[Hip necrosis. A severe complication after intragluteal injection of quinine salt in Bangui, Central African Republic]. / La nécrose de la hanche : Une complication grave de l'injection intrafessière de sels de quinine à Bangui, République centrafricaine.

Introduction: Intramuscular injection of quinine has been for long the most common treatment for malaria in children in endemic areas of Africa, especially sub-Saharan Africa, and remains too often used. However, it is frequently wrongly performed by unqualified people. When administered in a poorly developed or malnourished child, the injection can be done too deeply in the hip joint instead of the gluteus muscle area. Materials and Methods: The files of 3012 children examined in out-patient clinics in Bangui, Central African Republic, between 2011 and 2020 were reviewed. Sequelae of intramuscular injections were observed in 307 cases, including intraquadricipital injection in 170 cases (56%) and intragluteal injection in 137 cases (44%). The latter included 115 sciatic paralysis and 22 hip sequelae with stiffness, shortening of the limb, limping and pain at walking. In these 22 cases, an intragluteal injection was incriminated by the families. However, 16 files were considered as insufficient because of imprecise history or because poor quality or no radiograph was available. Although suspected of being hip necrosis, these files were excluded. Six cases presented specific clinical pictures and interpretable radiographs and were included in this study. Results: The clinical and the radiographic aspects of this severe complication apparently not documented in the literature are analyzed. The well-known toxicity of quinine may be responsible of a necrosis involving both the femoral head and the acetabular roof, resulting in a painful joint, stiff in adduction, with limping and with an apparent marked shortening of the lower limb. Radiographs show a subtotal femoral head necrosis associated to an acetabular roof necrosis with an upward displacement of the epiphyseo-metaphysal femoral stump, the latter keeping a roughly spherical aspect and remaining well-covered and fitted in a relatively deep neo-acetabulum. Discussion: In the African background, this picture of coxopathy occurring in childhood may suggest an avascular necrosis of the femoral head complicating a sickle-cells disease, or above all sequelae of septic osteoarthritis. Treatments are limited to the prescription of a partial weight bearing of the hip. Conclusion: Although no irrefutable arguments are existing, the observed clinical and radiographic pictures are sufficiently clear and typical to individualize this severe iatrogenic complication which should be avoided by a good technic or by using the intravenous way when necessary.

[Treatment of complications of intramuscular injection of quinine salts in Africa]. / Le traitement des séquelles d'injections intramusculaires de sels de quinine en milieu africain.

Intramuscular injection of quinine is a mainstay treatment for malaria in children. However it can lead to severe orthopedic complications including sciatic paralysis after intragluteal injection and quadriceps contracture after intraquadricipital injection. This report based on a 98-case series of complications following intramuscular quinine injection that were treated surgically in 88 cases describes clinical findings with special emphasis on the severity. Therapeutic alternatives for these complications are presented and discussed including the use of medial release or double subtalar and midtarsal arthrodesis for correction of foot deformity in function of age. Correction may be associated with anterolateral transposition of the posterior tibialis tendon that is generally not paralyzed. For correction of complications involving the knee, the authors recommend extended proximal quadriceps release that is more invasive but achieves better results than lengthening plasty of the distal quadriceps.

Surgical Treatment of Angular Pott's Kyphosis with Posterior Approach, Pedicular Wedge Osteotomy and Canal Widening.

BACKGROUND: It has been observed that the correction of severe posttuberculous angular kyphosis is still a challenge, mainly because of the neurologic risk. METHODS: Nine patients were reviewed after surgery (mean follow-up 18 months). There were 2 thoracic, 4 thoraco-lumbar and 3 lumbar kyphosis. The mean age at surgery was 23. Clinical results were evaluated by the Oswestry Disability Index (ODI) and by the neurologic evaluation. Preoperative, postoperative and final follow-up X-rays were assessed. The surgery included a posterior approach with cord release and correction by transpedicular wedge osteotomy and widening of the spinal canal. RESULTS: Average kyphotic angulation was 72° before surgery, 10° after surgery and 12° at follow-up. Three out of four patients with neural deficit showed improvement. Neurologic complications included a transitory quadriceps paralysis, likely by foraminal compression of the root. CONCLUSION: A posterior transpedicular wedge osteotomy allows a substantial correction of the kyphosis, more by deflexion than by elongation, with limited neurologic risks. However it is mandatory to widely enlarge the spinal canal on the levels adjacent to the osteotomy, in order to allow the dura to expand backwards.

Extraperitoneal approach to the lumbar spine with video assistance.

STUDY DESIGN: Description of a new operative techniques for anterior lumbar and lumbosacral fusion using an anterior approach optimized by video assistance. OBJECTIVES: To propose a less invasive technique for anterior lumbar fusion with low-grade morbidity. SUMMARY OF BACKGROUND DATA: Either anterior transperitoneal or anterolateral extraperitoneal approaches commonly are performed, but each involves specific drawbacks. The authors attempted to modify and simplify these approaches with the addition of retroperitonoscopy. METHODS: A small, vertical 4- to 5-cm inclusion is made on the midline, centered on the umbilicus for the L4-L5 approach and halfway between umbilicus and public symphysis for the L5-S1 approach. The peritoneum is dissected from the left abdominal wall, and the anterior aspect of the spine progressively is exposed. The endoscope is introduced laterally, providing excellent visualization of the prevertebral area. A specially designed retractor allows retraction of the iliac vessels. RESULTS: A midline anterior approach allows disc resection and grafting in a strict midline position. The extraperitoneal approach simplifies the postoperative course. Video assistance permits an approach to the spine by a short incision and facilitates the prevertebral dissection. Surgery with video assistance should be differentiated from true endoscopic surgery, which is performed under CO2 insufflation with exclusive endoscopic vision. CONCLUSIONS: Video assistance allows for an anterior extraperitoneal approach in the lumbar spine and has the potential for lower morbidity, increasing the possibilities of anterior fusion in the management of lumber disc disease.

The Dwyer procedure in the treatment of idiopathic scoliosis. A 10-year follow-up review of 21 patients.

Despite the well-known Dwyer procedure, developed in 1969, comprehensive reports on its use, with long-term follow-up, are relatively scarce. The purposes of this study were to detect eventual late complications and to compare late results with postoperative angular curve correction. This article reports on 21 children operated on between October 1972 and October 1975 and reviewed with a minimum follow-up of 10 years (10 other patients were lost to follow-up after 5 years). Patients had idiopathic lumbar or thoracolumbar curves (average curve, 56 degrees). Results are discussed with a special reference to longitudinal observation. There is a great correction of the instrumented curve (postoperative, 5 degrees), but a loss of correction of 10 degrees is generally observed, prevented by a complete immediate correction or even hypercorrection. The upper curve, noninstrumented, also shows improvement (mean preoperative, 38 degrees; postoperative, 22 degrees; 10 years, 22 degrees) but re-equilibration cannot be predicted. Pseudarthrosis of one intervertebral space occurs frequently, and may cause failure of the cable with a loss of correction of 10-20 degrees. Kyphosis (or simple loss of lumbar lordosis) is commonly observed but should be balanced with correction of rotation. The following conclusions were made: morbidity is not severe, despite the advanced surgical technique. The technique is difficult and has a direct consequence on the quality of results; pseudarthrosis is a frequent complication, followed by important loss of correction; indications should be discussed carefully in idiopathic lumbar and thoracolumbar curves. It is still too early to advocate either anterior instrumentation of Zielke (VDS) or segmental posterior instrumentation (C. D. Luque) because of short-term follow-up.

Surgical treatment of vertebral metastasis.

Fifty-seven patients with spinal metastases underwent 60 operations. 36 patients were operated on by anterior approach with decompressive coporectomy and stabilization by metal and methylmetacrylate and 24 patients by laminectomy and/or stabilization by osteosynthesis. Postoperative improvement of the pain syndrome was observed after 56 operations. Neurologic signs were present in 23 patients with paraplegia (5 patients) or paraparesis (18 patients); 15 of the latter patients improved and recovered walking capacity. Two types of metastasis were distinguished: corporal metastasis, in which vertebral wedging and posterior protrusion led to neural deficit, with a good prognosis if treated by anterior surgery, and pericordal metastasis in which the cord compression is due to metastatic proliferation into the spinal canal. Results after decompressive surgery, either by posterior or anterior approaches are more doubtful. Surgery is beneficial and should be preferred to radiation when there is medullary compression by corporal metastasis and also in the presence of intense pain or potential instability of the spine.

Early and semi-early surgery for scoliosis caused by hemivertebrae--indications and results.

We report a series of 50 congenital scolioses due to hemivertebrae. This malformation was responsible for progressive deformity, largely predominant on the frontal plane. The average follow-up was 5 years and 3 months. Seven patients had mature bones. The series comprised 31 girls and 19 boys. Three types of operations were performed: (a) hemivertebrae resection (5 cases); (b) early, most posterior convexity fusion carried out before the age of 6 years (26 cases), and (c) semi-early convexity fusion performed between the ages of 6 and 12 years (19 cases). The results obtained in children with a more than 2 years' follow-up were: (a) early convexity fusion (18 cases): 7 epiphyseodesis effects, 6 graft effects and 4 failures; (b) semi-early convexity fusion (16 cases): 6 epiphyseodesis effects, 8 graft effects and 2 failures; (c) hemivertebrae resection (5 cases): moderate gain that remained stable in 4/5 cases.

Posttraumatic scoliosis.

A case of posttraumatic scoliosis due a misdiagnosed lumbosacral unilateral dislocation was observed 6 weeks after a traffic injury in a 15-year-old boy. Cobb angle was 30 degrees on T10-L4 with 20 degrees rotation on L1 and L2. Initial radiographs were normal. The scoliosis was corrected after surgical correction of the dislocation; at 5-year follow-up, the patient worked normally; there was no scoliosis. The suggested physiopathology of this structural scoliosis is similar to spondylolisthetic scoliosis of childhood in which asymmetrical forward displacement of the vertebral body results in rotational shift of the vertebra, with lumbar scoliosis. Correction of the scoliosis depends on correction of the lumbosacral dislocation.

[Prospects in video-assisted spinal surgery]. / Les perspectives de la chirurgie du rachis vidéo-assistée.

Advances in spinal surgery for both posterior procedures on herniated discs and anterior procedures involving the vertebral body have been greatly affected by developments in video-assisted techniques. Many of the procedures mentioned here are still in the development stage, others have proven their efficacy. Discoscopy, achieved by introducing the endoscope via a posterolateral route into the intervertebral disc, can be used for diagnosis and treatment of the disc and the end plates. Other techniques exploring the spinal canal are also being developed. With miniaturization, these techniques will undoubtedly be predominant in the near future. The anterior route is facilitated at the thoracic level by the pleural cavity. Current indications for anterior endoscopic spinal surgery are limited to cord compression syndromes, but perspectives for trauma or tumor surgery as well as reconstruction surgery for malformations in children are quite promising. On the lumbar level, surgery involving the lombo-sacral disc is the main indication for transperitoneal endoscopy. The risks (sepsis, occlusion, gas emboli) cannot be overlooked, but few complications have been observed to date. The retroperitoneal route can be used to approach the anterolateral aspect of the spine, particularly useful for the upper lumbar bodies. A third possibility is the extraperitoneal anterior route for video-assisted procedures from L2-L3 to L5-S1. Although video-assisted procedures have not yet been shown to improve long-term outcome after spinal surgery, the immediate post-operative period is greatly simplified, a point which may be of particular importance depending on the patient's general status.

[Medial acetabular displacement and other pelvic displacements after Chiari osteotomy (author's transl)]. / La médialisation du cotyle et les déplacements parasites dans l'ostéotomie pelvienne de Chiari.

The authors have made a study of displacement after Chiari osteotomy in cadavers and in patients. In most of the cases, following osteotomy, there is movement not only at the pubic symphysis but also in the two sacro-iliac joints. Movement in the ipsilateral sacro-iliac joint is associated with upward and lateral displacement of the iliac crest giving an improved cover of the femoral head even though the acetabulum is not medially displaced. Movement in the controlateral sacro-iliac joint does result in medial displacement of the acetabulum but the whole of the opposite hemi-pelvis is also displaced so that the opposite acetabulum is displaced laterally and becomes more vertical. The authors attempt to draw conclusions on the biomechanical action of Chiari osteotomy on the opposite acetabulum.

[L5 sciatica caused by the compression of the lumbo-sacral trunk of osseous origin at the sacro-iliac level. Treatment by an antero-lateral subperitoneal approach]. / Sciatique L5 par compression du tronc lombo-sacré d'origine osseuse au niveau de la sacro-iliaque. Traitement par voie antéro-latérale sous péritonéale.

A 42 years old patient presented with a 4 years history of a left L5 sciatica unresponsive to a previous L4-L5 surgical decompression. CT scan showed a solid tumor developed on the anterior aspect of the sacro-iliac joint, in contact with the lumbo-sacral trunk. An antero-lateral extraperitoneal approach was performed, with progressive subperitoneal dissection along the inner aspect of the iliac wing to the sacro-iliac joint and sacral ala. The exostosis was removed with "en block" excision, Postoperatively pain completely disappeared. Considerations are made on the mechanism of the compression as well as on the surgical approach performed.

[Surgical stabilisation of metastatic fractures of the spine]. / Stabilisation chirurgicale des fractures métastatiques du rachis.

The authors have operated on 15 patients to stabilise metastatic fractures of the spine, either by an anterior approach with replacement of the vertebral body by methyl methacrylate, or by a posterior approach combining laminectomy with spine fixation. The posterior approach was considered to be better in cases of neurological impairment or in lesions of the lower lumbar spine. At cervical, thoracic and thoraco-lumbar levels, the anterior approach was preferred and gave rapid functional improvement. The use of cement allowed early walking without extensive bracing and improved the comfort of the patient. Neurological involvement was a good indication for surgery. In cases without cord lesions, the indications for treatment are related to the comfort of the patient.

[Post-operative instability after lamino-arthrectomy for degenerative lumbar stenosis]. / L'instabilité post-opératoire après laminoarthrectomie pour sténose lombaire dégénérative.

PURPOSE OF THE STUDY: The purpose of this paper was to investigate the post-operative instability after laminoarthrectomy for degenerative lumbar stenosis, and to evaluate the functional results when instability was present. MATERIAL AND METHOD: Thirty-eight patients presenting with degenerative lumbar stenosis were operated on at a mean age of 64 years, and were reviewed after a 6 years average follow-up (range 4-8). A laminectomy with partial arthrectomy removing the medial aspect of the articular facets was performed in all cases, extended on one level in 16 cases, 2 levels in 16 cases, 3 levels in 4 cases, and 4 levels in 2 cases. Functional results were evaluated according to Lassale criteria. Radiographic evaluation included measurement of static instability by comparing pre operative and last available X-Rays according to Johnsson and Lassale, and measurement of dynamic instability according to Dupuis. RESULTS: Mean relative gain was 57 per cent; result was rated as excellent in 11 cases, good in 17 cases, and poor in 10 cases. No instability was observed in 14 cases. A pre-existing instability was not modified at follow-up in 10 cases; spinal instability was aggravated or induced by surgery in 14 cases, with 8 antelisthesis (mean slip 6 mms), 2 retrolisthesis, and 4 scoliosis with rotatory dislocation: mean pre-operative angulation was 7 degrees; mean angulation at follow-up was 17 degrees. A dynamic instability was observed in 4 cases. Mean relative gain of the 14 patients with instability at follow-up was 58 per cent; relative gain was 62 per cent in patients with antero-posterior instability, relative gain was 40 per cent in patients with rotatory instability and scoliosis. No correlation was observed between functional results and static or dynamic instability. RESULTS: These results suggest that post-operative dynamic instability is uncommon after lamino-arthrectomy in elderly. On the other hand, a static instability is observed in half of patients at follow-up. Increase of a pre-existing slip is frequently observed but is moderate and does not impair the functional result. Increase of a pre-existing scoliosis is more worrying and is associated with less satisfactory functional results. Internal fixation should be recommended particularly when a scoliosis is present.

[Treatment of spinal deformities with the Hartshill frame]. / Le traitement des déformations rachidiennes par le cadre de Hartshill.

The Hartshill rectangle, a metal frame fixed to the laminae by sublaminar wires, has been used in 50 cases. Twenty idiopathic adolescent scolioses have been corrected from 49.3 degrees to 24.7 degrees with excellent stability of the curve at six and twelve months follow-up. Twelve paralytic scolioses were corrected from 71 degrees to 34.7 degrees but, in nine cases, the associated pelvic obliquity was not appreciably altered. Eleven adult scolioses, with an age range between 20 and 68 years, were corrected from 66.3 degrees to 38.7 degrees by a two-stage procedure of anterior release followed by posterior fixation with a Hartshill frame. In six patients with spinal metastases the Hartshill frame was used to provide spinal stability. The segmental fixation gave immediate post-operative comfort and allowed the patient to mobilise early without bracing. There were transient neurological complications--three cases of cutaneous hyperaesthesiae and one of monoparesis of a lower limb. Failure of the apparatus was encountered in cases of severe deformity with bending of the metal of the rectangle in two cases, breakage of distal wires in three cases and slipping of wires on the frame in two cases. The Hartshill frame provides stable fixation of the spine. It produces a three-dimensional correction of the scoliosis with preservation of reformation of the normal physiological kyphosis and lordosis. It is indicated for the correction of sagittal deformities, particularly in older patients and adults with thoracolumbar or lumbar curves and for spinal instability, especially in cases of destruction of posterior bony and ligamentous elements of the spine.

[Spontaneous elimination by the natural tracts of screws of anterior cervical osteosynthesis. Apropos of a case]. / Elimination spontanée de vis d'ostéosynthèse cervicale antérieure par les voies naturelles. A propos d'un cas.

PURPOSE OF THE STUDY: The authors report a case of a wellknown but very unusual complication of cervical spine anterior osteosynthesis: spontaneous recurrent elimination of anterior fixation device through the gastrointestinal track, with good outcome. MATERIALS AND METHODS: The patient (75 years old) was operated on for cervical myelopathia due to cervical stenosis. Surgical treatment included an anterior release with corporectomy of C4, C5 and C6 and iliac graft insertion, and fixation using plate and screws. Immediate post-operative course was uneventful. Plate incurvation and rupture were observed during the second post-operative month, with partial anterior migration of the lower screw. As the patient complained of dysphagia, removal of osteosynthesis was decided and scheduled 3 days later; however the screw was missing on a pre-operative radiograph. It was found on a routine abdominal X-Ray, and it passed out during the following week. Dysphagia disappeared in a few days and removal of osteosynthesis was given up for fear of oesophageal complications. Further evolution was favourable. Cervical fusion was obtained uneventfully. Post-operative myelmogram showed a good canal enlargement. The patient was temporarily lost for follow-up and was asked for review 2 years later. Mild difficulty in swallowing saliva was still present without dysphagia. On routine cervical X-Rays another screw had disappeared again. Oesophagoscopy was proposed but not accepted by the patient because he felt not significantly disturbed. DISCUSSION AND CONCLUSION: Complications associated with oesophageal perforation may range from massive infection and death to spontaneous resolution. Erosion due to extruded bulky constructs leads to persistent fistula with abscess or septic diffusion. Perforation due to complete migration of small foreign bodies like screws gives possibility of spontaneous oesophageal closure and healing without significant morbidity. The spontaneous recurrent elimination of 2 screws gives to this observation a very outstanding feature.

[Surgical treatment of cervical disk displacement. Anterior or posterior approach?]. / Le traitement chirurgical des hernies discales cervicales. Abord antérieur ou abord postérieur?

PURPOSE OF THE STUDY: This study is a retrospective analysis of the treatment of cervical soft disc herniation comparing anterior and posterior approach. MATERIAL AND METHODS: Twenty eight patients presenting with cervico-brachial radiculopathy secondary to acute soft posterolateral disc herniation were reviewed. Cases with myelopathy or radiculopathy secondary to chronic spondylosis were excluded. Involved level was C5-C6 or C6-C7 in most cases. There were 14 females and 14 males. Age at operation averaged 44 years. Fourteen patients underwent an anterior approach with discectomy and fusion using autologous iliac bone graft. Average age was 46 years in this group with an average follow-up of 30 months. Average duration of surgery was 2 hours. Average hospital stay was 6 days. Fourteen patients underwent a posterior approach with partial lateral laminotomy extending medially for several millimeters over the facet joint. Extruded disc material was removed in 10 cases. No curettage was performed. Average age at surgery was 41 years with an average follow-up of 36 months in this group. Average duration of surgery was 70 minutes. Average hospital stay was 6 days. RESULTS: Patients were evaluated 3 months post-operatively and at their maximum follow-up. At 3 months follow-up, no patient complained of radicular pain; occasional cervical pain was present in 5 cases following posterior surgery but was not observed at late follow-up. Return to work was possible on an average of 3 months in both series. Results were graded as excellent, good, fair and poor. At late follow-up, in patients with a posterior approach, there were 8 excellent results, 5 good results with neck fatigue at work, and 1 fair result requiring analgesics. In patients with an anterior approach, there were 7 excellent results, 6 good results, and 1 fair result. Two patients complained of pain at the iliac donor site. DISCUSSION: These results suggest that the anterior approach gives better short term results, but no significant difference is observed between anterior and posterior approaches a few years after surgery. Although the anterior approach is more appropriate than the posterior one for the treatment of central disc herniation, the posterior approach may be considered as an alternative to anterior discectomy and fusion for antero-lateral soft disc herniation.

[Surgical treatment of myeloma localized in the spine]. / Le traitement chirurgical des localisations rachidiennes du myélome.

PURPOSE OF THE STUDY: Myeloma represents as much as 40 per cent of malignant primary spine tumors. The aim of this study was to discuss the indications for surgical treatment of spinal myeloma. MATERIAL AND METHODS: 18 patients presenting spinal localization of myeloma were operated on. There were 10 males and 8 females. Mean age was 59.9 (41-86). Pain was present in all patients. Seven patients presented neurologic signs: Frankel B: 1 case, Frankel C: 3 cases, Frankel D: 3 cases. Surgical treatment included anterior approach in 6 cases, posterior approach in 5 cases and combined approach in 7 cases. Postoperative medical treatment (chemotherapy, radiotherapy, immunotherapy) was performed in all cases. RESULTS: Diagnosis was made after surgery in 10 patients on histological findings. There were 13 myelomas and 5 plasmacytomas. Decrease of pain was observed in all cases at first postoperative month; 9 patients were pain free at the 6th postoperative month. Complications occurred in 4 cases: 2 local infections after radiotherapy; mobilisation of an anterior implant in one case and local recurrence in one case requiring secondary surgery. Nine patients were alive at review with a mean follow-up of 57 months. Nine patients were dead with a mean follow-up of 15.4 months. Preoperative Karnofsky score was 50 per cent; Karnofsky score was 77 per cent at follow-up. Neurologic deficit improved in 5 out of 7 cases. DISCUSSION: Primary treatment of myeloma is medical associating chemotherapy, corticotherapy, radiotherapy and immunotherapy. Plasmocytoma is frequently revealed by neurologic deficit. Staging of myeloma gives the prognostic. Surgical treatment must be performed when pain is not controlled by medical treatment or when neurologic deficit is present. CONCLUSION: Surgery allows rapid and durable functional recovery in patients with spinal myeloma; surgery should be associated to additional medical treatment, unlike spinal metastasis.

[Surgery of the spine in Duchenne's muscular dystrophy]. / La chirurgie du rachis dans la dystrophie musculaire de Duchenne.

PURPOSE OF THE STUDY: The authors present a retrospective review of 27 patients presenting a Duchenne muscular dystrophy and who were operated for spinal deformity, with special reference to functional result and postoperative evolution of vital capacity. MATERIAL AND METHODS: Age at surgery averaged 14. Mean scoliotic angulation was 42 degrees. A thoraco-lumbar kyphosis was present in 15 cases (kyphotic index less than 10 degrees). A pelvic obliquity averaging 17 degrees was associated in 19 cases. Mean pre-operative vital capacity was 56 per cent. Preoperative evolution of vital capacity was documented in 18 cases: annual rate of decrease was 4.3 per cent. Heart ejection fraction averaged 63 per cent in 23 cases, and was normal in 4 cases. Instrumentation was extended from D3, D4 or D5 to L5 (5 cases) or S1 (22 cases). Spinal fixation was done in all patients by subliminar wiring with Luque rods (5 cases) or Hartshill rectangle (22 cases). Sacral fixation was done with ilio-sacral screws linked to the rectangle by Cotrel Dubousset rods and dominos (15 cases). RESULTS: Mean blood loss was 1750 cc. Postoperatively, 25 patients were extubated on the operative day, 1 patient at D + 1, and one patient underwent a tracheostomy after one month. Scoliosis was reduced to 10 degrees after surgery and 13 degrees after 30 months follow-up. Pelvic obliquity was reduced to 4 degrees after surgery and 7 degrees after 30 months. A good spinal balance was present after surgery in 20 patients; at follow-up, a coronal or sagittal imbalance averaging 40 mm was observed in 22 patients. Postoperative evolution of vital capacity was documented in 21 cases. The annual decrease rate was 6.4 per cent. Rate was higher in patients presenting a good preoperative vital capacity (over 70 per cent) and very low in patients presenting a preoperative vital capacity under 40 per cent. 10 patients were deceased at review after a mean 53 months survival, at a mean age of 19. 17 patients were alive with a 50 months follow-up. DISCUSSION: Spinal surgery in Duchenne muscular dystrophy has a low morbidity. It allows to keep sitting position to the child and to preserve quality of life. Surgery should be considered as soon as frontal or sagittal collapse of the spine is observed. However surgery does not result in respiratory improvement nor in life duration lengthening.

[Spinal localization of Gorham's syndrome. Case report]. / Localisation rachidienne d'un syndrome de Gorham. A propos d'une observation.

The authors report a case of massive osteolysis of the spine in an eighteen years old boy presenting a T9 collapse without neurological symptoms associated to a right chylothorax which disappeared after 5 days of drainage. MRI showed an increased signal on T1 and T2 weighted sequences. An orthopaedic treatment with a cast was decided as a first attempt. Because on increasing pain and kyphosis, surgery was considered, with posterior segmental fixation with Hartshill rectangle from T4 to L5. The result was satisfactory after 6 months of follow-UP. The vanished bone disease is a rare affection of unknown aetiology. 132 cases were published, 20 with spinal localization. The prognosis is uncertain with a mortality of 16 per cent. The treatment of bony lesions is difficult. Spinal localizations are best treated by segmental fixation extended on normal vertebrae.

[Surgery for degenerative lumbar disc disease. Should the black disc be grafted?]. / La chirurgie des discopathies lombaires. Faut-il greffer le disque noir?

PURPOSE OF THE STUDY: To determine predictive factors allowing to improve the results of fusion in low back pain treatment. MATERIAL AND METHOD: Fifty six patients were retrospectively reviewed. Average age at surgery was 42. In 29 cases, discectomy or nucleolysis had been previously performed. All patients were treated by anterior lumbar interbody fusion. Functional results were assessed by the Beaujon index, with determination of a relative improvement rate. Results were analyzed according to clinical symptoms, fused level, previous surgery, association to posterior osteosynthesis and MRI changes. MRI changes were classified according to Modic types. RESULTS: The average relative improvement rate was 66 per cent. Pain topography, previous surgery, fused level, association with posterior osteosynthesis had not statistical effect on the functional result. Inversely, a close relation was observed between pre-operative MRI changes and the result of surgery: best results were observed in Modic I changes on adjacent vertebral end plates, with decreased signal of T1 and increased signal on T2 weighted images, suggesting inflammatory changes; poor results were observed in isolated disc degeneration without vertebral end-plates changes; poor results were observed in Modic II changes with increased signal on both T1 and T2 weighted images, suggesting degenerative changes; but among 5 non unions, 3 were observed in Modic II changes. DISCUSSION: The authors identify a lumbar disc dysfunction syndrome characterized by mechanical pain, with disc narrowing and anterior condensation of the vertebral plates on MRI (Modic I changes). This syndrome should be differentiated from common degenerative disc disease, without vertebral plates abnormalities (the "black disc" on MRI). CONCLUSION: Anterior fusion is effective for the treatment of low-back pain due to degenerative disc disease, when associated to vertebral plate changes; as the pathology is mainly anterior. We prefer an anterior mini-invasive approach; furthermore, posterior elements are intact and canal exploration is unnecessary. However, an additional posterior osteosynthesis is preferable in Modic type II, as non union rate is increased by fatty degenerative involution.