Correction to: Outcomes of surgical treatments of spinal metastases: a prospective study.

The correct name of F. Saihlan should be F. Sailhan.

Outcomes of surgical treatments of spinal metastases: a prospective study.

BACKGROUND: Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases. OBJECTIVE: To analyse the outcomes of surgical treatments of spinal metastases. METHODS: Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status. RESULTS: A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function. CONCLUSION: Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.

Circulating tumour cells as a biomarker for diagnosis and staging in pancreatic cancer.

BACKGROUND: Current diagnosis and staging of pancreatic ductal adenocarcinoma (PDAC) has important limitations and better biomarkers are needed to guide initial therapy. We investigated the performance of circulating tumour cells (CTCs) as an adjunctive biomarker at the time of disease presentation. METHODS: Venous blood (VB) was collected prospectively from 100 consecutive, pre-treatment patients with PDAC. Utilising the microfluidic NanoVelcro CTC chip, samples were evaluated for the presence and number of CTCs. KRAS mutation analysis was used to compare the CTCs with primary tumour tissue. CTC enumeration data was then evaluated as a diagnostic and staging biomarker in the setting of PDAC. RESULTS: We found 100% concordance for KRAS mutation subtype between primary tumour and CTCs in all five patients tested. Evaluation of CTCs as a diagnostic revealed the presence of CTCs in 54/72 patients with confirmed PDAC (sensitivity=75.0%, specificity=96.4%, area under the curve (AUROC)=0.867, 95% CI=0.798-0.935, and P<0.001). Furthermore, a cut-off of ⩾3 CTCs in 4 ml VB was able to discriminate between local/regional and metastatic disease (AUROC=0.885; 95% CI=0.800-0.969; and P<0.001). CONCLUSION: CTCs appear to function well as a biomarker for diagnosis and staging in PDAC.

[Imaging of the postsurgical spine]. / Imagerie du rachis lombaire opéré

Some early complications (hematoma, spondylodiscitis, pseudomeningocele) can occur with all types of surgery while late complications vary with the type of surgery. After discectomy, postsurgical changes (osseous and ligamentous defects, scar tissue, granulation tissue) should be distinguished from postsurgical complications or recurrent disease (recurrent disc herniation, arachnoiditis, spondylodiscitis). Following spinal decompression and fusion procedures, standard radiographs and CT can confirm the adequate position of the fusion devices, the presence of fusion, and the development of late osseous complications: pseudarthrosis, instability and recurrent stenosis.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury.

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

The sacral chordoma margin.

OBJECTIVE: Aim of the manuscript is to discuss how to improve margins in sacral chordoma. BACKGROUND: Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in >50% after surgery. METHODS: A multidisciplinary meeting of the "Chordoma Global Consensus Group" was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. RESULTS: En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. CONCLUSION: Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients.

[Femoral neck fractures in patients over 50 years old]. / Les fractures du col du fémur après 50 ans.

INTRODUCTION: Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options. MATERIAL AND METHODS: Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients? RESULTS: For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients. DISCUSSION AND CONCLUSIONS: For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.

Thoracic disc herniation: Surgical treatment.

Thoracic disc herniation is rare and mainly occurs between T8 and L1. The herniation is calcified in 40% of cases and is labeled as giant when it occupies more than 40% of the spinal canal. A surgical procedure is indicated when the patient has severe back pain, stubborn intercostal neuralgia or neurological deficits. Selection of the surgical approach is essential. Mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision. The complication rate for transthoracic approaches is higher than that of posterolateral approaches; however, the former are performed in more complex herniation cases. The thoracoscopic approach is less invasive but has a lengthy learning curve. Retropleural mini-thoracotomy is a potential compromise solution. Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction. Along with complications specific to the surgical approach, the surgical risks are neurological worsening, dural breach and subarachnoid-pleural fistulas. Giant calcified herniated discs are the largest contributor to myelopathy, intradural extension and postoperative complications. Some of the technical means that can be used to prevent complications are explored, along with how to address these complications.

Developments in ambulatory surgery in orthopedics in France in 2016.

Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription.

Percutaneous posterior fixation for unstable pelvic ring fractures.

Several posterior fixation techniques for unstable pelvic ring fractures have been described. Here, we present a minimally invasive, percutaneous technique to fix the two posterior iliac crests using spinal instrumentation. Between September 2008 and March 2012, 11 patients with a mean age of 36.4 years were operated because of a vertically unstable Tile C pelvic ring fracture. Posterior fixation was performed using two polyaxial screws in each iliac crest with two subfascial connector rods. At the final follow-up, all patients were evaluated clinically and radiologically. The mean surgery time was 45 minutes; there were no intraoperative complications. At a mean follow-up of four years, the functional Majeed score was excellent in eight patients and good in three patients. The radiological results were excellent in eight patients and good in three patients. Percutaneous posterior fixation of vertically unstable pelvic fractures leads to good functional and radiological outcomes. TYPE OF STUDY: Technical note, retrospective. LEVEL OF EVIDENCE: IV.

[Predictive factors of spinal deformity following surgery for intramedullary tumors]. / Facteurs prédictifs de déformation rachidienne postopératoire des tumeurs intramedullaires.

INTRODUCTION: Spinal deformity following surgery for intramedullary tumors is a serious potential complication. The aim of the study was to identify potential predictive risk factors of spinal deformity after intramedullary tumor surgery. MATERIAL AND METHODS: Retrospective study including patients harboring intramedullary tumors who underwent surgery in a single center (Hôpital Bicêtre, AP-HP, Paris) between 1985 and 2011. The main outcome was the difference at last follow-up between post- and preoperative measure of Cobb angles formed by the superior and inferior limits of the laminectomy (Δ_Cobb). RESULTS: Sixty-three patients included. Mean sagittal deformity was 15.9° (0°-77°) for a mean follow-up of 85 months (4-240). Univariate analysis of potential predictive factors showed an increased deformity for patients undergoing a 4-or-more levels laminectomy, (19.3° versus 12.1°; P=0.04), for patients aged less or equal to 30 years of age and when it included a junction (20.8° versus 12.4°; P=0.02). A neurological deficit, either pre- or postoperatively, was not associated with a greater deformity. Multivariate analysis showed that only age (P=0.01) and the number of spinal levels involved (P=0.014) were significant and independent predictors of postoperative deformity. CONCLUSION: This study indicates predictive factors of spinal deformity in any patient undergoing surgery for intramedullary tumors, allowing improvement in the planning of surgery and patients' follow-up.

Late local recurrence, at 19 and 17 years, of sacral chordoma treated by en bloc resection.

UNLABELLED: Sacral chordoma (SC) is a malignant bone tumor with high risk of local recurrence (LR) even after en bloc resection, generally in the first 10 years after resection. We report two cases of late LR, at 17 and 19 years. Two male patients, aged 45 and 53 years, presented with large SC needing a combined approach for en bloc resection. Surgical margins were safe for the first patient and borderline for the second. The patients had yearly follow-up. The first patient developed LR on the posterior wall of the right acetabulum and the second developed LR in the right sciatic notch, at 17 and 19 years, respectively. These two cases of very late LR of SC advocate for yearly screening of patients even more than 20 years after resection. LEVEL OF EVIDENCE: IV (case report).

Glutamate synthase (NADH) from lupin nodules. Specificity of the 2-oxoglutarate site.

The binding of substrate analogues including potential alternative substrates, to glutamate synthase (NADH) (L-glutamate: NAD+ oxidoreductase (transaminating) E.C. 1.4.1.14) has been investigated by studying competitive inhibition with respect ot 2-oxoglutarate. Binding requires two terminal carboxyl groups on a C5 straight chain molecule although some C4 molecules bind weakly. Bulky substituents at C2 decrease or prevent binding. Glutarate, the most potent inhibitor, binds much less tightly than the substrate. A 2-oxo group in a molecule other than the substrate does not appear to contribute significantly to binding. None of the analogues was able to act as an alternative substrate.

Postoperative pain expression in preschool children: validation of the child facial coding system.

OBJECTIVE: The purposes of the study were threefold: (a) to determine whether a measurement system based on facial expression would be useful in the assessment of post-operative pain in young children; (b) to examine construct validity in terms of structure, consistency, and dynamics of the facial display; and (c) to evaluate concurrent validity in terms of associations with global judgments of the children's pain. PATIENTS: One hundred children between the ages of 13 and 74 months were video-taped for a maximum of 1 hour after arrival in the postanesthesia care unit (PACU) at British Columbia's Children's Hospital. OUTCOME MEASURES: Videotapes were edited into 20-second blocks, randomly selected from each 2-minute time period taped during the hour following surgery, and coded for the presence or absence of 13 facial actions in the Child Facial Coding System (CFCS). RESULTS: Facial expressions were characterized primarily by the following constellation of actions: open lips, lowered brows, a deepened nasolabial furrow, mouth stretched wide in both horizontal and vertical directions, eyes squeezed shut or squinted, and raised cheeks. A principal components analysis indicated that these actions comprised a single factor, accounting for 55% of the variance in CFCS actions. Facial action summary scores were correlated with a visual analog rating of global pain, confirming that the CFCS has convergent validity. Facial action summary scores, i.e., pain displays, were at their lowest immediately after admittance to the PACU and just before the child's release from the PACU. CONCLUSIONS: The present study demonstrated that the CFCS serves as a valid measurement tool for persistent pain in children.

Loss of sagittal plane correction after removal of spinal implants.

STUDY DESIGN: A retrospective review of a clinical series was performed. OBJECTIVES: To evaluate the incidence of adult patients who experienced spinal collapse after spinal implant removal after a long spinal arthrodesis, and to assess the various factors that may influence the likelihood of collapse after implant removal. SUMMARY OF BACKGROUND DATA: Published reports describing the benefits or complications of spinal implant removal do not exist. Spinal implant removal, often considered a benign procedure, is even required by the Food and Drug Administration (FDA) for certain implants. METHODS: The medical records and radiographs of 116 consecutive adult patients with long posterior instrumented fusions (>5 segments) were reviewed. The information obtained included original diagnosis, patient age, number of previous surgeries before implant removal, levels of anterior and posterior fusion, time from fusion to implant removal, time from implant removal to failure, and reason for hardware removal. Radiographs also were assessed including scoliosis, lordosis, and kyphosis measurements before implant removal, after hardware removal, after failure, and after revision surgery. RESULTS: Of 116 patients, 14 underwent spinal implant removal. Most of these patients reported prominent implants either proximally in the thoracic spine or distally in the ilium (Galveston technique). Of these 14 patients, 4 experienced increased pain and collapse after implant removal despite thorough intraoperative explorations demonstrating solid fusion. CONCLUSIONS: Spinal implant removal after long posterior fusion in adults may lead to spinal collapse and further surgery. Removal of instrumentation should be avoided or should involve partial removal of the prominent implant.

The effect of static in vivo bending on the murine intervertebral disc.

BACKGROUND CONTEXT: Intervertebral disc cell function in vitro has been linked to features of the local environment that can be related to deformation of the extracellular matrix. Epidemiologic data suggest that certain regimens of spinal loading accelerate disc degeneration in vivo. Yet, the direct association between disc cell function, spinal loading and ultimately tissue degeneration is poorly characterized. PURPOSE: To examine the relationships between tensile and compressive matrix strains, cell activity and annular degradation. STUDY DESIGN/SETTING: An in vivo study of the biologic, morphologic and biomechanical consequences of static bending applied to the murine intervertebral disc. SUBJECT SAMPLE: Twenty-five skeletally mature Swiss Webster mice (12-week-old males) were used in this study. OUTCOME MEASURES: Bending neutral zone, bending stiffness, yield point in bending, number of apoptotic cells, annular matrix organization, cell shape, aggrecan gene expression, and collagen II gene expression. METHODS: Mouse tail discs were loaded for 1 week in vivo with an external device that applied bending stresses. Mid-sagittal sections of the discs were analyzed for cell death, collagen II and aggrecan gene expression, and tissue organization. Biomechanical testing was also performed to measure the bending stiffness and strength. RESULTS: Forceful disc bending induced increased cell death, decreased aggrecan gene expression and decreased tissue organization preferentially on the concave side. By contrast, collagen II gene expression was symmetrically reduced. Asymmetric loading did not alter bending mechanical behavior of the discs. CONCLUSIONS: In this model, annular cell death was related to excessive matrix compression (as opposed to tension). Collagen II gene expression was most negatively influenced by the static nature of the loading (immobilization), rather than the specific state of stress (tension or compression).

WHO claims maternal mortality has been underestimated.

PIP: New data produced by the WHO and Unicef demonstrated that maternal mortality has been underestimated by a third, with nearly 80,000 more pregnancy-related deaths than previously reported. About 585,000 maternal deaths occur every year, 99% of them in developing countries. 55% of the deaths occur in Asia, which is responsible for 61% of the world's births, while Africa accounts for 40% of deaths and 20% of the world's births. Developed countries account for only 1% of maternal deaths and 11% of all births. Specific statistical models were used to assess the amount of underreporting that is common in developing countries, but can also occur in developed countries. When a pregnant woman is moved from the obstetrics department because of complications and subsequently dies, the original cause of the complication often is missing from the death certificate. A representative of WHO's maternal health and safe motherhood program remarked that these estimates are a great improvement over previous data. They also should encourage action to expand access to quality care for all women during pregnancy and childbirth. In North Africa, southern Africa, eastern Asia, Central America, and South America the estimates of maternal mortality were slightly lower than those available from earlier studies. The situation was particularly worrisome in eastern, middle, and western Africa, where the earlier estimates had been underestimated by almost one-third.^ieng

Doctor on a mountaineering expedition.

Doctors are welcome members on mountaineering expeditions to remote areas, but practical advice on how to prepare and what kit to take can be difficult to find. This article is a ragbag of useful advice on diverse topics. It explains the necessary preparation, provides tips for a healthy expedition, and summarises the common disorders encountered at high altitude. The comprehensive drug and equipment lists and first aid kit for climbers were used for the 1992 Everest in winter expedition. They are there to be sacrificed to personal preference and the experience and size of individual expeditions.

[Surgical treatment of metastases from thyroid cancer in the axial skeleton. A retrospective study of 18 cases]. / Traitement chirurgical des métastases des cancers thyroïdiens au niveau du squelette axial. Etude rétrospective d'une série de 18 cas.

Between 1990 and 1997, 18 patients with a mean age of 55.5 years (11 females, 7 males) underwent surgical treatment for a metastasis from thyroid cancer involving the axial skeleton. At the time of surgery all patients had a poor prognosis: 7 metastases revealed the thyroid cancer, all 18 patients had a neurological or mechanical complication, 9 had multiple metastases, all were over 40 years of age. After arteriography with embolization, the surgical procedure consisted of curettage of the tumor and reconstruction, followed by treatment with iodine 131. The survival rate 3 years after surgery was 50%. At the last review, the functional outcome was good and 17 patients had total neurological recovery. Four complications occurred: 1 operative hemorrhage, 3 postoperative infections. Four patients had local recurrence of the metastasis with a one-year survival rate of 20%. When the thyroid cancer was revealed by the axial metastasis, the 3-year-survival rate was 42%. In cases with huge metastases, the 3-year-survival rate was 71%. It appears from these data that surgical treatment of metastases from thyroid cancer in the axial skeleton still achieves a good functional outcome even in cases where neurological or mechanical complications had occurred before surgery.

[Revision arthroplasty of the shoulder for painful glenoid loosening: a series of 14 cases with acromial prostheses reviewed at four year follow up]. / Arthroplastie d'épaule itérative pour descellement glénoïdien douloureux: quatorze cas reprix par prothèse à appui acromial revus au recul moyen de 4 ans.

PURPOSE OF THE STUDY: We present the results of a continuous series of 14 patients who underwent revision arthroplasty of the shoulder for painful major loosening of the glenoid component. MATERIAL AND METHODS: Mean follow-up was four years after revision. Loosening was diagnosed seven and a half years after the primary arthroplasty. The diagnosis of loosening was based on the association of a painful impairment of the shoulder with increasing radiolucency or migration of the component. The degree of pain alone guided the surgical decision. The posterior approach provided wide exposure. A glenoid component with an acromial fixation was used in all cases. RESULTS: The loosening was confirmed in all cases at surgery. Two were early failures of the fixation. The glenoid required a bone graft in all cases. The acromion was a useful landmark for proper positioning of the prosthesis. Fixation with cement and screws provided a strong fixation allowing immediate rehabilitation exercises. Good fixation of the glenoid component was achieved in all cases. After seven years follow-up there has been evidence of iterative loosening in one patient. In another case, one screw broke, suggesting forthcoming loosening. Twelve cases had no or very little pain. Two painful cases were associated with anterior migration of the humeral head. DISCUSSION: Even when the local conditions are unfavorable, good implant fixation can be achieved by grafting the glenoid bone loss. Functional improvement is essentially due to pain relief. CONCLUSION: This series, the largest published to date on revision surgery of painful loosening of total shoulder arthroplasty, demonstrated that iterative fixation is technically possible and can provide highly significant pain relief.