUMMARY OF BACKGROUND DATA: FA is a spinocerebellar degenerative disorder responsible for gait impairment in children and young adults, and several orthopedic deformities can occur during growth, including scoliosis. However, curves' characteristics and their natural evolution have been poorly described, and the subsequent therapeutic management remains controversial. METHODS: Sixty six FA patients were prospectively included between 2008 and 2017. Clinical, functional, and radiologic records were conducted twice a year. Coronal curve types, segmental measurements, and skeletal maturity were assessed. RESULTS: A scoliotic deformity was reported in 71% of the patients at a mean age of 11.7 ± 3.1 years. Average follow-up was 6 years, including 75% of patients with closed triradiate cartilage at latest examination. Mean Cobb angle was 34° ± 2°. Main right thoracic curves were the most frequent curves observed (36%), followed by double major (21%), thoracolumbar and left thoracic curves (13%), main lumbar (11%), and long C-shape curves (6%). Hyperkyphosis (>40°) was present in 66%, with an average kyphosis angle of 50° ± 3°, and anterior misalignment (>5°) occurred in 53%. The severity of the Cobb angle was neither correlated to the FA severity scores nor the age at FA diagnosis. An arthrodesis was performed in 9 patients, including 5 patients (45%) who were ambulatory at least 1 year after surgery. CONCLUSIONS: The prevalence of scoliosis in FA was high (71%), and thoracic hyperkyphosis, with anterior misalignment, was frequently observed, which might be related to the anterior imbalance frequently encountered in patients with an ataxia. Posterior fusion including sacral instrumentation was only performed in nonambulatory patients, and the loss of ambulation was not associated with spinal surgery. LEVEL OF EVIDENCE: Level IV.