Posterior hinge fixation for the treatment of unstable traumatic sacroiliac joint injuries.

INTRODUCTION: Posterior hinge fixation (PHF) is a sacroiliac joint fixation method indicated for the surgical treatment of unstable pelvic ring fractures (tile C). HYPOTHESIS: PHF yields good functional outcomes based on the Majeed score at more than 1 year of follow-up. METHODS: A single-center, retrospective study of patients who had a Tile C pelvic ring fracture, who were operated by PHF and who were evaluated at a minimum follow-up of 1 year. The functional outcome was determined using the Majeed score and pain was evaluated by the patients using a visual analog scale (VAS). The preoperative, intraoperative and postoperative data, complications and sequelae were documented. A CT-scan was done at least 1 year after the surgical treatment to determine the SI joint's reduction and fusion. RESULTS: Included were 22 patients (59% men) who had a mean age of 37.3±11.9 years; 21 of these patients were reviewed at a mean of 4.8±4 years. The mean Majeed score at the final assessment was 76.4 points±15.3, with 24% of patients having excellent results (n=5), 53% having good results (n=11), 19% having average results (n=4) and 5% having poor results (n=1). The mean pain level on VAS was 28±23mm. Of the eight surgical site infections, seven occurred in the PHF (88%). CT-scans taken at 1 year postoperative were compared to the preoperative scans. The pelvic opening was reduced by -9±6 (p<0.01), SI diastasis by -11mm±9 (p<0.001), vertical displacement by-7mm±8 (p<0.001), symphysis opening by -15mm±15 (p<0.001), median transverse diameter by -10mm±9 (p<0.001) and bispinal diameter by -5mm±7 (p<0.001). SI fusion was confirmed in 43% of patients (n=9). CONCLUSION: PHF is a surgical instrumentation method that provides satisfactory long-term reduction of Tile C pelvic ring fractures. The clinical outcomes are good or excellent in 77% of cases. The perioperative morbidity is marked by surgical site infections, all of which healed. LEVEL OF EVIDENCE: IV; retrospective, non-comparative cohort study.

Anterior cage migration during spine surgery: An unusual and severe complication.

We report the case of an anterior cage migration that was incarcerated between the abdominal aorta and inferior vena cava. Removal of the cage was favored over conservative treatment because of potential migration and vessel injury.

Influence of transforaminal lumbar interbody fusion procedures on spinal and pelvic parameters of sagittal balance.

INTRODUCTION: Restitution of sagittal balance is important after lumbar fusion, because it improves fusion rate and may reduce the rate of adjacent segment disease. The purpose of the present study was to describe the impact of transforaminal lumbar interbody fusion (TLIF) procedures on pelvic and spinal parameters and sagittal balance. MATERIALS AND METHODS: Forty-five patients who had single-level TLIF were included in this study. Pelvic and spinal radiological parameters of sagittal balance were measured preoperatively, postoperatively and at latest follow-up. RESULTS: Age at surgery averaged 58.4 (±9.6) years. Mean follow-up was 35.1 months (±4.1). Twenty-nine percent of the patients exhibited anterior imbalance preoperatively, with high pelvic tilt (17.6° ± 7.9°). Of the 32 (71%) patients well balanced before the procedure, 22 (70%) had a large pelvic tilt (>20°), due to retroversion of the pelvis as an adaptive response to the loss of lordosis. Three dural tears (7%) were reported intraoperatively. Interbody cages were more posterior than intended in 27% of the cases. Disc height and lumbar lordosis at fusion level significantly increased postoperatively (p < 0.05 and p < 0.001). Pelvic tilt was significantly reduced (p < 0.01) postoperatively, whereas the global sagittal balance was not significantly modified (p = 0.07). CONCLUSION: Single-level circumferential fusion helps patients reducing their pelvic compensation, but the amount of correction does not allow for complete correction of sagittal imbalance.

Intrasacral rod fixation for pediatric long spinal fusion: results of a prospective study with a minimum 5-year follow-up.

BACKGROUND: Lumbosacral fusion is often needed in cases of pediatric neuromuscular spinal deformities. Despite the numerous fixation techniques described, the procedure remains challenging. Jackson has described a method of intrasacral fixation providing immediate 3-dimensional stability and promising clinical results. The purpose of this study was to report our experience with long spinal fusion using Jackson intrasacral fixation in pediatric patients. METHODS: All patients with at least 5 years of follow-up were reviewed. No brace was used postoperatively. Clinical data and radiographs were collected and analyzed preoperatively, postoperatively, and at latest follow-up. Intraoperative and postoperative complications were reported. Paired t test was used for statistical analysis. RESULTS: Fifty-six patients were included. The average age at surgery was 15.3 years. Mean follow-up period was 10.3 years and no patient was lost to follow-up. All radiographic parameters (frontal balance, frontal Cobb angle of the primary curve, iliolumbar angle, pelvic obliquity, sagittal balance, lumbosacral lordosis, and sacral slope) were significantly improved postoperatively (P<0.001), without significant loss of correction at latest follow-up. Four early infections, 1 pressure sore, and 4 cases of radicular pain, which resolved without intervention, were reported postoperatively. At latest follow-up, no patient complained of lumbar pain, and neither ambulatory status nor activity level ability worsened in any case. Sixteen of the 20 patients who needed a sitting orthosis preoperatively achieved a functional sitting posture without bracing. CONCLUSIONS: Jackson fixation is a safe and reliable technique providing immediate stability. In our series, no mechanical complication occurred and no loss of correction was observed, despite immediate unprotected mobilization. The method provides reliable good sacral fixation for pediatric neuromuscular spinal deformities, especially when the correction of severe pelvic obliquity is necessary. LEVEL OF EVIDENCE: This consecutive series provides level IV evidence.

Neurological and functional outcome after unstable cervicothoracic junction injury treated by posterior reduction and synthesis.

BACKGROUND CONTEXT: Unstable lesions of the cervicothoracic junction present a severe clinical problem for diagnosis, treatment, and prognosis. PURPOSE: The objective of the present study was to evaluate the neurological and functional outcomes following surgical treatments which combine in all cases posterior reduction and stabilization. STUDY DESIGN: Retrospective clinical and radiological study. PATIENT SAMPLES: Between September 1996 and September 2003, 30 patients underwent surgery for unstable fracture at the cervicothoracic junction. This group included 23 patients who sustained a motor vehicle accident, 5 who had fallen from a height, 1 case of ballistic trauma, and 1 person injured by diving in shallow water. There were 22 male and 8 female patients aged between 18 and 80, with an average age of 49. In 18 cases the lesion level was vertebra C7, in 5 cases vertebra T1, in 2 cases vertebra T2, and in 5 cases vertebra T3. Neurologically, on initial clinical examination 16 patients were classified Frankel A, 6 Frankel B, 2 Frankel C, and 6 Frankel D. Surgically, all the patients underwent posterior reduction and synthesis. Posterior stabilization was performed using rods and screws 3 times, plate-screw fixation 25 times, and rods and screws at the thoracic level linked to plate-screw at the cervical level 2 times. Spinal cord compression of more than two levels was associated with 25 cases. In these 25 cases, spinal cord decompression was associated with reduction and stabilization. OUTCOME MEASURES: Clinical outcome using neurological scale of Frankel, radiological outcomes using computed tomographic (CT) scans and plain X-ray evaluations. METHODS: Follow-up periods ranged from 11 to 48 months, with an average of 18 months. Seven patients died as a result of cardiopulmonary insufficiency within 4 months postoperative. Twenty-eight CT scans with sagittal and frontal slides were examined to evaluate postoperative reduction and to control screw placement. RESULTS: The observed reductions were satisfactory in 27 cases. In one case, reduction was satisfactory in the sagittal plane but lateral translation persisted in the frontal plane. Two mechanical failures with delayed mobilization of implants occurred. Bony fusion was recorded in all cases on CT scan evaluation. Complete or partial neurological recovery was observed in only 10 of 14 patients. The initial neurological status of these 14 patients was Frankel B, C, or D. CONCLUSION: The surgical procedure was chosen according to the particularity of the anatomical region and the possibility of associated medullar decompression. Insertion of pedicle screws in the upper thoracic portion in T1, T2, and T3 requires a careful technique and knowledge of the posterior projection points of the pedicles and their orientation in space. The high rate of fusion observed in these patients justified posterior reduction and stabilization. The high death rate and the low rate of neurological recovery in this group of patients emphasizes the severe prognosis of unstable injuries of the cervicothoracic junction. Considering the few mechanical failures observed at the last examination, the choice of the posterior approach was appropriate as the one stage procedure. Plate synthesis is preferable in fractures that do not require extension of synthesis beyond T2, whereas screws and rods systems are more appropriate for superior thoracic injuries. Despite early diagnosis and surgical treatment, the presence of neurological or pulmonary lesions resulted in increased mortality of the operated patients.