Abnormalities of the lumbar spine in the coronal plane on plain abdominal radiographs.

The main objective of this study is to determine the prevalence of coronal abnormalities of the lumbar spine in a large population of patients with respect to their age and sex. Lumbar degenerative disease is associated with degenerative scoliosis. Degenerative scoliosis and lateral listhesis are important features to identify before decompressive surgery as deformity may not be seen on magnetic resonance imaging scans. Scoliosis and lateral listhesis may be important in the development of symptoms especially in an ageing population. All abdominal and plain kidney-ureter-bladder radiographs performed over a 10-month period were reviewed. 2,765 radiographs were assessed for scoliosis (Cobb angle greater then 10°), lateral listhesis and evidence of osteoarthritis. The prevalence of scoliosis, lateral listhesis and osteoarthritis of the lumbar spine increased with age. Scoliosis and lateral listhesis were significantly more prevalent in women. Deformity starts to occur after the age of 50 and steadily increases with age. By the ninth decade nearly a quarter of patients have evidence of scoliosis and lateral listhesis. As the adult lumbar spine ages, the prevalence of lateral listhesis and degenerative scoliosis increases. It is important to appreciate these coronal abnormalities in patients undergoing decompressive surgery for spinal stenosis. This increase in deformity may have a greater impact as the population continues to age.

Lumbar disc degeneration below a long arthrodesis (performed for scoliosis in adults) to L4 or L5.

A retrospective analysis of adults treated with long instrumented fusion for scoliosis from the thoracic spine proximally to L4 or L5. To evaluate the long-term clinical outcomes as well as radiological changes in distal unfused mobile segments and to evaluate factors that may predispose to distal disc degeneration and/or poor outcome. A total of 151 mobile segments in 85 patients (65 female), mean age 43.2 (range 21-68), were studied. Curve type, number of fused levels and pelvic incidence were recorded. Clinical outcome was measured using the Whitecloud function scale and disc degeneration using the UCLA disc degeneration score. Spinal balance, local segmental angulations and lumbar lordosis were measured pre- and post-operatively as well as at the most recent follow up--mean 9.3 years (range 7-19). A total of 62% of patients had a good or excellent outcome. Eleven had a poor outcome of which ten underwent extension of fusion--five for pain alone, three for pain with stenosis and two for pseudarthroses. Pre-operative disc degeneration was often asymmetric and was slightly greater in older patients. Overall, there was a significant deterioration in disc degeneration (P < 0.0001) that did not correlate with clinical outcome. Disc degeneration correlated with the recent sagittal balance (Anova F = 14.285, P < 0.001) and the most recent lordosis (Anova F = 4.057, P = 0.048). The post-operative sagittal balance and local L5-S1 sagittal angulation correlated to L4 and L5 degeneration, respectively. There was no correlation between degeneration and age, pre-operative degenerative score, pelvic incidence, sacral slope, number of fused levels or distal level of fusion. Disc degeneration does occur below an arthrodesis for scoliosis in adults which does not correlate with clinical outcome. The correlation of loss of sagittal balance with disc degeneration may be as a result of degeneration causing the loss of balance or vice versa, i.e. sagittal imbalance causing degeneration. Immediate post-operative imbalance correlates with degeneration of the L4/5 disc, which may imply the latter.

The paraspinal splitting approach: a possible approach to perform multiple intercosto-lumbar neurotizations: an anatomic study.

STUDY DESIGN: Descriptive anatomy. OBJECTIVE.: To describe the anatomy associated with the extensive transmuscular paraspinal approach required to perform multiple intercosto-lumbar neurotizations. SUMMARY OF BACKGROUND DATA: Neurotization of lumbar roots using lower intercostal nerves is a potential method of treating neurologic deficits after spinal cord injury. It appeared to us that the paraspinal splitting approach was potentially an optimal method to perform intercostal nerve harvesting, rerouting, and intercosto-lumbar neurotizations. METHODS: Ninth, 10th, and 11th intercostal nerve harvesting and rerouting down to L2, L3, and L4 roots were performed on 50 cadavers. The descriptive anatomy and topographic landmarks are reported. RESULTS: The mean total length of intercostal nerve harvested was 17.96 (range, 10-27) cm for the 9th intercostal nerve, 17.14 cm (range, 10-20) for the 10th intercostal nerve and 15.94 cm (range, 10-25) for the 11th intercostal nerve. The length of harvested nerve was not correlated to the size of the trunk. The length of harvested nerve was sufficient to perform lumbar roots neurotizations in the 300 cases of nerve harvesting. CONCLUSION: Multiple lumbar roots neurotizations with lower intercostal nerves already have been proposed by other authors. In this strategy, the use of the spinal cord and intercostal nerves above the spinal cord lesion avoids the axonal regrowth required via the injured central nervous system. Rerouting intercostals nerves down to the lumbar roots at their exit from the intervertebral foraminae is less invasive that the same procedure performed down to the vertebral canal at the level of the cauda equina as we used in previous protocols. Our anatomic study confirms the advantage of the paraspinal sacrospinalis splitting approach in multiple intercosto-lumbar neurotizations. The approach is quick and easy and allows a good exposure of the nerve roots at the thoracic and lumbar levels. The L2, L3, and L4 roots could be satisfactorily neurotized with this procedure.

Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy.

PURPOSE OF THE STUDY: Traumatic lumbosacral dislocation is a rare lesion often characterised by a fracture dislocation of L5-S1 articular facets associated with anterior L5 slipping. Because of its rarity, the surgical strategy of lumbosacral traumatic dislocation remains controversial. We report the most important series of traumatic lumbosacral dislocation. The cases of six men and five women are presented. We discuss the diagnosis and surgical treatment options regarding the different type of lesions. A moderate anterior slipping of L5 over S1 was present in eight cases. The lesion was a bilateral lumbosacral fracture dislocation in eight cases, a pure lateral dislocation in two cases and a unilateral rotatory dislocation in one case. Patients were multiple-trauma patients in eight cases. A radicular deficit was present in two cases. All patients were treated surgically with a posterior osteosynthesis and fusion. A circumferential fusion was made in six cases. In four cases, the anterior fusion was made during the posterior approach. The postoperative course was favorable in all the cases. One patient necessitated secondarily an iterative posterior lumbosacral fixation and anterior fibular bone graft because of a lumbosacral pseudarthrosis. Traumatic dislocation of the lumbosacral junction is a rare and severe spinal fracture which occurs in patients after high energy trauma and could be initially misdiagnosed. We devised a new classification based on anatomical lesions. Treatment is always surgical, requiring reduction, osteosynthesis, and fusion. In case of L5 anterior slipping, it is crucial to assess the L5S1 disc by MRI or surgical exploration for disc disruption. In such case, we recommend to perform circumferential fusion to prevent lumbosacral pseudarthrodesis.

Surgical treatment of high-grade lumbosacral spondylolisthesis in childhood, adolescent and young adult by the "double-plate" technique: a past experience.

Between 1979 and 1996, 40 patients with high-grade lumbosacral spondylolisthesis were treated in our institution using a newly designed osteosynthesis device. The mean age was 13 years and 6 months, and the mean follow-up was 18 years. Combined posterior decompression and anterior reduction, instrumentation and fusion of the slippage were performed in all cases. The technique includes reduction of the slippage by means of an anteriorly placed plate that engages two screws, previously placed during the posterior approach, going through the S1 vertebra. Progressive compression applied on the plate by the screws achieves reduction. Complete fusion was obtained in all 40 patients. Twelve patients presented a postoperative radiculopathy, from which only ten recovered completely. There were six L4-L5 annulus lesions, responsible for instability, produced by the plate. We report five late infections. Thirty-five of the forty patients were asymptomatic at the latest follow-up. The double compressive plate technique proved to be effective in obtaining lumbosacral fusion and optimal slippage reduction. However, the high rates of neurological and infectious complications preclude recommendation of this technique in its present form.

Long-term results of Schollner costoplasty in patients with idiopathic scoliosis.

STUDY DESIGN: A retrospective analysis of patients with idiopathic scoliosis treated with Schollner costoplasty. OBJECTIVE: To evaluate the long-term effects of Schollner costoplasty on rib hump and respiratory function SUMMARY BACKGROUND DATA: Costoplasty is an established technique to improve chest wall deformity in patients with scoliosis. Concerns have been raised of the long-term effects of costoplasty on respiratory function in adults. No long-term studies of this procedure exist. METHODS: A total of 25 patients with idiopathic scoliosis rib hump deformity underwent Schollner costoplasty. There were 12 patients who underwent surgery on the convexity alone, and 13 underwent additional "concave surgery" (6 Silastic [Dow Corning Corp., Midland, MI] implants, 7 concave lengthenings). Five patients underwent simultaneous spinal arthrodesis. The remaining patients underwent delayed procedures (0.4 -19 years) following the index operation. Vital capacity (VC) and rib hump were measured before and after surgery, and at each attendance thereafter. RESULTS: Mean follow-up was 10.8 years. Average reduction in rib hump was 38 mm at 6 months and 29 mm at long-term. There was no significant difference in the preoperative and long-term VC (P = 0.4), although at 6 months after surgery, there was a significant reduction in VC of 5.1%(P = 0.03). Subgroup analysis (convex only, concave lengthening, concave Silastic) revealed a similar pattern for rib hump correction and maintenance of VC in the long-term for each group. There was no significant difference between adults and adolescents in terms of both the reduction in rib hump and the VC (P = 0.2 and 0.3) CONCLUSIONS: Rib hump correction and lung function are preserved in the long-term following Schollner costoplasty in both adults and adolescents.

Artrosis de rodilla posterior a plastica ligamentaria / Secondary knee arthrosis following ACL reconstruction

Presentamos un estudio retrospectivo de 20 pacientes con diagnostico de lesion de ligamento cruzado anterior y cuerno posterior de menisco interno. En todos los casos, se realizo plastica ligamentaria por via artroscopica con la tecnica de Clancy (injerto hueso-tendon-hueso) y meniscectomia parcial del cuerno posterior del menisco interno. El promedio de seguimiento de los pacientes fue de 4 años y 8 meses, con un minimo de 4 años y 5 meses y un maximo de 5 años. Obtuvimos un score clinico (KDS) de 35 puntos sobre 50, lo cual nos habla de una funcion articular aceptable. Sin embargo, hemos encontrado en el 60 por ciento de los pacientes dolor en la interlinea articular interna, lo cual sugiere que la degeneracion probablemente este en desarrollo. Respecto a los cambios radiologicos, el 80 por ciento de los pacientes no mostraron signos degenerativos articulares, aun cuando aproximadamente la mitad de los mismos presentan cambios periarticulares como espolon tibial o patelar. Los resultados de nuestra serie confirman la efectividad de la reparacion quirurgica del ligamento cruzado anterior en la prevencion de la artrosis

Artrosis de rodilla posterior a plastica ligamentaria / Secondary knee arthrosis following ACL reconstruction

Presentamos un estudio retrospectivo de 20 pacientes con diagnostico de lesion de ligamento cruzado anterior y cuerno posterior de menisco interno. En todos los casos, se realizo plastica ligamentaria por via artroscopica con la tecnica de Clancy (injerto hueso-tendon-hueso) y meniscectomia parcial del cuerno posterior del menisco interno. El promedio de seguimiento de los pacientes fue de 4 años y 8 meses, con un minimo de 4 años y 5 meses y un maximo de 5 años. Obtuvimos un score clinico (KDS) de 35 puntos sobre 50, lo cual nos habla de una funcion articular aceptable. Sin embargo, hemos encontrado en el 60 por ciento de los pacientes dolor en la interlinea articular interna, lo cual sugiere que la degeneracion probablemente este en desarrollo. Respecto a los cambios radiologicos, el 80 por ciento de los pacientes no mostraron signos degenerativos articulares, aun cuando aproximadamente la mitad de los mismos presentan cambios periarticulares como espolon tibial o patelar. Los resultados de nuestra serie confirman la efectividad de la reparacion quirurgica del ligamento cruzado anterior en la prevencion de la artrosis