Does Spinal Surgery in Elderly Patients (Over 80 Years-Old) Lead to More Early Post-Operative Complications Than Lower Limb Prosthetic Surgery?

Purpose: Patients and surgeons may be reluctant on spinal surgery over 80 years old, fearing medical complications despite the possible improvement on quality of life. However, fewer reservations for lower limb prosthetic surgery (LLPS) seem to be arisen in this population. Is spinal surgery after 80 years-old responsible of more complications than lower limb surgery? Methods: The consecutive files of 164 patients over 80 years that had spinal surgery or LLPS were analyzed. The data collected pre-operatively were demographic, clinical and post-operatively the number and types of medical complications and length of stay. Results: The mean number of medical complications was 1.11 ± 0.6 [0-6] for spinal surgery and 1.09 ± 1.0 [0-3] for LLPS, (p = 0,87). The length of stay in orthopedic unit was comparable between the two groups: 10.7 ± 4.9 days [2-36] for SS and 10.7 ± 3.0 days [5-11] for LLPS (p = 0,96). Conclusion: The global rate of peri-operative complications and the length of hospital stay were similar between spinal surgery and lower limb prosthetic surgery. These results may be explained by the rising cooperation between geriatric specialist and surgeons and the development of mini-invasive surgical technics, diminishing the early post-operative complication rates.

Kappa: Preliminary Results on a Novel Technique for Pelvic Fixation in Adult Spinal Deformity Correction.

Study Design: Retrospective cohort study. Objectives: Pelvic fixation in degenerative spinal deformation is as crucial as demanding. Several pelvic anchoring technics have been described, but loosening rates remain high for most solutions. Here is described the "Kappa" technic, combining ilio-sacral screws to S2A1 screws at 2 years of follow-up. Methods: Thirteen patients that underwent a spinal deformity correction with "Kappa" fixation to the pelvis and with more than 2 years of follow-up were prospectively included in this study. The surgical technic is described, and clinical and radiographic data have been collected for all patients. Results: The population exhibited an important pre-operative sagittal imbalance (mean SVA of 104,4 mm, mean PI-LL mismatch of 22,8°) that had improved significatively after surgery (mean SVA of 75,5 mm and mean PI-LL mismatch of 4,9°). No loosening of pull-out of the implants was to deplore at 2 years of follow-up. Conclusions: The association of ilio-sacral screw, resistant to pull-out because of the traction axis perpendicular to the construct, to S2A1 screws, known to be effective in sagittal balance restoration seems to be an effective and safe option to pelvic fixation for adult spinal deformity correction. Level of Evidence: IV.

Degenerative cervical myelopathy.

Degenerative cervical myelopathy (DCM) frequently leads to severe neurologic disability but is still frequently underdiagnosed. One explanation may be the variability of the symptoms presented by the patients, from paresthesia to quadriplegia, making it another great masquerader. What do we know? How can we manage better these patients? We will review the keys points concerning its challenging diagnosis (clinical and radiologic), some of the recent discoveries about DCM, notably the underlying genetic mutations identified, linked to its pathophysiology, before addressing the consensual points concerning its management and the major evolutive risk: acute decompensation.

Functional results and patient satisfaction after long fusion for spinal deformity in Parkinson's disease.

BACKGROUND: Patients with Parkinson's disease often present abnormal posture or severe sagittal malalignment, causing significant disability. Surgical fusion is these cases shows high rates of complications, but may nevertheless provide functional benefit; however, this remains to be assessed. HYPOTHESIS: Long fusion for patients with Parkinson's disease and postural disorder could alleviate disability despite the high risk of complications. METHODS: We retrospectively reviewed 18 Parkinson patients treated by long fusion for spinal deformity. Functional results on the Oswestry Disability Index (ODI) and patient satisfaction were assessed at a minimum 2 years' follow-up. Predictive factors for good outcome were analyzed. RESULTS: Median follow-up was 44.4 months (IQR, 36-62.4 months). ODI showed significant improvement, from 64 (IQR, 59-77) preoperatively to 49 (IQR, 40-57) at last follow-up (p=0.0014). Fifteen patients (83%) were very satisfied (n=5) or satisfied (n=10) with the procedure. On multivariate analysis, only age was significantly associated with improvement in ODI at last follow-up (estimate: -9.8; p=0.5). DISCUSSION: Although long spinal fusion involves a high risk of complications in Parkinson's patients, the improvement in autonomy and patient satisfaction should be borne in mind before rejecting surgery, especially with motivated patients. LEVEL OF EVIDENCE: IV.

Evolution and complications after surgery for spine deformation in patients with Parkinson's disease.

INTRODUCTION: Surgical treatment of spinal deformity is high risk in patients suffering from Parkinson's disease (PD). Several series have already reported a high rate of complications. However, none of these studies included more than 40 patients and none of the risk factors of complications were described. The aim of this study was to describe the rate and risk factors of revision surgery as well as the clinical outcome at the last visit in a large multicenter study of PD patients operated for spinal deformities. METHODS: A multicenter retrospective study included arthrodesis for spinal deformity in patients with PD. Clinical and surgical data including revision surgeries were collected. Assessment of functional outcomes at last follow-up was classified in 3 grades and spinal balance was assessed on anteroposterior and lateral plain X-rays of the entire spine. RESULTS: Forty-eight patients were included. Median age was 67 years old (range 41-80). Median follow-up was 27 months. The rate of surgical revision was 42%. Eighty per cent of revisions were performed for chronic mechanical complication. Global results were considered to be good in 17 patients (35%), doubtful in 17 patients (35%) and a failure in 14 patients (30%), for the whole series. CONCLUSIONS: The results of surgery for spinal deformities in patients with Parkinson disease vary with a high rate of complications and revisions. Nevertheless, these results should be seen in relation to the natural progression of these spinal deformities once spinal imbalance has developed. The association between preoperative clinical balance and final outcome suggests that early surgery can probably play a role in treatment. LEVEL OF EVIDENCE: Level IV (e.g. case series).

Functional and ultrasonographic outcomes after surgical fibular tendon stabilisation by isolated re-tensioning of the superior fibular retinaculum.

BACKGROUND: Fibular tendon dislocation is a rare and usually sports-related injury. We report the functional and ultrasonographic outcomes of a simple technique for re-tensioning the superior fibular retinaculum. HYPOTHESIS: Our retinaculum re-tensioning technique is not followed by recurrent fibular tendon dislocation, as demonstrated by ultrasonography. MATERIAL AND METHOD: This single-centre single-surgeon retrospective study included 17 patients who underwent surgery to treat fibular tendon dislocation between January 2008 and December 2013. The functional outcome at last follow-up was assessed based on the AOFAS score. Subjective patient satisfaction and return to sports were recorded. Dynamic comparative ultrasonography was performed at last follow-up and the results used to separate the patients into four categories: normal, recurrent dislocation, subluxation, and residual tendinopathy. RESULTS: The 17 patients had a mean age of 32.6±9.7 years (range, 18-52 years) and a mean pre-operative AOFAS score of 59.9±11.3 (range, 34-71). Mean follow-up was 36.9±16.9 months (range, 12-60 months). The mean AOFAS score at last follow-up was 89±9.0 (range, 68-100). Of the 17 patients, 7 (41%) returned to the same level of sports. The remaining 10 patients returned to a lower level or did not return to sports, usually (70%) for personal or work-related reasons. Follow-up ultrasonography was normal in 12 (71%) patients. Of the remaining 5 patients, 2 had clinically silent recurrent dislocation and 3 had residual tendinopathy, including 1 who was only moderately satisfied due to persistent pain. Of the 4 patients who reported pain due to the knots in the non-absorbable sutures used to tighten the retinaculum, 1 required removal of the sutures. No other complications were recorded. Finally, 16 (94%) patients were satisfied or very satisfied. DISCUSSION: Retinaculum re-tensioning is effective in stabilising the fibular tendons, with no true recurrences. Ultrasonography can detect clinically silent subluxation. This simple and reproducible technique is associated with a very low complication rate and with excellent functional and anatomical outcomes. LEVEL OF EVIDENCE: Retrospective, level IV.

Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft.

INTRODUCTION: The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. MATERIAL AND METHODS: A single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. RESULTS: At a mean 4.6±1.6 years' follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. CONCLUSION: Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. LEVEL OF EVIDENCE: IV, retrospective study.

Osteosynthesis in sacral fracture and lumbosacral dislocation.

Sacral fracture and lumbosacral hinge trauma are rare but serious lesions. Neurologic disorder is frequently associated, and nerve release may be required, with reduction and stabilization of the fracture. Management requires knowing the fracture lines and reduction maneuvers and the fixation techniques that may need to be associated. Three classifications allow these fractures to be well understood: the Roy-Camille classification identifies high transverse fractures and their displacement; the Denis classification identifies vertical fracture line location within the sacrum, which correlates with neurologic risk; and the Tile classification analyzes pelvic ring trauma when associated with the sacral fracture. Treatment, when surgical, requires careful patient positioning, sometimes on an orthopedic table. Reduction maneuvers are founded on the fracture classification. Isolated U-shaped fracture of the sacrum is to be distinguished from sacral fracture associated with pelvic ring lesion. Osteosynthesis may be lumbopelvic or restricted to the pelvic ring (sacroiliac or iliosacral). Open osteosynthesis allows reduction to be finalized by intraoperative maneuvers on the implant, while closed osteosynthesis requires perfect preoperative reduction. Complications are frequent and neurologic recovery is uncertain. Fatigue and osteoporotic fractures show little displacement and are good indications for cementoplasty, either isolated or associated to iliosacral screwing. In lumbosacral hinge trauma, and dislocation in particular, reduction surgery with fixation (usually 360°) is indicated. The present study details the analysis and classification of these fractures, the technical pitfalls of reduction and fixation, and treatment indications.

Initial disc structural preservation in type A1 and A3 thoracolumbar fractures.

PURPOSE: Despite a sizable amount of literature, the optimal management of thoracolumbar fractures remains controversial and many authors assume the existence of disc lesions in Magerl type A fractures. The purpose of the study was to assess the intervertebral discs in these fractures at the time of trauma. The hypothesis was that there was no change in shape and signal intensity of the discs initially. METHODS: Fifty-one patients diagnosed with 87 types A1 and A3 thoracolumbar fractures were enrolled in a prospective study. MRI analysis involved evaluation of disc signal, height and morphological modifications according to Oner's classification. RESULTS: No signal intensity modification was identified on MRI. Disc morphology was either normal or altered with creeping of discal tissue in the vertebral endplate depression. Overall, 98% of the discs were either type 1 or type 3. Mean disc height on MRI was 1.03 ± 0.36 initially. CONCLUSIONS: In this study, MRI showed that no loss of height occurred in discs adjacent to fractured vertebra and that there was no major alteration of the disc in terms of signal intensity and morphology. Therefore, the intervertebral disc should not be removed in Magerl type A fractures. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Atlanto-axial dislocation complicating a type II odontoid fracture. Reduction and final fixation.

A case of traumatic posterolateral C1-C2 dislocation associated with odontoid fracture is reported. This is a rare case of traumatic posterolateral C1-C2 dislocation associated with odontoid fracture. Its management is discussed. A traumatic dislocation of atlanto-axial joint associated with an odontoid fracture remains a rare injury. No case of posterior dislocation has been reported so far in the literature with this type of management. The case is of a 25 year-old-man with a primary atlanto-axial posterolateral dislocation associated with a type II displaced odontoid fracture without any neurological complication. The patient underwent gentle traction during 24 hours with a halo frame. An incomplete reduction was achieved. Two days later, a complete reduction was obtained thanks to a preoperative manual traction maintained by a Mayfield (R) modified skull clamp. Anterior C1-C2 fixation was performed according to Vaccaro's technique. The patient wore a cervical collar and underwent physiotherapy during three months. To our best knowledge, this case represents the first traumatic atlanto-axial dislocation associated with an odontoid fracture which was treated through retropaharyngeal approach. This had been rendered possible thanks to the final reduction maneuver in extension.

Pneumorachis: a possible source of traumatic cord compression.

The presence of air within the spinal canal secondary to trauma is a rare condition. These rare cases are generally asymptomatic. We report our first case of closed thoracic trauma with pneumorachis associated with neurological disorders. According to a review of the literature and after personal record analysis, neurologic symptoms can be correlated to the occurrence of intraspinal air. Therefore pneumorachis appears as a possible cause of traumatic spinal cord compression. In this particular case, pneumorachis spontaneously resolved and early outcome was favourable.

[Experimental evaluation of microscan assessment of bone fusion]. / Etude expérimentale de la microtomographie X dans l'évaluation de la fusion osseuse.

PURPOSE OF THE STUDY: Certain confirmation of bone fusion remains difficult to obtain after arthrodesis despite progress in imaging techniques. Microscanning enables both qualitative and quantitative analysis of the bone microarchitecture. The purpose of this study was to evaluate this technique using a cervical arthrodesis with an intersomatic cage on an animal model and to validate results with histological analysis and electron scan microscopy (SEM). MATERIAL AND METHODS: C3-C4 discectomy was performed in 8 goats divided into two groups. In group 1 (3 animals), PEEK cages were inserted without bone graft. In group 2 (5 goats) the same cage was inserted and filled with an autologous iliac graft. The animals were sacrificed at six months. The instrumented levels were analyzed with a microscan. Histological slides were obtained and SEM performed. RESULTS: Nonunion was observed in the three animals with an empty cage (group 1) while only one animal in group 2 presented nonunion. Histology and SEM confirmed the diagnosis established with the microscan which also enabled a 3D analysis of the sample and study of the trabecular architecture of the intersomatic graft. DISCUSSION: The microscan enabled a micrometric analysis of the sample. This is the only technique enabling 3D analysis (slices can be obtained in the three planes for 3D reconstruction) for both qualitative and quantitative assessment. Analysis of the trabecular microstructure constitutes a major progress in evaluating the mechanical value of the fusion. The sample is not destroyed and can be studied further with other biomechanical techniques. CONCLUSION: Microscanning is an important technical advancement for the analysis of bone fusion. Future applications will undoubtedly be numerous (follow-up after arthrodesis, analysis of the mechanical quality of a graft). In vivo applications will probably be adapted soon.

[Neurological recovery after cervical cord decompression for canal stenosis myelopathy]. / La récupération neurologique après décompression d'une myélopathie cervicale par sténose canalaire.

PURPOSE OF THE STUDY: Progressive myelopathy secondary to stenosis of the spinal canal is generally treated by surgery. Results of surgical decompression are generally good but the pattern of neurological recovery has not been studied. We followed a cohort of patients who underwent cervical cord decompression to study the course of neurological recovery. MATERIAL AND METHODS: The study cohort included 39 patients (22 men and 17 women), mean age 65.7 years who underwent surgery between 1998 and 2002 for progressive cervical myelopathy. The same surgeon performed all procedures (23 posterior and 16 anterior approaches). The JOA score and MRI findings were noted. The patients were seen at 1, 3, 6, 12, and 18 months then annually (JOA score). The Hirabayashi score was used to assess neurological recovery. Two populations were identified (group 1: preoperative JOA score > 6, group 2: preoperative JOA score

Compressive thoracic spondylodiscitis associated with a pleural abscess: Surgical treatment through an enlarged posterior approach.

The authors report a case of a patient with paraparesis secondary to T5-T6 spondylodiscitis accompanied by a closely lying, well-formed pleural abscess. This rare association has previously been reported only twice in the literature. The technical difficulty of surgery for both the abscess and the compressive spondylodiscitis was resolved by the use of an enlarged posterior approach. This approach enabled evacuation of the pleural lesion, curettage of the disc space, interbody grafting, and spinal osteosynthesis in one stage.

[Rehabilitation treatment in lumbar canal stenosis. Intermediate results of a prospective study (Télemar)]. / Prise en charge rééducative des sténoses du canal lombaire. Résultats intermédiaires d'une étude prospective (Télemar).

STUDY DESIGN: Lumbar spine stenosis is a common cause of lower back pain and lower extremity pain especially in people over 60-years-old. Treatment can be surgical or non-surgical. The efficacy of these treatments remains unclear. The purpose of this study was to assess the result of a medical management in a prospective study. Preliminary results are presented. PATIENTS AND METHODS: Patients following the clinical and the radiological criteria of inclusion were included in the study. Pain was assessed by visual analogic scale (VAS) and Oswestry scale. Sixty patients meeting inclusion criteria underwent non-surgical intervention including therapeutic exercises and 2 epidural injections. Patients were followed up at 3 and 6 months. RESULTS: The main score on VAS was 5.2 for lumbar pain, 5.8 for radicular pain and 21/50 on the Oswestry scale. Three months later an improvement was noticed in 12 cases. Thirty-seven patients remained unchanged and surgery was decided for 11 patients. At 6 months an improvement was reported by 47% of the patients who have been managed by conservative treatment. No predictive factor except VAS was noticed. DISCUSSION: Our results are inferior to those previously reported. Most of previous studies are retrospective and criteria of assessment are not based on functional scale as we done. The fact that the treatment management was ambulatory without supervision is probably the main explanation. CONCLUSION: Conservative treatment for spinal lumbar stenosis remains a reasonable option.

[Developmental lumbar stenosis in eleven French Antilles patients]. / Canal lombaire étroit constitutionnel chez des patients antillais.

PURPOSE OF THE STUDY: Developmental lumbar stenosis is a rare entity, exceptionally described in the literature. No study has been directly devoted to this condition. The purpose of the present study was to examine specific features, particularly clinical and anatomic expression, observed in a series of operated patients. MATERIAL AND METHODS: Eleven patients from the French Antilles were treated for developmental lumbar stenosis between 1996 and 2000. The Verbiest criteria were used to define canal narrowness. Signs of degeneration and presence of discal herniation were exclusion criteria. Epidemiological and clinical data were collected for the 11 patients. The degree of sagittal stenosis (fixed diameter at the bone level and mobile diameter at the discal level) was measured on computed tomography images. Transverse stenosis was determined by measuring the interpedicular and interapophyseal distances. Lateral stenosis was determined by measuring the depth of the recessus. RESULTS: These patients were young (mean age 42.4 years). Most of the clinical signs were monoradicular. Discal level stenosis predominated, generally at level L4-L5. It was generally central and lateral, sagittal and transverse. The interpedicular distance was the only diameter that remained within normal limits. Soft tissues (yellow ligaments and joint capsules) played an important role in the stenosis. DISCUSSION: The rare reports of developmental lumbar stenosis describe decompensated stenosis due to discal herniation in the adolescent. Developmental lumbar stenosis is considered to be a genetic disease and its particular high frequency in the French Antilles favors this hypothesis. The stenosis results from bony (short pedicles, hypertrophic lateral masses) and ligament (hypertrophy of the yellow ligament and joint capsules) structures. CONCLUSION: Developmental lumbar stenosis produces a global (sagittal, transverse, central, lateral) narrowing of the lumbar canal where soft tissue structures apparently play a greater role than usually thought. A prospective study examining the impact of ethnic origin is required to analyze the genetic hypothesis.

Six cases of cervical ligamentum flavum calcification in Blacks in the French West Indies.

OBJECTIVE: Calcification of the ligamentum flavum at the cervical spine is an uncommon condition reported mainly in Japanese patients. We describe the clinical manifestations, imaging study findings, and outcomes in six cases seen in the French West Indies. MATERIAL AND METHODS: We retrospectively reviewed the medical charts of six patients admitted to an orthopedics department for spinal cord compression shown upon computed tomography to be caused by calcification of the ligamentu flavum. There were five women and one man, mean age at admission was 71.7 years (range, 64-79 years) and all six patients were Black. RESULTS: Five patients had cervical myelopathy and one was asymptomatic. All five symptomatic patients had cervical spinal stenosis, explaining the rapid symptom onset (within six and a half months) and severe motor loss. Computed tomography reconstruction in the sagittal plane ruled out ossification of the ligamentum flavum. Magnetic resonance imaging of the neck failed to demonstrate the calcifications but was useful in evaluating the severity of the spinal cord compression. One patient had articular chondrocalcinosis in both knees and another had calcifications in the basal ganglia. Surgical decompression by the posterior route was performed in two patients and was effective in both, whereas two of the three symptomatic patients who did not have surgery experienced worsening neurological loss. Analysis of the operative specimens from the two surgically treated patients showed a mixture of calcium pyrophosphate dihydrate crystals and apatite microcrystals. CONCLUSION: Calcification of the ligamentum flavum is probably underrecognized in blacks. This condition causes severe neurological loss. Imaging studies provide the diagnosis. The pathogenesis remains unclear.

[Double dislocation of the fifth metacarpal. A case report and review of the literature]. / Luxation bipolaire du 5e métacarpien. A propos d'un cas et revue de la littérature.

A case of traumatic double dislocation of the fifth metacarpal is reported. Both dislocations, hamatometacarpal and metacarpophalangeal, were dorsal. This rare combination of injury has been reported twice only. Our case was managed successfully by closed reduction and immobilization. Eight month later, the patient had a full range of wrist and finger movement, he was pain-free without any residual disability.

Myelopathy due to calcification of the cervical ligamenta flava: a report of two cases in West Indian patients.

Two cases of cervical myelopathy due to calcification of the ligamenta flava (CLF) are described for the first time in black patients from the French West Indies. A pre-operative CT scan differentiated the diagnosis from one of ossification of the ligamenta flava. Microanalysis on the operatively excised specimen in one patient revealed a mixture of calcium pyrophosphate dihydrate crystals and hydroxypatite crystals. Poor outcome in one patient contrasting with excellent recovery in the other one, who had undergone posterior decompressive laminectomy, emphasizes the importance of surgery in the management of CLF.