[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.

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.

[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.

Le traitement des sequelles d'injections intramusculaires de sels de quinine en milieu africain

L'injection intra-musculaire de quinine; traitement habituel de l'acces palustre chez l'enfant; est trop souvent a l'origine de complications orthopediques graves : paralysie sciatique apres injection intrafessiere; raideur du genou en extension apres injection intraquadricipitale. A partir d'une serie de 98 cas; dont 88 operes; les auteurs etudient les tableaux cliniques presentes et ils insistent sur la gravite des sequelles fonctionnelles. Ils analysent les possibilites therapeutiques des sequelles : au niveau du pied correction selon l'age par liberation interne ou double arthrodese sous-talienne et mediotarsienne; associee a une stabilisation par transposition antero-externe du tendon du tibial posterieur qui est tres habituellement non paralyse. Au niveau du genou; les auteurs proposent une correction par desinsertion large du quadriceps; intervention plus lourdemais dont les resultats sont meilleurs que la simple plastie d'allongement du tendon quadricipital

Le traitement des sequelles d'injections intramusculaires de sels de quinine en milieu africain

L'injection intra-musculaire de quinine; traitement habituel de l'acces palustre chez l'enfant; est trop souvent a l'origine de complications orthopediques graves : paralysie sciatique apres injection intrafessiere; raideur du genou en extension apres injection intraquadricipitale. A partir d'une serie de 98 cas; dont 88 operes; les auteurs etudient les tableaux cliniques presentes et ils insistent sur la gravite des sequelles fonctionnelles. Ils analysent les possibilites therapeutiques des sequelles : au niveau du pied correction selon l'age par liberation interne ou double arthrodese sous-talienne et mediotarsienne; associee a une stabilisation par transposition antero-externe du tendon du tibial posterieur qui est tres habituellement non paralyse. Au niveau du genou; les auteurs proposent une correction par desinsertion large du quadriceps; intervention plus lourdemais dont les resultats sont meilleurs que la simple plastie d'allongement du tendon quadricipital

Surgery in spinal metastasis without spinal cord compression: indications and strategy related to the risk of recurrence.

Surgery in patients presenting with vertebral metastasis without neural deficit is controversial. A series of 107 patients (54 female, 53 male) were operated on at a mean age of 58. The metastasis was the first manifestation of the cancer in seven cases. In 100 patients, the cancer had been diagnosed 30 months earlier (average). Vertebral pain was present in all cases, with associated radicular pain in 43 cases. Pyramidal irritation without neural deficit was present in seven cases. The mean preoperative Karnofsky index was 64.7%. The mean preoperative Tokuhashi score was 8.6. The surgical approach depended on the topography of the metastasis. Ninety-three patients were dead at review, with a mean survival of 8 months. Seventeen patients underwent further spinal surgery, for local recurrence in nine cases, and for another spinal localization in eight cases, after a mean interval of 8 months. Recurrence occurred at the same level in all seven patients presenting with neural deficit at recurrence. Among ten recurrences without neural deficit, two were observed at the same level and eight were observed on another level. Surgery in vertebral metastasis without neural deficit results in substantial functional improvement, but does not increase the duration of life. For kidney metastasis, total vertebrectomy must be performed because of the risk of recurrence. For thyroid metastasis, total vertebrectomy is a good alternative to increase the efficacy of iodotherapy. In other cases, for patients with good general status, surgery must be adapted to the location of the involvement.

[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.

Peripheral primitive neuroectodermal tumors of bone. A review of three cases.

The recently individualized and still incompletely understood family of peripheral neuroectodermal tumors encompasses several tumor types, of which some have a predilection for bone. Immunocytochemical studies are essential and usually provide the diagnosis. A t(11;22)(q24;q12) translocation is present in over 80% of cases. Ewing's sarcoma is now viewed as an undifferentiated form of peripheral neuroectodermal tumor, and both tumors require management with combination chemotherapy plus radiation therapy and/or surgery. Contradictory data have been reported regarding the comparative prognosis of peripheral neuroectodermal tumor and Ewing's sarcoma, indicating a need for further studies in large numbers of patients. We illustrate these points by three case-reports, two in girls diagnosed with a vertebral primary at five and nine years of age, respectively, and one in a man diagnosed with a pelvic primary at 29 years of age.

[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.

[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.

[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.

[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.

[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.

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.

[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.

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.

Results of surgical treatment of spinal thoracic and lumbar metastases.

The results of surgical treatment of vertebral metastases were evaluated from a retrospective review of a consecutive series of 100 patients, with special reference to anatomoclinical aspects and functional outcome. The primary tumour in most cases was lung, breast, or prostate; it was unknown in 11 cases. Diagnosis of the metastasis occurred 4-86 months after that of the primary tumour (lung metastasis: 4 months; breast metastasis: 86 months; prostatic metastasis: 22 months). Patients complained of vertebral pain in 96 cases and/or radicular pain in 43 cases. Intractable pain was observed in lung metastasis in particular. All patients received analgesics, and 57 received morphinics. Walking was impossible for 50 patients. Thirty-eight patients presented with neurologic deficit; neurologic status varied according to the primary tumour. Treatment included anterior surgery in 58 patients, posterior surgery in 33 patients, and combined surgery in 9 patients. Mean duration of hospitalisation was 12 days. No patient was admitted to the intensive care unit. Mean follow-up was 13.5 months. Eighty-nine patients were dead at follow-up, with an average survival of 10 months. Mean survival time was 7 months for patients with lung metastasis, 12 months for those with breast metastasis and 24 months for those with prostatic metastasis. Ten patients were still alive at follow-up (mean follow-up period 45 months, range 17-72 months). Analgesics were stopped for 62 patients following discharge from hospital. Morphinics had to be continued in seven patients. Thirty-five patients out of 50 (70%) recovered walking capacity. Neurologic status improved in 30 out of 38 patients. Although duration of survival was limited, surgery proved to be beneficial in providing a significant and early improvement in the functional status of more than 80% of patients. A precise evaluation of preoperative pain is necessary. Pain is dependent upon the bony lesion, the primary tumour, and the tumoral topography, which defines the surgical approach.

[Video-assisted anterior extra-peritoneal approach of the inferior lumbar spine]. / L'abord antérieur extra-péritonéal vidéo-assisté du rachis lombaire inférieur.

PURPOSE OF THE STUDY: The aim of this study is to describe a new operative technique for anterior lumbar and lumbosacral fusion using a video assisted anterior extra peritoneal approach. MATERIAL: Ten patients were operated on. There were 3 men and 7 females. Age at operation ranged from 18 to 55. There were 8 degenerative and 2 iatrogenic discopathias. Fused level was L4-L5 (5 patients) and L5-S1 (5 patients). Average hospital stay was 6 days. METHODS: A small vertical 4-5 cm incision is made on the mid line, centered on the umbilicus for the approach to L4-L5, and between the umbilicus and pubis for the L5-S1 approach. The peritoneum is cleaved from the abdominal wall on the left side, and the anterior aspect of the spine is progressively freed. The endoscope is laterally introduced. It gives an excellent view of the prevertebral area. A specially designed retractor is used for retraction of the iliac vessels. Following removal of the intervertebral disc, a special spreader allows obtention of a normal intervertebral space height and insertion of an autogenous iliac graft. DISCUSSION: Anterior approach of the lumber intervertebral discs allows disc resection and grafting in a strict middle position. The extra peritoneal simplifies the postoperative course and avoids digestive and septic complications of the transperitoneal approach. The video assistance gives excellent exposure by a small incision with direct visual control; it should be differentiated form the true endoscopic lumbar surgery which is performed under C02 insufflation, with exclusive endoscopic vision and with instruments introduced through trocards. CONCLUSION: Video-assistance allows an approach to the lumbar and lumbosacral spine by an anterior non invasive extra peritoneal approach, with low morbidity, increasing the possibilities of anterior fusion in the treatment of lumbar discopathias and instability without radicular compromise.

[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.

[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.