Intraspinal Extradural Degenerative Cervical Cyst Treated by Anterior Cervical Discectomy and Fusion: A Surgical Alternative to the Posterior Approach, about One Case.

Introduction: Intraspinal extradural arthrosynovial cysts, which belong to the spectrum of degenerative spinal diseases are mainly located at lumbar level and their location at cervical level joint is therefore unusual. The most common surgical approach for symptomatic arthrosynovial cervical cyst remains a direct resection of the cyst by a cervical hemilaminectomy with or without a posterior arthrodesis. However, another surgical approach may also be discussed when considering the cyst as a result of a local spinal instability or hypermobility. Case Report: We report in this work the case of a patient with cervical radiculopathy due to intraspinal extradural compressive arthrosynovial cervical cyst which was treated by anterior discectomy and fusion without direct resection of the cyst. The post-operative radiological control performed at 3 months showed a complete regression of the cyst with a patient pain-free. To the best of our knowledge, this is the first case of intraspinal cervical degenerative cyst at C7-T1 level treated by anterior approach and fusion without direct cyst resection. Conclusion: For the treatment of a joint spinal cervical cyst, the anterior approach is a relevant option that gives the advantages to respect the posterior cervical muscles and articular structures.

A prospective multicenter randomized study comparing the SpineJack system and nonsurgical management with a brace in acute traumatic vertebral fractures: the SPICO study.

OBJECTIVE: The objective of this study was to evaluate the efffectiveness of a titanium vertebral augmentation device (SpineJack system) in terms of back pain, radiological outcomes, and economic burden compared with nonsurgical management (NSM) (bracing) for the treatment of vertebral compression fractures. Complications were also evaluated for both treatment methods. METHODS: A prospective multicenter randomized study was performed at 9 French sites. Patients (n = 100) with acute traumatic Magerl type A1 and A3.1 vertebral fractures were enrolled and randomized to treatment with the SpineJack system or NSM consisting of bracing and administration of pain medication. Participants were monitored at admission, during the procedure, and at 1, 12, and 24 months after treatment initiation. Primary outcomes included visual analog scale back pain score, and secondary outcomes included disability (Oswestry Disability Index [ODI] score), health-related quality of life (EQ-5D score), radiological measures (vertebral kyphosis angle [VKA] and regional traumatic angulation [RTA]), and economic outcomes (costs, procedures, hours of help, and time to return to work). RESULTS: Ninety-five patients were included in the analysis, with 48 in the SpineJack group and 47 in the NSM group. Back pain improved significantly for all participants with no significant differences between groups. ODI and EQ-5D scores improved significantly between baseline and follow-up (1, 12, and 24 months) for all participants, with the SpineJack group showing a larger improvement than the NSM group between baseline and 1 month. VKA was significantly lower (p < 0.001) (i.e., better) in the SpineJack group than in the NSM group at 1, 12, and 24 months of follow-up. There was no significant change over time in RTA for the SpineJack group, but the NSM group showed a significant worsening in RTA over time. SpineJack treatment was associated with higher costs than NSM but involved a shorter hospital stay, fewer medical visits, and fewer hours of nursing care. Time to return to work was significantly shorter for the SpineJack group than for the NSM group. There were no significant differences in complications between the two treatments. CONCLUSIONS: Overall, there was no statistical difference in the primary outcomes between the SpineJack treatment group and the NSM group. In terms of secondary outcomes, SpineJack treatment was associated with better radiological outcomes, shorter hospital stays, faster return to work, and fewer hours of nursing care.

Unusual Presentation of Lumbar Surgical Site Infection: A Case Study of Early Onset Pasteurella multocida Infection after Arthrodesis.

BACKGROUND Infection is a serious surgical complication that significantly increases morbidity rates and health care expenses. Most human Pasteurella multocida infections are soft-tissue infections caused by dog or cat bites. Pasteurella multocida (P. multocida) is present in the oral, nasopharyngeal, and upper respiratory tract microbiota among cats, dogs, and other domestic or wild animals. Here, we report a case of lumbar surgical site infection caused by this bacterium. CASE REPORT A 70-year-old diabetic and overweight woman had a Pasteurella multocida surgical site infection after lumbar arthrodesis carried out for lumbar stenosis associated with spondylolisthesis. The patient had been in contact with her cat and claimed to have simply slept with it in her bed. Multiple antibiotic therapies and 3 debridement-irrigations with change of spinal implants during the last revision were needed. CONCLUSIONS Infections caused by P. multocida are rare and most often occur as a result of animal scratches or bites, but can sometimes occur after simple contact with an animal. Surgical site infection of spinal arthrodesis due to Pasteurella multocida implies treatment difficulties. In case of Pasteurella multocida infection of lumbar spinal arthrodesis, even in the early period, implant removal seems to be useful to limit the appearance of biofilm more specific to this micro-organism.

Thoracogenic scoliosis: coronal deformity progression in paediatric patients.

PURPOSE: To assess the risk of developing thoracogenic scoliosis (THS) in paediatric patients, depending on the side of lateral thoracotomy (LT) and of spine deviation in the coronal plane by means of logistic regression and scoliosis-free survival analyses. METHODS: A total of 307 consecutive patients undergoing LT were retrospectively reviewed; 32 patients met the inclusion criteria: 1) underwent LT and developed THS; 2) age < 15 years at LT; 3) clinical and radiographic follow-up ≥ 5 years. Patients were divided into ipsilateral group (convexity ipsilateral to LT) and contralateral group (convexity contralateral to LT). RESULTS: The mean follow-up was 10 ± 4.7 in the ipsilateral group (n = 13) and 12 ± 4.8 years in the contralateral group (n = 19). The contralateral group underwent LT at a younger age (4.4 vs 6.4 years, p = 0.55), developed more severe coronal deformity (27.8° vs 18.9°, p = 0.15), had higher rate of THS > 20° (47.5% vs 38.4%; p = 0.34) and > 45° (21.1% vs 0%; p = 0.99). The mean time from LT to THS diagnosis was 4.2 ± 2.9 in ipsilateral group and 5.5 ± 4.2 years in contralateral group. Left-side LT (p = 0.03) and age > 5 years (p = 0.01) showed a lower risk of THS diagnosis. The group variable had a statistically significant effect on the risk of developing THS > 45° (p = 0.03). CONCLUSION: In this series, children that developed THS with a convexity contralateral to the side of LT had more severe and progressive coronal spine deformity. LEVEL OF EVIDENCE: III.

Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF.

INTRODUCTION: Circumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques-TLIF versus ALIF plus posterior instrumentation-for low-grade isthmic spondylolisthesis in adults. MATERIALS AND METHODS: This was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1-3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion. RESULTS: The cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18-79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=-0.3295; p=.021). CONCLUSION: ALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis. LEVEL OF EVIDENCE: III; multicenter comparative study.

Implications of cage impactions in single-level OLIF treatment of degenerative spondylolisthesis.

INTRODUCTION: Cage impactions (CI) of Oblique Lumbar Interbody Fusion (OLIF) appear to be a frequent mechanical complication with a potential functional impact. OBJECTIVES: To determine the rate of CI occurrence, their risk factors and clinical implications in the case of combined single-level arthrodesis. METHOD: A retrospective analysis of prospectively collected data was performed. All our patients with degenerative spondylolisthesis initially underwent OLIF combined with pedicle screw fixation (PSF). Intraoperative control with an image intensifier and a standard radiograph in the immediate postoperative period made it possible to assess the occurrence of CI, depending on the position of the implant. Secondary subsidence was sought on the standing radiological examination using EOS biplanar radiography during follow-up. The pelvic parameters were analyzed, as well as the occurrence of bone fusion. The clinical evaluation was made at≥1 year, by the Oswestry Disability Index (ODI), the walking distance (WD) and the Visual Analogue Scale (VAS). RESULTS: In all, 130 patients out of the 131 included were analyzed. A CI occurred in 25.3% (n=33) of cases and of these, 94% (n=32) occurred intraoperatively. Postmenopausal women had more CI with an odds ratio (OR) of 5.8 (P=0.034). The "CI" group had a 9.5% lower ODI score than the "non-CI" group (P=0.0040), but both provided excellent ODI gains of 30.8±16 and 32.9±15.5% (P<0.0001). An "anterior" position of the implant allowed a greater gain in lumbar lordosis (P<0.001) but was associated with greater CI occurrence (P<0.001), with an OR of 6.75 (P=0.0018). CONCLUSION: The occurrence of intraoperative cage impaction is a frequent event when performing OLIF. Postmenopausal women have an approximately 6 times greater risk of impaction than men, and patients with an "anterior" implant placement have a 7 times greater risk than with central placement. The negative impact of cage impactions on the clinical score (ODI) was significant after one year of follow-up. LEVEL OF EVIDENCE: IV, non-comparative cohort study.

Fusion and clinical outcomes of lumbar interbody fusion for low-grade isthmic spondylolisthesis.

INTRODUCTION: Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique. HYPOTHESIS: The various interbody fusion strategies provide satisfactory fusion rates and clinical results. METHODS: A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF)+posterolateral fusion (ALIF+PLF: n=60), and ALIF+percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R), Oswestry Disability Index (ODI) and Short Form 12 (SF12). RESULTS: Among the 129 patients, 85.3% showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p<0.001) and VAS-R (p<0.0001), ODI (p<0.001) and SF12 physical (PCS) (p<0.01) and mental component sores (MCS) (p<0.001) all showed significant improvement at 12months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p<0.0001) and radicular pain (p<0.05), ODI (p<0.0001) and SF12 PCS (p<0.01). At 12months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p<0.004) and VAS-L ratings (p<0.001) than Lenke 1-2 patients. CONCLUSION: Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results. LEVEL OF EVIDENCE: IV.

Common carotid artery medialization and fracture dislocation of the cervical spine.

PURPOSE: To describe the management of the discovery of a retropharyngeal carotid artery in the context of a cervical dislocation. DESCRIPTION OF THE CASE: A 68-year-old female presented acute neck pain and incomplete tetraplegia following a fall on the stairs. Radiographs, contrast-enhanced computed tomography scan and magnetic resonance of the cervical spine revealed a C5-C6 bi-articular dislocation. A detailed preoperative assessment of the images discovered a medialization of the left common carotid artery. An external reduction and a left anterior cervical approach allowed a careful management of the vascular variation and an anterior C5-C6 arthrodesis. At six months, a full neurological recovery was assessed and radiographs demonstrated successful fusion of the cervical arthrodesis. DISCUSSION/CONCLUSION: Anatomical features such as medialization of the common carotid artery may affect patients with traumatic cervical spine injuries. The severity of the traumatic bone lesions should not overshadow the preoperative analysis of the adjacent anatomical structures encountered during the surgical approach, even in an emergency situation.

Thoracogenic scoliosis: a retrospective review of 129 pediatric patients with a mean follow-up of 10 years.

PURPOSE: To determine the midterm outcome of lateral thoracotomy (LT) in skeletally immature patients concerning thoracogenic scoliosis development and lung parenchyma resection (LPR) extent. METHODS: In total, 129 children met the inclusion criteria: (1) LT during the study period; (2) skeletally immature at the time of LT; (3) clinical and radiographic follow-up of at least 3 years; and (4) no spinal or thoracic deformity on radiographs before LT. Patients were grouped according to their underlying disease, age at LT, and LPR extent. Radiographic parameters were assessed. Kaplan-Meier survival curves and univariate and multivariate analysis were performed. RESULTS: Of 129, 108 patients underwent pneumonectomy (9; 9.1%), lobectomy (79; 61.2%), segmentectomy (20; 15.5%) and 21 patients LT without LPR. The mean age at LT and at last radiological follow-up was 5.5 years (birth-17.8) and 15.2 years (3.4-33.2). The mean follow-up was 10 years (3-28.1). Scoliosis developed on average 5.3 years after LT. The mean Cobb angle was 22.1° (11-90°); > 10° in 37/129 patients (28.7%), of whom 5/129 (3.9%) had > 45°. The average vertebral rotation was 16.2° (2-43°; grade 0-II). RVAD was 26.5° (8°-33°) and 15.3° (2-43°) in patients with Cobb > 45° and ≤ 45°. Gender, age at surgery, and extent of LPR were not risk factors for post-thoracotomy scoliosis (p > 0.05), although younger patients developed a more severe deformity. CONCLUSION: Although post-thoracotomy scoliosis is not associated with significant rotation, the risk of curve progression > 45° is relatively high. Regular follow-up is required as scoliosis may develop several years after LT with or without LPR.

Surgical outcomes of spinal osteochondroma in children: A multicentre observational study.

BACKGROUND: Spinal osteochondroma (or exostosis) is a rare benign tumour whose clinical manifestations are delayed due to their slow growth and location. Few studies have addressed the characteristics and the diagnostic and therapeutic peculiarities of spinal osteochondroma in children. The objective of this multicentre observational study was to assess the outcomes of a cohort of children after surgery for spinal osteochondroma. HYPOTHESIS: Surgical excision of spinal osteochondroma in children is not followed by complications or recurrences. MATERIAL AND METHODS: We included consecutive children who had surgery between 2010 and 2018 at any of eight participating centres to remove spinal osteochondromas. The cause, clinical manifestations, and location of the lesions were collected. The surgical outcomes were evaluated after at least 2 years' follow-up. RESULTS: We identified 22 patients who had surgery to remove 26 spinal osteochondromas at a mean age of 12.8±2.6 years. Among them, 7 had a solitary osteochondroma (SO group) and 15 had hereditary multiple osteochondromas (HMO group). At diagnosis, 72% of patients had clinical signs (spinal pain, n=4; one or more lumps, n=5; and neurological manifestations, n=3). In the HMO group, the diagnosis was made during routine MRI screening for tumours involving the spinal canal. Most osteochondromas involved the cervical spine (n=13), with no difference between the two groups (p=0.9). The lamina was the most common location but 54% of the tumours were growing within the canal (92% in the HMO group). After a mean follow-up of 5.2±4.4 years, no patients had experienced any recurrences or complications related to the disease or treatment. DISCUSSION: Surgical excision of spinal osteochondromas in children is effective, with no medium-term recurrences. Our results also confirm the low peri-operative morbidity, even when the canal is involved, and the absence of any effect at last follow-up on spinal alignment. All patients with neurological manifestations at diagnosis made a full recovery. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

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.

Optoelectronic Study of Gait Kinematics in Sagittal Spinopelvic Imbalance.

OBJECTIVE: Degenerative processes induce loss of lumbar lordosis and anterior sagittal imbalance (ASI). Optoelectronic study provides kinematic analysis of movement and can also detect ASI. The aim of the present study was to assess gait kinematic modifications induced by ASI. METHODS: Thirty-five healthy male volunteers were subjected to reversible ASI induced by wearing a kyphotic thermoformed thoracolumbar corset. The deformation was assessed by C7 tilt on EOS (EOS Imaging, Paris, France) full-spine views. Ten optoelectronic gait recordings were made with corset and 10 without. Gait kinematic parameters (stride length, walking speed, rhythm), gait balance parameters (center of mass braking index, stride width, double support time) and spinal sagittal balance parameters (C7T10S1, C7´S1' and spinal angles) were averaged. Adjusted analysis distinguished direct ASI impact from locomotor factors. RESULTS: The corset-induced ASI produced +15° change in C7 tilt (P < 0.0001), -7.4° in C7T10S1 (P < 0.0001), +66.2 mm in C7´S1' (P < 0.0001), and +13.1° in spinal angle (P < 0.0001). Radiographic and optoelectronic data correlated significantly. Stride length (P < 0.0001) and rhythm (P = 0.0003) were significantly reduced, contributing to a reduction in walking speed (P < 0.0001), and strongly influencing double support time (ß = -0.38; 95% confidence interval [CI]: -0.69; -0.06). Center of mass braking index was significantly reduced (P < 0.0001) and significantly influenced by ASI (ß = -0.51; 95% CI: -0.78; -0.28). Stride width was significantly increased by ASI (P < 0.0001), independently of rhythm and stride length. CONCLUSIONS: ASI induced by a kyphotic corset was detectable on the optoelectronic system, leading to significant changes in gait kinematics. Locomotor parameters were significantly reduced. Balance parameters were significantly and directly altered by ASI.

Posterior vertebral column resection for pediatric rigid spinal deformity.

INTRODUCTION: Surgery for pediatric spinal deformity may involve vertebral osteotomies in complex cases. Vertebral column resection (VCR) is the most technically demanding procedure, with the severest morbidity. It can use a double anterior and posterior approach (APVCR), though a single posterior approach (PVCR) is gaining in popularity. HYPOTHESIS: PVCR provides effective correction with acceptable morbidity in children. METHOD: A single-center retrospective series included spinal deformities treated by PVCR. Surgical data and global pelvic-spinal balance parameters were analyzed. RESULTS: Sixteen PVCRs were performed in 13 patients, with a mean age of 14.1±2.8 years. Mean operative time was 411±54minutes. Mean preoperative rigid principal Cobb angle was 74.3°. Mean correction was 64.3% postoperatively, without significant correction loss at last follow-up. Mean blood loss was 941±221ml. The cell-saver enabled 92.3% autologous transfusions, with 53.4% homologous transfusions. Transient monoplegia and permanent psoas deficit were observed during the postoperative period. Radiologic follow-up found 4 non-unions requiring revision. CONCLUSION: PVCR provided major correction of rigid spinal deformity in children. Complications mainly comprised mechanical or neurological incidents. LEVEL OF EVIDENCE: IV, non-comparative cohort study.

Static and dynamic stabilometric force platform study of spinopelvic anterior sagittal imbalance.

BACKGROUND DATA: Anterior sagittal imbalance (ASI) is a severity factor in spinal pathology. Stabilometric study of the dynamic position of the center of pressure (CoP) assesses orthostatic control. These analyses provide the energy expenditure used for this control. HYPOTHESIS: Stabilometric signs are associated with ASI indicate increased energy expenditure. PATIENTS AND METHODS: Healthy male volunteers were subjected to reversible ASI induced by wearing a kyphotic thermoformed thoracolumbar corset. The deformation was assessed by C7 tilt on EOS whole-spine views. Static and dynamic posturographic force platform study was performed under conditions of anteroposterior and mediolateral instability. Mean CoP position (Xmean, Ymean) was studied on statokinesigram, with scatter assessed as confidence ellipse (CE). Path length according to CE surface (LAS) indicated energy expenditure. The stabilogram quantified displacement over time as lengths (Lx, Ly) and amplitudes (Ax, Ay). RESULTS: The corset significantly increased C7 tilt (p<0.0001). This did not significantly change mean CoP positions (Xmean and Ymean), but LAS was significantly increased (p=0.003). Static tests showed changes in Ly (p=0.0008) and Ax (p=0.003), and dynamic tests showed changes in Ly (p<0.0001), Lx (p<0.0001), Ax (p<0.0001), Ay (p<0.05) and CE (p<0.004). DISCUSSION: Posturographic parameters were impacted by inducing ASI in healthy subjects. Significant differences were seen in stabilography, CE and LAS, were greater on dynamic testing, and correlated with radiologic sagittal balance. Force platforms can reveal increased energy expenditure in maintaining posture. LEVEL OF EVIDENCE: II; Single-center prospective study involving healthy volunteers.

Kinematics or Kinetics: Optimum Measurement of the Vertical Variations of the Center of Mass during Gait Initiation.

BACKGROUND: During gait, the braking index represents postural control, and consequently, the risk of falls. Previous studies based their determination of the braking index during the first step on kinetic methods using force platforms, which are highly variable. This study aimed to investigate whether determining the braking index with a kinematic method, through 3D motion capture, provides more precise results. METHODS: Fifty participants (20 to 40 years) performed ten trials in natural and fast gait conditions. Their braking index was estimated from their first step simultaneously using a force platform and VICON motion capture system. The reliability of each braking index acquisition method was assessed by intraclass correlation coefficients, standard error measurements, and the minimal detectable change. RESULTS: Both kinetic and kinematic methods allowed good to excellent reliability and similar minimum detectable changes (10%). CONCLUSION: Estimating the braking index through a kinetic or a kinematic method was highly reliable.

Extended anterolateral transiliac approach to the sacral plexus.

The approach to the sciatic plexus and lateral part of the sacrum is difficult. A subperitoneal anterolateral approach can be extended by sectioning the iliac bone above the acetabulum and lowering it toward the external part of the iliac wing and buttock. This transiliac anterolateral approach exposes the lumbosacral trunk, first sacral foramina and sciatic plexus to the origin of the sciatic trunk. Exposure can be extended upward by subperitoneal lumbotomy, downward by opening the ischiorectal fossa, or outward by trochanterotomy. This approach was used 18 times by one of the authors (FHD) for resection of 13 malignant tumors and 5 plexus releases. Procedure time was 3-6hours, with 500-4,000ml blood loss. The approach systematically enabled surgical objectives to be met. There was 1 septic complication that healed after debridement.

Iliocava junction to L4-L5 disc anatomical relationship in L5-S1 isthmic spondylolisthesis.

BACKGROUND: Anterior lumbar interbody fusion finds a place in L5-S1 isthmic spondylolisthesis (ISPL) treatment. Extension of this arthrodesis at L4-L5 level is sometimes required. Anterior approach of the L4L5 disc is considered difficult due to the anatomical relationship between the iliocava junction (ICJ) and the spine. HYPOTHESIS: Does the lumbosacral deformation induced by ISPL allows anterior approach of L4-L5 disc between the iliac? STUDY DESIGN: Retrospective radiographic analysis of consecutive patients. METHODS: This retrospective imaging study of a continuous series of 97 patients treated for an L5-S1 ISPL involved radiological parameters specific to ISPL and pelvic-sagittal balance. The distance between the ICJ and the L4 lower endplate was measured in millimeters. The factors influencing this distance were sought in order to identify a predictive model of high ICJ. RESULTS: The ICJ took a cranial position with respect to the L4-L5 disc with an average distance of 1.8mm±16.4. This distance was statistically higher in the case of high-grade ISPL (p<0.01). The high ICJ position was correlated with a high Taillard index (r=0.39; CI95% [0.13; 0.61]; p<.001) and a low lumbar-sacral angle (LSA) (r=-0.33; CI95% [-0.56; -0.06]; p<0.01). Among the parameters specific to spino-pelvic statics, pelvic incidence, pelvic tilt and lumbar lordosis had similar correlations (r>0.30). CONCLUSION: ISPL induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the ICJ. The anterior approach technique of L4-L5 disc in the presence of an L5-S1 ISPL is possible between the iliac veins for the large displacement and low LSA forms. LEVEL OF EVIDENCE: IV, retrospective analysis.

Minimally invasive unilateral lumbar interbody fusion (UNILIF) in over-80-year-olds. Continuous series of 42 patients at 1.4 years' follow-up.

INTRODUCTION: In lumbar stenosis, surgery aims to improve quality of life in increasingly elderly patients. Minimally invasive techniques better suit the requirements of elderly patients with increasing functional demand. HYPOTHESIS: The UNILIF unilateral lumbar interbody fusion technique improves functional scores at 1 year in over-80 year-olds, with low morbidity. METHOD: Patients undergoing minimally invasive decompression with transforaminal lumbar interbody fusion (TLIF) associated to unilateral pedicle screwing for degenerative lumbar stenosis were analyzed at a minimum 1 year's follow-up. SF12, Oswestry Disability Index (ODI) and Quebec scores and sagittal spinopelvic radiographic parameters were assessed at follow-up. Surgical and general complications were also collated. RESULTS: In all, 42 patients (64.3% female; mean age, 83.7±2.9 years) were treated by UNILIF at levels L2-L3 (3.8%), L3-L4 (15.4%), L4-L5 (71.2%) and L5-S1 (9.6%). Mean follow-up was 520±226 days (range, 340-1166 days). Mean preoperative SF12 score was 77.5±10.9, with significant improvement at last follow-up: 81.9±138 (p<0.05). Mean preoperative ODI was 44.4%±14.0, with significant improvement at last follow-up: 32.4%±13.3 (p<0.001). Mean preoperative Quebec score was 42.9±19.9, with significant improvement at last follow-up: 28.5±21.9 (p<0.001). Spinopelvic sagittal balance was not affected by the UNILIF procedure. There were no cases of infection or severe general complications during follow-up, although 2 cases of non-union required revision surgery. CONCLUSION: Lumbar stenosis surgery by UNILIF improved functional scores at 1 year, with low morbidity. It is a suitable strategy for degenerative lumbar stenosis in elderly patients. LEVEL OF EVIDENCE: IV, non-comparative cohort study.

Impact of assessment of bone status before corrective surgery of lumbar spine in patients over 50 years old.

Background and objective: There is absence of data on the prevalence of osteoporosis before corrective surgery of the lumbar spine. We do not know the impact of bone assessment before corrective spine surgery, regarding the prevalence of osteoporosis, risk factors for osteoporosis, and prescription of osteoporotic treatment. Our objective was to evaluate the impact of assessment of bone status before corrective surgery of the lumbar spine. Methods: This retrospective study was conducted over a period of 30 months. Patients included were over 50 years old and had been referred to rheumatology consultation prior to corrective surgery of the lumbar spine with osteosynthesis, for scoliosis or spondylolisthesis. Assessment of bone status consisted in looking for risk factors for osteoporotic fracture, performing bone densitometry with the calculation of TBS (trabecular bone score) and the possible introduction of treatment for osteoporosis. Data were collected on complications related to bone fragility during follow-up. Results: Twenty-eight patients with a median age of 71.2 years (55.5-84.8) were included; 89% were women. T score was <-2.5 in 14.3% (4/28) and -1 to -2.5 in 42.9% (12/28) on at least one of the three sites analyzed. Fifty percent of patients had a TBS <1.2, a history of more than four falls per year, a duration of more than 20 s in the Timed Up and Go Test, and/or sedation treatment. Vitamin-calcium supplementation and treatment for osteoporosis were prescribed in 71.4% and 17.8% of cases, respectively. During follow-up, 3 patients had one or more osteoporotic vertebral fractures and 4 patients had loosening of implanted devices. Conclusion: Despite a low prevalence of densitometric osteoporosis and therapeutic management, one in four patients had a bone complication, suggesting the superiority of TBS as an indicator of bone status.