Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice.

STUDY DESIGN: Retrospective multicenter cohort study. OBJECTIVE: Recurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France. METHODS: This retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively. RESULTS: The study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups. CONCLUSIONS: The decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.

Midline anterior approach from the right side to the lumbar spine for interbody fusion and total disc replacement: a new mobilization technique of the vena cava.

STUDY DESIGN: Prospective study. OBJECTIVE: To describe a midline anterior approach to the lumbar spine from the right side, below the aortic bifurcation to L5-S1, and by mobilizing the vena cava from right to left between L2 and L5. Feasibility and complication rate related to the approach have been studied. SUMMARY OF BACKGROUND DATA: Midline anterior approach to the lumbar spine has developed during these last years, mainly for interbody fusion and disc arthroplasty surgery. This retroperitoneal approach is well described in publications and classically made from the left side. Major complications associated with the approach are known: retrograde ejaculation, venous injuries, and arterial thrombosis. METHODS: A total of 469 patients were included in a prospective study between August 2003 and November 2010, either for interbody fusion by anterior approach or for total disc replacement, on one or several levels between L2-L3 and L5-S1. RESULTS: On the 154 patients who had a mobilization of the vena cava, no injury occurred. Only 4 major venous injuries occurred. There was no arterial complication, and the oxygen saturation signal was interrupted in only 1 case. No case of retrograde ejaculation was found. CONCLUSION: The midline anterior retroperitoneal approach from the right side is a safe alternative compared with the classical approach from the left side. The low rate of venous injury is explained by the sidewall thickness of the vena cava compared with the left iliac vein sidewall. Contrary to what happens by left-sided approach, the vascular retraction required for access to L4-L5 and above does not lead to arterial occlusion and therefore diminishes the risk in atheromatous patients. The absence of retrograde ejaculation confirms previous studies conducted on the left anastomosis of the superior hypogastric plexus, suggesting that its approach and mobilization by the left side are delicate.

Scoliotic curve patterns in patients with Marfan syndrome.

PURPOSE: Cases of "non-idiopathic" scoliosis are deemed atypical. These require a comprehensive work-up in order to choose the best treatment (and to determine an extent of fusion if needed). Marfan syndrome (MFS) is a genetic disease often marked with the presence of scoliosis, which is poorly described in the literature. Knowing that the clinical diagnosis of MFS is not always obvious, we investigated how atypical the scoliosis associated with MFS was when compared with that of adolescent idiopathic scoliosis (AIS). METHODS: In our series, we included 30 patients diagnosed with MFS. Each patient was proposed to undergo a plain radiographic examination of the spine. Scoliotic patients were classified according to the Scoliosis Research Society (SRS) curve pattern classification. Curve patterns with a very low rate of occurrence in historic control were defined as "atypical". RESULTS: A total of 19 patients were defined as scoliotic. In 9 cases, the curve pattern was atypical. In the other 10, the curve pattern was typical, but a fine analysis revealed some atypical features in the position of the apex and end vertebrae. CONCLUSIONS: Scoliosis associated with MFS was found to be atypical in all cases. This supports the idea that an atypical curve pattern should be considered as an argument in favour of a non-idiopathic aetiology and, therefore, an appropriate work-up should be performed before deciding treatment.