Adjacent segment disease after anterior cervical interbody fusion: a multicenter retrospective study of 288 patients with long-term follow-up.

INTRODUCTION: Cervical discectomy with interbody fusion is a common procedure in spinal surgery. The resultant biomechanical alterations accelerate degeneration of the adjacent segment, but the contribution of natural degeneration to adjacent segment disease is unclear. OBJECTIVE: To assess the long-term rate of surgery to discs adjacent to cervical interbody fusion; and to assess the associated incidence of cervico-brachial neuralgia and radiological degeneration of adjacent discs. MATERIAL AND METHOD: A multicenter retrospective study included anterior cervical discectomy patients at a minimum of 10 years' follow-up. Clinical variables comprised pain, use of analgesics and surgical revision. Functional assessment was performed on the Neck Disability Index (NDI). Radiologic degeneration was assessed on the Goffin score based on cervical spine X-ray. RESULTS: Two hundred and eighty-eight patients were contacted and filled out the clinical questionnaire. Among the patients, 153 underwent radiological reassessment. Mean age was 46 years (range, 16-73 years). Mean follow-up was 14.5 years (12-18 years). The rate of surgical revision on a disc adjacent to the primary level was 5.9%. Frequent attacks of cervico-brachial neuralgia were reported in 20.5% of cases. Radiologic adjacent segment degeneration was found in 81.3% of cases over follow-up. There was a significant correlation between degree of radiologic adjacent segment degeneration and NDI (P=0.02). DISCUSSION: Degeneration adjacent to discectomy/fusion is partly due to aging. The present findings, however, agree with the literature and indicate accelerated degeneration in adjacent segments. These findings should be taken into account in treatment decision-making and suggest a possible interest of more physiological surgery such as arthroplasty. LEVEL OF EVIDENCE: IV - Multicenter retrospective study.

Surgical discectomy for lumbar disc herniation: surgical techniques.

Discectomy for lumbar discal herniation is the most commonly performed spinal surgery. The basic principle of the various techniques is to relieve the nerve root compression induced by the herniation. Initially, the approach was a unilateral posterior 5-cm incision: the multifidus was detached from the vertebra, giving access through an interlaminar space in case of posterolateral herniation; an alternative paraspinal approach was used for extraforaminal herniation. Over the past 30 years, many technical improvements have decreased operative trauma by reducing incision size, thereby reducing postoperative pain and hospital stay and time off work, while improving clinical outcome. Magnification and illumination systems by microscope and endoscope have been introduced to enable minimally invasive techniques. Several comparative studies have analyzed the clinical results of these various techniques. Although the methodology of most of these studies is debatable, all approaches seem to provide clinical outcomes of similar quality. At all events, minimally invasive techniques reduce hospital stay. While technical proficiency is essential, the final result depends on strict compliance with a prerequisite for surgical indication: close correlation between clinical symptoms and radiological findings. It is essential to discuss the risk/benefit ratio and explain the pros and cons of the recommended technique to the patient.

Surgery of lumbar and thoracolumbar scolioses in adults over 50. Morbidity and survival in a multicenter retrospective cohort of 180 patients with a mean follow-up of 4.5 years.

INTRODUCTION: The increasing life expectancy of the population and the improvement in surgical and medical management of elderly patients mean that the indication for surgical treatment of adult lumbar and thoracolumbar scolioses has been extended. However the benefit/risk ratio of these procedures is still under debate. MATERIALS AND METHODS: We reviewed 180 patients, mean age 63years old with a minimum follow-up of 1year in a retrospective, continuous, multicenter study. The incidence rate of complications from surgery and the factors influencing their frequency were evaluated by uni- and multivariate analysis. The risk of a second operation was studied by actuarial survival analysis. RESULTS: After a mean follow-up of 4.5years, 79 patients (44%) presented with at least one complication, including 32% with a serious complication. The most frequent complications were mechanical. The risk factors were medical co-morbidities, the extent of fusion and the extent of the preoperative sagittal imbalance. A second operation was necessary in 25% of patients at 1year and 50% of patients at 6years of follow-up. DISCUSSION: Studies in the literature show that functional results are better with surgical treatment than with medical treatment in the management of thoracic spine and thoracolumbar deformities in patients over 50years old. An objective assessment of this deformity and associated co-morbidity should make it possible to reduce the rate of complications for this type of surgery. LEVEL OF EVIDENCE: Level IV.

Applications in spinal imbalance.

The pelvis may be seen as a single vertebra, between the spine and the femurs. The anatomy of this pelvic vertebra has changed with the evolution of species, notably with the transition to bipedalism, with the consequent appearance of lumbar lordosis. The lumbosacral angle, almost non-existent in other mammals, is at its greatest in humans. Pelvic and spinal radiological parameters reflect the sagittal balance of the spine in bipedal humanity. Applications in the management of spinal imbalance are numerous. Arthrogenic or degenerative kyphosis is the stereotypic example of spinal aging. Postoperative flat back following spine surgery is hard to prevent. Scoliosis surgery in adults should now take greater account of the patient's individual sagittal balance, by analyzing the pelvic and spinal parameters. The extent of arthrodeses performed during adolescence to manage idiopathic scoliosis may also induce problems of balance in adulthood if these elements are not taken into account.

[Complications of surgical treatment of spinal deformities: a prospective multicentric study of 3311 patients]. / Les complications du traitement chirurgical des déviations rachidiennes: etude prospective multicentrique d'une cohorte de 3311 patients.

PURPOSE OF THE STUDY: The incidence of complications secondary to surgical treatment of spinal deformations remains imprecise. The purpose of this prospective multicentric observational study was to assess the incidence of intra- and postoperative complications secondary to this type of surgery to detail the observed complications and to identify favoring factors. MATERIAL AND METHODS: For this study, we included 3311 patients who underwent surgery during a 12-month period for spinal deformation, defined as idiopathic or secondary scoliosis or kyphosis, irrespective of the localization, severity, or type of surgery performed. Four main categories of complications were studied: general, infectious, neurological, and mechanical. Pre- and intraoperative variables recorded were: epidemiological and morphological data, history of surgery for the same spinal deformation, comorbid conditions, type of deformation treated (nature, anatomic localization, severity, reducibility), type of surgery performed (approach, duration of the operation), operative blood loss, extent and localization of the fusion, associated neurological release, vertebral osteotomy or not, type of graft used. Two types of analysis were performed. The first was a descriptive analysis to detail the overall incidence of complications and the incidence of each of the four main categories. The second was a multivariate analysis designed to determine factors significantly associated with complication occurrence. RESULTS: Mean age of the cohort was 27 +/- 18 years; 6.8% of the patients had had a prior operation for the spinal deformation. The deformation was scoliosis in 90% (mean angle 56 +/- 20 degrees) and kyphosis in 10% (mean angle 47 +/- 23 degrees). An isolated posterior approach was used for 72.5% of patients, an isolated anterior approach for 6.4%, and a combined anteroposterior approach for 21.1%. Seven hundred four patients (21.3%) had one or more complications (850 complications) during or shortly after their operation. The incidences of general, infectious, mechanical and neurological complications were: 5.7%, 4.7%, 11.5%, and 1.8% respectively. Globally, considering all types of complications, the following factors were found to be significantly associated with complication occurrence: patient age, ASA score, extent of the fusion, presence of vertebral osteotomy, inclusion of the sacrum in the arthrodesis, and initial angle of the treated deformation. For patients with scoliosis, the following factors were significantly associated with a secondary central neurological disorder: initial angle of the deformation, use of vertebral osteotomy, type of curvature with greater risk for thoracic curvatures and double thoracic and lumbar curvatures. CONCLUSION: This work enabled us to determine the overall rate of complications after surgical treatment of spinal deformations. Certain risk factors related with complication occurrence were identified, but the heterogeneous nature of the population and the methodology used to identify these factors only allowed detection of trends. A future study by etiological group or focusing on specific complications should allow a more precise analysis of these risk factors. This overall rate of complications should be used to better inform patients and their family about the risks of this type of surgery.

[Intraspinal rib penetration in four patients in neurofibromatosis vertebral deformities]. / Pénétration intra-canalaire de côtes dans les déformations vertébrales de la neurofibromatose.

We describe the clinical and radiological features observed in four patients with neurofibromatosis-related scoliosis or kyphoscoliosis who developed rib penetration into the intervertebral foraminae. Rib penetration should be searched for on standard and elective x-rays in patients with moderate curvatures. The diagnosis can be confirmed by computed tomography or magnetic resonance imaging of the spine. In case of major deviation, x-rays must be carefully examined, with an accurate search for spinal cord compression to avoid missing the diagnosis. Surgical treatment must consist in ablation of the posterior ends of the dislocated ribs associated with anterior and posterior fusion. It should be performed early to avoid the development of spinal cord compression.

[Validation of a self-administered functional evaluation questionnaire after surgical treatment of lumbar spine stenosis]. / Validation d'un auto-questionnaire d'évaluation fonctionnelle du traitement chirurgical des sténoses lombaires.

PURPOSE OF THE STUDY: The main aim of this prospective, multicentric, observational study was to validate a self-administered quality-of-life questionnaire for patients with lumbar spine stenosis treated surgically. MATERIAL AND METHODS: The self-administered questionnaire was composed of eight questions exploring three dimensions: lumbalgia, radiculalgia, radicular ischemia. This questionnaire was associated with an index of neurological involvement (to take into account objective neurological data), and with an index of patient satisfaction (to assess the patient's perception of the impact of surgery on lumbalgia, radiculalgia, and gait disorders). The scoring scale was validated by studying the structure of the questionnaire (to ascertain the pertinence of the proposed three dimensions), by determining the questionnaire's reproducibility (intraobserver variability) and sensitivity to change, and by examining the contents of the questions (to assess the capacity of the scale to effectively measure the parameters it was designed to measure). Cronbach's alpha coefficient and principal component analysis were used to assess the questionnaire's structure. Reproducibility was tested on 49 patients who completed the self-administered questionnaire twice at a 15-day interval; intraclass correlation coefficients were determined. Sensibility was tested by correlating variation in the scores obtained pre- and postoperatively with the index of satisfaction; mean standard responses were determined. The validity of the questionnaire's content was assessed by correlating the scores obtained with the questionnaire to those obtained with three other self-administered questionnaires: SF36, EIFEL2 and GHA38. RESULTS: This work included 104 patients, 96 of whom were reviewed at consultations 6 and 12 months after surgery. The principal components analysis confirmed the presence of the three dimensions. The global Cronbach alpha coefficient was 0.86. The global intraclass coefficient of correlation was 0.95, varying from 0.86 to 0.97 depending on the dimension studied. There was a good correlation (0.82) between changes in the score studied and the index of satisfaction. All the mean standardized responses were higher than 1, indicating good sensitivity to change. There was also a good correlation between the questionnaire tested and the EIFEL2 self-administered questionnaire and the following dimensions of the SF36: physical activity, physical pain, vitality, and limitation due to physical pain. DISCUSSION AND CONCLUSION: Associating a simple 8-question self-administered questionnaire with an index of satisfaction (4 questions) and an objective index of neurological involvement provided a reliable, sensitive, and reproducible assessment of the changes in functional disorders resulting from lumber stenosis before and after surgical treatment.

[Thoracic spinal cord compression by radiation-induced exostosis: a case report and review of the literature]. / Compression médullaire thoracique par une exostose radio induite: à propos d'un cas et revue de la littérature.

A 38-year old man developed compressive myelopathy due to radiation-induced osteochondroma at T7. The patient had been given radiotherapy at the age of 7 years for a lymphosarcoma situated at the lower part of the neck. Radiation is an exceptional cause of spinal compression which can be avoided by regular surveillance of patients given radiotherapy in the spinal area as children.

Successful epidural blood patch in a patient with headache for 6 months after lumbar root decompression.

Prolonged headache following dural puncture is an uncommon problem that may occur after a spinal tap, often as a complication of epidural anaesthesia. This problem has also been described after long-term epidural or spinal anaesthesia, myelography or spinal surgery. A case of prolonged postdural puncture headache following lumbar nerve root decompression is described in a healthy young man. No other cause could be found either clinically or with the aid of scanning by computerized tomography or magnetic resonance imaging techniques at the spinal level involved. The symptoms were successfully treated with an epidural blood patch performed seven months following the original surgical operation.

[Irreductible congenital dislocation of the hip at birth]. / Luxation congénitale de hanche irréductible à la naissance.

BACKGROUND: Rare congenital dislocation of hip (CDH) (0.03 for 1,000 births) are irreducible at birth; they are named teratologic in literature. However some of them are isolated without any pathological context, having a postural origin or due to an underlying disease. PATIENTS: Seventeen dislocated hips, irreducible at birth, were seen in 12 infants and included in this study. Clinical examination of these neonates was normal with the exception of signs of CDH. Postural abnormalities such as pes calcaneus, genu recurvatum, torticolis were seen in ten infants but none of the 12 had any manifestation of neurologic, dystrophic or malformative disease. However, manifestations of a disease able to explain the CDH such as congenital myopathy, cutis laxa, cortical atrophy, Klinefelter syndrome, appeared within the following months in four infants. Treatment of these CDH started in every case by an attempt of reduction by continuous traction and was efficient in eight cases. A redislocation occurred for four hips and this treatment was uneffective for five hips. Finally seven hips had to be treated by open reduction. Reduction was maintained for nine hips after closed treatment (one of them after a redislocation and a second time of orthopaedic treatment). One hip is still dislocated after failure of closed treatment. Stabilisation of the reduction was necessary by pelvic and/or femoral osteotomy in majority of cases. CONCLUSIONS: Morphological modifications of hip established from X-rays and during the surgical procedure are rather related to the age of the dislocation making inappropriate the term "teratologic". The irreducible and isolated CDH can be postural in origin but as well due to a disease whom manifestations will appear lately. Their treatment, orthopaedic or surgical, is difficult and the results often disappointing.

[Remodeling of the spinal canal after comminuted fracture of the spine. Apropos of a case]. / Remodelage du canal rachidien après fracture comminutive du rachis. A propos d'une observation.

A burst fracture of T 12, without neurological impairment, was treated by plaster cast. Prior to treatment, there was a significant narrowing of the spinal canal, due to posterior displacement of a bone fragment. This was not modified by treatment, as the narrowing was unchanged on the second CT scan, done eight days later. At 17 months, there was no more narrowing on the CT scan, as a consequence of vertebral body remodeling. The patient had no pain and performed several sport activities.

[Supracondylar fractures of the humerus associated with ipsilateral fractures of the forearm]. / Fracture supra-condylienne de l'humérus associée à une fracture homolatérale de l'avant-bras chez l'enfant.

We report 20 cases of ipsilateral supracondylar elbow fracture and forearm fracture in childhood. The mean follow-up was 20 months. For an analysis of the results, we used a global rotation of the upper limb. We appreciated the motion and the carrying angle of the elbow and the wrist. 15 cases were very good or good; there were 4 cubitus varus without functional impairment and 1 failure after one open Monteggia fracture. The therapeutic strategy is discussed. If one does not want to increase the damage to periosteum in the elbow during the forearm reduction, one must first reduce the supracondylar fracture and fix it by 2 pins like in Judet procedure. Then, the forearm fracture should be treated conservatively.

[Cotrel-Dubousset instrumentation in the treatment of thoracolumbar and lumbar spine fractures]. / L'instrumentation de Cotrel-Dubousset dans le traitement des fractures de la charnière dorso-lombaire et du rachis lombaire.

Thirty-three thoracolumbar and lumbar spine fractures have been operated on using Cotrel-Dubousset instrumentation. Most were thoracolumbar burst fractures. Regional kyphosis at follow-up was 4 degrees, vertebral kyphosis was 8 degrees. Secondary loss of regional kyphosis was 1 degree, and 10 degrees of vertebral kyphosis. This construct with screws varies according to the level (thoraco-lumbar or lumbar); it seems reliable, as compared with other kinds of internal fixation. Restoring the height of the vertebral body is essential and is the key to a good final result. Addition of a postero-lateral fusion and or a brace did not improve the results.

Osteochondral fractures of the glenoid fossa of the ulna in children: review of four cases.

Osteochondral fractures of the glenoid fossa of the ulna are exceptional injuries in children. These lesions can present diagnostic problems because the fragments are often radiolucent. We followed four children for 3, 6, and 24 months and 12 years, respectively. The elbow was definitely dislocated in two, and was probably dislocated in two other, children. The most reliable paraclinical examination was conventional sagittal tomography. Open revision is mandatory for reduction of the fracture and, when performed early, may lead to excellent functional results.

[Salter innominate osteotomy for the treatment of congenital dislocation of the hip]. / L'ostéotomie innominée de salter dans le traitement de la luxation congénitale de hanche. Résultats à plus de 10 ans de recul de 43 ostéotomies.

Thirty-one children (43 hips) were reviewed after having sustained a Salter innominate osteotomy. The average follow up was 10 years. The indication for the osteotomy was a persisting dysplasia after conservative treatment of congenital dislocation of the hip. The X rays study allowed to describe the importance of the remodeling of the femoral head. The overall results were satisfactory in 60 per cent of the cases. The age of the patient at the time of surgery was important: the results being much better in children under 5 years of age. The failures were mostly related to technical faults. However some failures could not be predicted.

[The fate of fat grafts used in surgery of the lumbar spine]. / L'évolution des greffons graisseux utilisés en chirurgie du rachis lombaire.

The fate of fat grafts thicker than 5 mm applied to prevent post-operative peridural fibrosis was followed by CT scanning between the second and fourth months and in later months in four patients treated for lumbar spinal stenosis. The CT scanning findings were verified in two patients who were operated on again. The fat grafts lost thickness and became more even. In one case, the graft had completely disappeared.